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Paper text:
ureteric injuries and strictures can occur iatrogenically from pelvic surgery or result from urolithiasis , repeated ureteroscopic procedures and congenital vesicoureteric reflux .
the available options include ureteroscopic stenting and ureteric reimplantation by open , laparoscopic or robotic approaches .
minimally invasive techniques are preferred in patients in whom open surgery is a high risk . they have been shown to be feasible , and short - term outcomes are comparable to open surgery . preserving renal function in a solitary kidney is vital , and in the current case , the patient was unsuccessfully treated with repeated ureteric stenting for a ureteric stricture . in the current report
, laparoscopic reimplantation of ureter in a complex case of ureteric stricture secondary to urolithiasis and repeated ureteroscopy is described .
a 56-year - old caucasian female who has a history of recurrent pyelonephritis , obstructive uropathy and stage 4 chronic kidney disease initially presented to the infectious disease team with bacterial endocarditis .
a ct demonstrated bilateral renal obstruction : right secondary to two 4-mm distal ureteric stones , and left secondary to long - standing pelviureteric junction ( fig .
the patient recovered well and outpatient investigations revealed the following : ( 1 ) a 5 mm distal right ureteric calculus and a further 7-mm calculus more distally on repeat ct , ( 2 ) kidney split function of the left kidney 17% , and of the right 83% on the dmsa renogram .
the patient desired an improved quality of life and wanted to be free of repeated urosepsis and free of the insertion of nephrostomy . in view of this , an open left nephrectomy was performed 13 months later , following a period of haemodialysis .
a nephrostogram demonstrated a right renal obstruction due to an ureteric stricture , showing inflammatory changes secondary to the patient 's infected stones .
ureteroscopic laser fragmentation of the right ureteric calculi and stent insertion was performed ; however , a repeat nephrostogram showed a long stricture in the lower third of the right ureter .
the stent expelled spontaneously , and a new antegrade ureteric stent and nephrostomy was inserted , and a post - procedure ct confirmed a satisfactory nephrostomy and stent position ; but , in addition , a persistent 7-mm right distal ureteric calculus was shown .
the stent expelled again spontaneously , and the right kidney was found to be grossly hydronephrotic on the ultrasound scan ( creatinine 476 mol / l , egfr 8 ml / min/1.73 m ) , and a right nephrostomy was inserted temporarily .
another nephrostogram showed a persistent 4-cm - long stricture within the distal right ureter ( fig .
2 ) . in view of her chronic ureteric stricture and repeated spontaneous passing of stents , laparoscopic right ureteric reimplantation into the bladder dome was performed on her single urinary tract system .
routine pre - operative assessment and optimisation was employed with no specific mechanical bowel preparation .
the ascending colon was mobilised , the right ureter was identified and dissected off of iliac vessels to scar tissue .
the bladder was mobilised , the umbilical artery obliterated and the superior vesical pedicle clipped .
the bladder was hitched to the psoas muscle , opened , and the ureter spatulated .
3 ) performed at 6 weeks revealed free urine flow into the bladder , and the nephrostomy was subsequently removed .
sixteen months post - operatively , the patient is well , nephrostomy - free , and her renal function has improved with a creatinine of 291mol / l ( egfr = 14 ml / min/1.73 m ) .
routine pre - operative assessment and optimisation was employed with no specific mechanical bowel preparation .
the ascending colon was mobilised , the right ureter was identified and dissected off of iliac vessels to scar tissue .
the bladder was mobilised , the umbilical artery obliterated and the superior vesical pedicle clipped .
the bladder was hitched to the psoas muscle , opened , and the ureter spatulated .
3 ) performed at 6 weeks revealed free urine flow into the bladder , and the nephrostomy was subsequently removed .
sixteen months post - operatively , the patient is well , nephrostomy - free , and her renal function has improved with a creatinine of 291mol / l ( egfr = 14 ml / min/1.73 m ) .
laparoscopic ureteric re - implantation was initially performed on animal models for vesicoureteric reflux in 1993   and was introduced in humans in 1994 shortly after . since then , refinements , including laparoscopic boari flap procedures , have been described to enable the repair of more complex distal ureteric strictures .
( no symptoms , renal deterioration , radiological evidence of residual obstruction , or need for subsequent procedures ) [ 5 , 6 , 7 ] .
rassweiler et al .   performed a retrospective comparison of laparoscopic ( n = 10 ) and open ( n = 10 ) techniques and concluded that the laparoscopic approach is feasible , provides comparable functional outcomes , but offers the advantages of less post - operative analgesic requirement , shorter hospital stays and convalescence .
the patient in the current case developed ureteric stricture in a solitary kidney secondary to repeated instrumentation . preserving renal function in a single system is vital .
the patient had repeated stent insertion ; however , these expelled spontaneously on a number of occasions , and no clear causes were identified . in patients
who experience repeated spontaneous passing of stents , titanium - nickel memokath stents can be offered ; however , these are not permanent and may occlude , and multiple further procedures are likely to be required in the future .
laparoscopic reimplantation offers treatment of the stricture and avoidance of stent complications and the need for further ureteroscopy or nephrostomies .
the current report presents a successful case of laparoscopic ureteric reimplantation in a solitary kidney to preserve renal function and to avoid repeated endoscopic procedures and nephrostomies .
ureteric strictures can be caused by traumatic pelvic surgery , urolithiasis and instrumentation . 
 there are various treatment options for ureteric stricture , including laparoscopic ureteric reimplantation . a 56-year - old female with a history of chronic left pelviureteric junction obstruction presented with urosepsis secondary to right - sided urolithiasis . 
 the patient had a left nephrectomy and developed right - sided ureteric stricture following repeated ureteroscopy to manage her stone disease . 
 the treatment with ureteric stenting was unsuccessful . here 
 we present a case on the feasibility of laparoscopic reimplantation for ureteric stricture in a solitary kidney to preserve renal function and avoid further ureteroscopy or nephrostomies .