laparoscopic ureteroneocystostomies have recently been performed as a definite treatment for ureteral stenosis ( either neoplastic or iatrogenic ) .
the techniques used to treat these lesions may or may not include the simultaneous performance of a distal ureterectomy .
the surgical principles of maintaining appropriate ureteral continuity and performing watertight and tension - free vesicoureteral anastomosis must be respected .
ureteral injuries are not rare complications after any difficult abdominopelvic surgical procedure , including gynecologic , obstetric , general surgical , and urologic surgery .
distal ureteral injuries are more commonly diagnosed after or during laparoscopic pelvic surgery , which is now a widely used technique for pelvic surgery . as a result
moreover , recent reports have described laparoscopic ureteric segmental resection with ureteral reimplantations for the minimally invasive management of low - grade upper urinary tract transitional cell carcinoma . for ureteral strictures ,
various treatment options are available . however , the localization , length , and etiology of the stricture affect the choice of technique .
short distal ureteric defects can be managed by end - to - end anastomosis or ureteroneocystostomy .
occasionally , longer obstructed ureter segments may require complex techniques , such as a psoas hitch or boari - flap [ 4 - 6 ] .
to the best of our knowledge , this is the first case series experience of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end with a reasonable follow - up .
in addition , the role of laparoscopy in the management of distal ureteral stricture due to iatrogenic injury and an early stage of malignancy is evaluated , with a focus on feasibility , safety , and short - term outcome .
between december 2008 and january 2012 , a single surgeon ( swp ) performed five laparoscopic ureteroneocystostomies with or without a psoas hitch for benign or malignant lesions in the distal ureter .
the etiology of the ureteral reimplantations was iatrogenic injury after hysterectomy in two patients , infiltrative endometriosis in two patients , and low - grade distal ureter cancer in one patient ( table 1 ) .
the status of the strictures or lesion was evaluated preoperatively with a combination of intravenous pyelography or antegrade pyelography and computed tomography scans .
two patients had a ureteral stent , whereas two patients had percutaneous nephrostomy tubes placed before surgery .
we retrospectively collected information on patient demographics and performed follow - up intravenous pyelography and voiding cystourethrography studies 3 months after surgery . under general anesthesia ,
a 12-mm trocar was placed at the umbilicus for the camera , and two 5-mm trocars were placed in the right and left lower quadrants .
an additional 10-mm port on the affected side was added for extracorporeal eversion of the ureteral end .
simultaneously , a cystoscope was prepared for intraoperative ureteral catheter insertion and for confirming the neoureteral orifice .
all surgical steps were performed purely laparoscopically via transperitoneal access , except for extracorporeal ureteral eversion .
the procedure began by incising the retroperitoneum along the line of toldt and by medializing the colon on the side of the affected ureter .
once identified , the ureter was carefully dissected down to the level of the stricture .
isolation of the obstructed ureteral segment can occasionally be challenging because of previous inflammation , infection , or scaring .
it is essential that care is taken during ureteric dissection to preserve the ureteric blood supply to prevent excessive devascularization .
the ureter was transected just superior to the level of the stricture or at a minimum distance from the malignant lesion .
after transecting the ureter above the narrow lesion or safety tumor margin , the ureter was prepared for removal .
the lower end of the affected ureter was held with a laparoscopic grasper and was brought out the abdominal wall from the ipsilateral 10-mm port .
the desufflated abdomen helped to reduce the amount of ureteric mobilization required for extracorporeal eversion .
1 ) . excellent mobilization of the bladder is essential for the creation of a tension - free anastomosis .
we identified an area on the bladder on the cranial aspect of the posterior bladder wall where an approximately 3-cm detrusor incision for the neoureteral orifice was made with a 1-cm mucosal incision .
after several stitches for vesicoureteral anastomosis , a suitably sized double - j ureteral stent was passed with the aid of a guidewire through the simultaneous cystoscope in a retrograde manner into the proximal ureter and kidney .
after the remaining suturing for the mucosa - to - mucosa anastomosis was completed with 4 - 0 polyglactin ( vicryl ) interrupted sutures , normal saline was instilled to confirm that the anastomosis was watertight ( fig .
the detrusor was incised by cautery down to the level of the mucosa , which should remain intact .
apposition of the muscle fibers and perivesical tissue above the anastomosed ureter was undertaken , producing the second plane of detrusorrhaphy while creating a 2-cm long submucosal tunnel .
care was taken to not close the tunnel too tightly and to not kink the ureter , both of which can result in ureteral obstruction .
under general anesthesia , the patient was positioned in the lithotomy position for simultaneous cystoscopy and laparoscopy .
a 12-mm trocar was placed at the umbilicus for the camera , and two 5-mm trocars were placed in the right and left lower quadrants .
an additional 10-mm port on the affected side was added for extracorporeal eversion of the ureteral end .
simultaneously , a cystoscope was prepared for intraoperative ureteral catheter insertion and for confirming the neoureteral orifice .
all surgical steps were performed purely laparoscopically via transperitoneal access , except for extracorporeal ureteral eversion .
the procedure began by incising the retroperitoneum along the line of toldt and by medializing the colon on the side of the affected ureter .
once identified , the ureter was carefully dissected down to the level of the stricture .
isolation of the obstructed ureteral segment can occasionally be challenging because of previous inflammation , infection , or scaring .
it is essential that care is taken during ureteric dissection to preserve the ureteric blood supply to prevent excessive devascularization .
the ureter was transected just superior to the level of the stricture or at a minimum distance from the malignant lesion .
after transecting the ureter above the narrow lesion or safety tumor margin , the ureter was prepared for removal .
the lower end of the affected ureter was held with a laparoscopic grasper and was brought out the abdominal wall from the ipsilateral 10-mm port .
the desufflated abdomen helped to reduce the amount of ureteric mobilization required for extracorporeal eversion .
1 ) . excellent mobilization of the bladder is essential for the creation of a tension - free anastomosis .
we identified an area on the bladder on the cranial aspect of the posterior bladder wall where an approximately 3-cm detrusor incision for the neoureteral orifice was made with a 1-cm mucosal incision .
after several stitches for vesicoureteral anastomosis , a suitably sized double - j ureteral stent was passed with the aid of a guidewire through the simultaneous cystoscope in a retrograde manner into the proximal ureter and kidney .
after the remaining suturing for the mucosa - to - mucosa anastomosis was completed with 4 - 0 polyglactin ( vicryl ) interrupted sutures , normal saline was instilled to confirm that the anastomosis was watertight ( fig .
the detrusor was incised by cautery down to the level of the mucosa , which should remain intact .
apposition of the muscle fibers and perivesical tissue above the anastomosed ureter was undertaken , producing the second plane of detrusorrhaphy while creating a 2-cm long submucosal tunnel .
care was taken to not close the tunnel too tightly and to not kink the ureter , both of which can result in ureteral obstruction .
the procedure began by incising the retroperitoneum along the line of toldt and by medializing the colon on the side of the affected ureter .
once identified , the ureter was carefully dissected down to the level of the stricture .
isolation of the obstructed ureteral segment can occasionally be challenging because of previous inflammation , infection , or scaring .
it is essential that care is taken during ureteric dissection to preserve the ureteric blood supply to prevent excessive devascularization .
the ureter was transected just superior to the level of the stricture or at a minimum distance from the malignant lesion .
after transecting the ureter above the narrow lesion or safety tumor margin , the ureter was prepared for removal .
the lower end of the affected ureter was held with a laparoscopic grasper and was brought out the abdominal wall from the ipsilateral 10-mm port .
the desufflated abdomen helped to reduce the amount of ureteric mobilization required for extracorporeal eversion .
excellent mobilization of the bladder is essential for the creation of a tension - free anastomosis .
we identified an area on the bladder on the cranial aspect of the posterior bladder wall where an approximately 3-cm detrusor incision for the neoureteral orifice was made with a 1-cm mucosal incision .
after several stitches for vesicoureteral anastomosis , a suitably sized double - j ureteral stent was passed with the aid of a guidewire through the simultaneous cystoscope in a retrograde manner into the proximal ureter and kidney . after the remaining suturing for the mucosa - to - mucosa anastomosis
was completed with 4 - 0 polyglactin ( vicryl ) interrupted sutures , normal saline was instilled to confirm that the anastomosis was watertight ( fig .
the detrusor was incised by cautery down to the level of the mucosa , which should remain intact .
apposition of the muscle fibers and perivesical tissue above the anastomosed ureter was undertaken , producing the second plane of detrusorrhaphy while creating a 2-cm long submucosal tunnel .
care was taken to not close the tunnel too tightly and to not kink the ureter , both of which can result in ureteral obstruction .
mean operation time was 137 minutes ( range , 104 to 228 minutes ) , and average blood loss was 100 ml ( range , 50 to 250 ml ) .
the foley catheter was removed at 7 days postoperatively after a cystogram showed no evidence of anastomotic leakage .
subsequent intravenous pyelography and voiding cystourethrography revealed no evidence of stricture or reflux 3 months after surgery .
the mean length of follow - up of the entire group was 12 months ( range , 3 to 30 months ) .
the complication of ureteral injury in laparoscopic surgery in gynecology was first presented in 1974 .
the incidence of iatrogenic ureteral injuries in laparoscopy has increased since then owing to the increasing complexity of laparoscopic surgeries and retroperitoneal dissection .
therefore , during laparoscopy , a high index of suspicion for ureteral injury is required .
delayed diagnosis of ureteral injury is most often achieved by computed tomography , antegrade ureterography , retrograde ureterography , or intravenous pyelography .
first - line minimally invasive management is an immediate attempt at placement of a double - j ureteral stent , but this is possible in only 20% of patients . when stent placement is possible
, some authors have reported an ultimate success rate as high as 73% without the need for additional surgery .
different laparoscopic techniques have been described for the treatment of distal ureteral stenoses , ranging from resection of the ureteral lesion and direct uretero - ureteral anastomosis to reimplantation by means of the psoas hitch or boari flap .
recent reports have described laparoscopic ureteric segmental resection with ureteral reimplantations for the minimally invasive management of low - grade upper urinary tract transitional cell carcinoma .
those authors suggested that minimally invasive surgery for malignancy is a feasible , safe , and effective option for distal ureteral malignancy .
because midureteral and distal - ureteral tumors are not amenable to endoscopic resection , distal ureterectomy with ureteral reimplantation is a treatment option .
when the ureteral length is insufficient for direct reimplantation , additional length can be gained with either a psoas hitch or a boari flap .
the performance of the antireflux technique in ureteroneocystostomy is probably the most troublesome part of this procedure .
although some authors did not perform it , most of the reports preferred some antireflux mechanism .
it is convenient to inject serum or normal saline under the mucosa through a laparoscope or cystoscope . during the procedure ,
these techniques are not easy to perform without hesitation . modi et al .   used a nonrefluxing extravesical lich - gregoir technique to prevent vesicoureteric reflux .
the authors initially incised the detrusor and bladder mucosa by use of electrocautery , and anastomosed the bladder mucosa and ureteral end by means of a 4-zero interrupted suture .
apposition of the muscle fibers and pericystium above the anastomosed ureter was undertaken , creating a 1- to 2-cm long submucosal tunnel .
we used the same approach for the antireflux structure , which significantly simplified the surgical procedure .
the eversion of the ureteral end for ureteroneocystostomy reduces postoperative restricture [ 17 - 20 ] .
although ureteral intussusception to produce a nipple is considered an important part of ureteral reimplantation in open surgery , it has never been reported accompanying laparoscopic ureteroneocystostomy .
our series is the first report of extracorporeal eversion of the ureteral end during laparoscopic ureteroneocystostomy .
extracorporeal eversion of the ureteral end for laparoscopic ureteroneocystostomy could make the procedure easier with fewer postoperative complications .
one of the fundamental principles of a ureteroneocystostomy is to achieve tension - free anastomosis .
we had to appropriately move the ureter , preserving the periureteral fat for the purpose of preventing ischemia , and also appropriately move the bladder . occasionally , for achievement of greater bladder movement , it was necessary to dissect the contralateral superior vesical artery , which allowed us to fill the ureteral defect up to 5 cm without the need to resort to a psoas hitch or boari flap .
many authors have reported that a bladder boari - flap or psoas - hitch procedure can be successfully used to bridge ureteral defects .
an additional or established port or a percutaneous needle was used to place a ureteral stent in previous reports .
several authors have recommended that placement of the new ureteral orifice in the bladder and the double - j stent in the affected ureter be monitored by simultaneous cystoscopy and laparoscopy . in all our cases ,
a double - j stent was inserted through simultaneous cystoscopy before completing the ureteric reimplantation .
we believe that placing a double - j stent by use of an intraoperative cystoscope is fast and easy and allows us to check the watertight suture and shape of the neoureteral orifice .
the ureter is most vulnerable laparoscopically at the infundibulopelvic ligament and uterine artery . despite prophylactic ureteral stenting before surgery to prevent iatrogenic ureteral injury , all clinicians should still promptly recognize any injuries so that immediate correction can be carried out .
in addition , ureteral eversion might reduce the recurrence of stricture after surgery . in our cases ,
an established port on the affected side was used for eversion of the ureteral end .
simple modifications with our current technique for laparoscopic ureteroneocystostomy will be crucial for ease of performance and a successful outcome .
 purposeto review the feasibility of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end in various distal ureteral lesions.materials and methodswe conducted a retrospective review of 5 laparoscopic procedures of ureteroneocystostomy with extracorporeal eversion of the ureteral end . of these , 4 patients ( range , 45 to 54 years ) had distal ureter stricture or obstruction after gynecological surgeries for endometriosis or a large uterine myoma . 
 one patient ( male , 67 years ) had low - grade distal ureter cancer . 
 the laparoscopic procedure was combined with cystoscopic insertion of a ureteral stent and extracorporeal eversion of the ureter through the 10-mm port on the affected side.resultsthe laparoscopic ureteral reimplantations with and without a psoas hitch in patients with distal ureteral lesions was successful in all patients . 
 the mean operation time was 137 minutes ( range , 104 to 228 minutes ) . 
 two patients underwent additional psoas hitch . in all patients , 
 short - term success was confirmed by voiding cystourethrography and intravenous pyelography conducted 3 months after the operation . 
 the mean follow - up of the entire group was 12 months ( range , 3 to 30 months ) . 
 we noted no major or minor complications over the follow - up period.conclusionsthe technique of laparoscopic ureteroneocystostomy for benign or malignant ureteral strictures continues to evolve . 
 surgeons should be versatile with various options and technical nuances when dealing with these cases . 
 simple modifications of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end , nonreflux extravesical anastomosis , and simultaneous cystoscopy will be crucial to the ease of performance and a successful outcome . 
INTRODUCTION
MATERIALS AND METHODS
1. Surgical technique
1) Extracorporeal eversion of ureteral end
2) Vesicoureteral reimplantation
3) Detrusorrhaphy
RESULTS
DISCUSSION
CONCLUSIONS