Renal autotransplant for ureteral loss

The ileal ureter is the default

When the whole ureter is out, the ileal ureter is my default replacement, because it is less work and carries less risk of losing the kidney. No single factor decides it the other way. Autotransplant is reserved for the ureter that has already been replaced and has failed again, in a patient with recurrent infections or pain. Many options come first, and the segmental repairs that keep a native ureter in place come before both; those are on the proximal and long-segment page.

Radiation moves the choice through two channels. It damages the iliac vessels, which makes the vascular anastomosis of an autotransplant harder to sew. It damages the bowel too, but there is more bowel, so a catastrophic bowel complication is less likely. The net lean in a radiated field is toward the ileal ureter, and the call is still weighed rather than automatic.

What rules it out

Iliac vessels that cannot be released. If the artery and vein cannot be freed for an anastomosis, there is no autotransplant, and if there is also no bowel for an ileal ureter, the patient is in native-tract salvage: an onlay or inlay on whatever narrow ureteral end survives, which works only if the ureter is not missing altogether. A solitary kidney with a short gut after several ureteroscopies is the patient who lands there.

Who does it, and the early tell

The autotransplant is a two-team operation. Jeffrey Stern of NYU Langone transplant surgery and I do them together, the same partnership as the single-port donor nephrectomy. A routine transplant ultrasound on the first or second day after the operation reads the vascular anastomosis, and a flow or perfusion abnormality on that early study is the tell that the anastomosis is in trouble.

Videos by operation

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