Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature

Abstract

Context and aim: Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options.

Methods: From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14-50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years.

Results: All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage.

Conclusions: Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.

Keywords: Laparoscopic repair; preureteral vena cava; retrocaval ureter; transperitoneal; ureteroureterostomy.

Figure 1

Three dimensional reconstruction of computed tomography urography images show Type 1, low loop type of retrocaval ureter. There is gross hydronephrosis and upper hydroureter up to L4 level. Beyond L4 the ureter goes posterior to inferior vena cava and is atretic due to which its lumen is not opacified by contrast and proximal hydroureter and hydronephrosis results. The course of ureter produces a typical “S-” shaped/Fish-hook/Shepherd-crook deformity

Figure 2

The right ureter (blue) runs posterior to the inferior vena cava (inferior vena cava – yellow)

Figure 3

Ureter (blue) being cut just lateral to the inferior vena cava

Figure 4

The two ends of mobilized ureter (blue), lateral to the inferior vena cava (yellow). Note the ureteric catheter coming out from the lower end

Figure 5

Double J stent placed across the anastomosis

Figure 6

Embryological basis of retrocaval ureter (original, not borrowed)