APPENDICEAL SUBSTITUTION OF THE URETER IN RETROPERITONEAL FIBROSIS

Abstract

A 73-year-old white male presented with oliguric renal failure (creatinine 784 mmol/l). Computerized tomography (CT) demonstrated bilateral hydronephrosis and an atrophic left kidney secondary to idiopathic retroperitoneal fibrosis (fig. 1). Abdominal aortic aneurysm and lymphoma were excluded. Isotope renography confirmed a nonfunctioning left kidney. Co-morbid disease included ischemic heart disease, peripheral vascular disease, hypertension, noninsulin-dependent diabetes, hypercholesterolemia and diverticular disease. Initial management included retrograde placement of a right Double-J stent (Medical Engineering Corp., New York, New York) and high dose steroids (40 mg per day) for 3 months. Creatinine declined to a baseline of 177 mmol/l. Following removal of the Double-J stent creatinine increased during a 4-month period to 400 mmol/l with CT evidence of recurrent hydronephrosis. A right percutaneous nephrostomy was inserted and a preoperative nephrostogram showed an extensive ureteral stricture involving the distal and lower mid ureter. A midline laparotomy revealed dense retroperitoneal fibrosis encasing the right ureter. Multiple biopsies for frozen section confirmed fibrosis without malignancy. Ureterolysis proved impossible due to the degree of fibrosis and extensive stricturing of the right ureter. A defect of approximately 9 cm between the proximal ureter and the bladder resulted. Because of significant arteriopathy, renal autotransplantation was not considered appropriate, and substitution of the ureter with an enteric segment was elected. The appendix was isolated on its mesentery, and an end-to-end anastomosis was created between the proximal ureter and the tip of the appendix. The cecal end of the appendix was anastomosed to the bladder over a 2.3Fr Double-J stent using a modified Lich technique (fig. 2). Postoperative recovery was uneventful. The Double-J stent was removed 6 weeks postoperatively. Nephrostogram on postoperative day 7 demonstrated no evidence of obstruction with good flow of contrast material into the appendiceal conduit. At 2-year followup the patient remains well with a serum creatinine of 176 mmol/l.