Laparoscopic Circumcaval Ureteral Repair with Concomitant Laparoscopic-Guided Nephroscopic Calculi Extraction

Abstract

Introduction: The pre-ureteral vena cava anomaly, erroneously termed the retrocaval or circumcaval ureter, is a relative rare condition of extrinsic ureteral obstruction. Despite being more common on the right kidney, when present on the left side, it is usually associated with sites inverses. The laparoscopic approach, with all of its know advantages, has good results when used to treat this congenital anomaly. The present surgical video shows a ureteral transposition with ureteropyolostomy, associated with a nephroscopic calyceal calculi extraction. Case Report: A 54 years old man, with discomfort in the right flank and abdominal echography showing a pelvicalyceal dilatation of this side and a calculus of 1.5 cm in a lower calyx. An intravenous pyelogram and abdominal computed tomography showed an S-shaped (Atkinson classification) pre-ureteral vena cava, and a mid-ureteral extrinsic stricture associated with it. There were no patient pre-operative comorbities and a percutaneous nephrolithotripsy was done 4 years prior on the right kidney. In the present video, a transperitoneal laparoscopic approach was conducted, with 4 trocars. In a stepwise fashion, the ureter suband supracaval was gently dissected, sectioned near the renal pelvis, transposed, and spatulated .A ureteropyelostomy was done over a double J stent, which was placed in an antegrade manner. After the posterior wall anastomosis completed, we performed a nephroscopy through the left hand trocar and the calyceal stone was removed by percutaneous stone instrumentation. Result: The surgery lasted 240 minutes, with minimum blood loss. The diet was resumed on the first postoperative day and he was discharged home on the third postoperative day. After 8 months of follow up, the patient remains asymptomatic and his excretory urography shows good drainage of the right kidney as well a diuretic renography reveals good response following 20 minutes after furosemide intravenous administration. Furthemore, the pelvicalyceal dilatation improved and there are no subsequent calculi. Conclusion: The laparoscopic approach to circumcaval ureteral anomalies is a feasible option, with concomitant endourologic procedures possible with good results. Int Braz J Urol. 2009; 35 (Video #2): 753_4 Available at: www.brazjurol.com.br/videos/november_december_2009/Curcio_753_754video.htm Accepted: November 8, 2009 Correspondence address: Dr. Lessandro Curcio Goncalves Section of Urology Ipanema General Hospital Rio de Janeiro, RJ, Brazil E-mail: lessandrocg@ig.com.br doi: 10.1590/S1677-553820090006000031