A ureterectomy is the surgical removal of a ureter, one of the two tubes that carry urine from the kidneys to the bladder. This operation is performed when the ureter is affected by a condition that cannot be resolved with less invasive treatments. Depending on the specific medical issue, the procedure can involve removing the entire ureter or only a portion. The goal is to remove the diseased tissue while preserving as much urinary function as possible.
Medical Conditions Requiring Ureterectomy
The most frequent reason for a ureterectomy is upper tract urothelial carcinoma (UTUC). This cancer originates in the specialized lining of the urinary tract, which includes the kidneys, ureters, and bladder. For high-risk UTUC located in the ureter, the standard treatment is removing the entire ureter and the associated kidney to prevent the cancer from recurring or spreading. High-risk tumors include those that are large, multifocal, or show signs of local invasion on imaging scans.
A ureterectomy may also be necessary for severe, non-cancerous conditions. This includes significant trauma that has severed or destroyed a section of the tube beyond repair. Long-standing ureteral strictures, which are areas of scarring that narrow the tube, are another reason for surgery. If these strictures do not respond to other treatments like dilation or stenting, removing the affected segment may be the only option to restore proper urine flow.
Surgical Approaches and Procedure
A segmental ureterectomy involves removing only the affected portion of the ureter. This approach is used for small, localized tumors or non-cancerous strictures with the goal of preserving the kidney. A kidney-sparing approach is a priority for individuals with a solitary kidney, pre-existing kidney disease, or tumors in both ureters. After the diseased segment is removed, the healthy ends are sutured together or the ureter is reimplanted into the bladder to restore urinary flow.
A radical nephroureterectomy is a more extensive procedure involving the removal of the entire ureter, the corresponding kidney, and a small piece of the bladder called the bladder cuff. This is the standard treatment for high-risk UTUC, providing the most thorough removal of cancerous tissue. The bladder cuff is removed because cancer cells can be present where the ureter enters the bladder wall.
These procedures can be performed using different techniques. Open surgery involves making one or two larger incisions in the abdomen or flank to access and remove the ureter and kidney. This approach is used for very large or complex tumors where advanced disease is suspected.
Minimally invasive techniques include laparoscopic and robotic-assisted surgery. The surgeon makes several small incisions to insert a camera and specialized instruments. In robotic surgery, the surgeon controls a robotic system with highly precise instruments from a console. These methods result in less blood loss, smaller scars, and a quicker recovery period compared to open surgery.
Recovery and Hospital Stay
The length of the hospital stay depends on the surgical approach. Minimally invasive procedures may require a two to three-night stay, while open surgery requires a longer stay for recovery. Pain is initially managed with intravenous medication, sometimes with a patient-controlled analgesia (PCA) pump, before switching to oral pain relievers.
Patients wake from surgery with tubes in place to assist healing. A urinary (Foley) catheter in the bladder drains urine for one to two weeks, allowing surgical connections to heal. A surgical drain may also be placed near the incision to remove fluid, which is removed before the patient leaves the hospital.
A ureteric stent, a thin flexible tube, is placed inside the ureter during surgery to keep it open and prevent leaks while it heals. The stent extends from the kidney to the bladder and is removed in a follow-up appointment four to six weeks later. While the stent is in place, patients may experience an increased urge to urinate, burning, and blood in the urine.
Recovery focuses on a gradual return to normal activities. The diet progresses from liquids to solid foods as bowel function returns. Early mobilization, such as walking, is encouraged to prevent complications like blood clots and pneumonia. Patients should avoid strenuous activity and driving until cleared by their surgeon.
Potential Complications and Risks
Like any major operation, a ureterectomy carries general surgical risks. These are discussed with the surgeon and anesthesiologist before the procedure and include:
- Significant bleeding that could require a blood transfusion
- Post-operative infections at the incision site or in the urinary tract
- Formation of blood clots
- Risks associated with general anesthesia
- Injury to surrounding organs, such as the bowel or large blood vessels
Specific complications related to the procedure can also occur. A primary concern is a urine leak (urinoma), which happens if the reconnected ureter does not heal properly. This may require a drain or catheter to be left in longer until the leak resolves. For cancer patients, there is a risk of tumor seeding, where cancer cells spread and grow at the surgical site.
A long-term complication is a ureteral stricture, the formation of scar tissue at the surgical site that narrows the ureter over time. A stricture can obstruct urine flow from the kidney, leading to pain, infection, or kidney damage if not addressed. Correcting a post-surgical stricture may require additional procedures.