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Distal Ureterectomy -Types, Procedure, Risk Factors, and Complications

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Distal ureterectomy is a procedure in which the lower part of the ureter is removed if found to be cancerous. Read the article to know more about it.

Written byDr. Shaikh Adibanaz Jamil Ahemad

Medically reviewed byDr. Pandian. P

Published At March 31, 2023
Reviewed AtMarch 31, 2023

What Are Ureters?

The ureters are a pair of organs that connects the urinary bladder to the kidneys. The urine flows from the kidneys towards the bladder via the ureters.The ureter in length is divided into three parts - the (upper) proximal ureter is the segment that starts from the ureteropelvic junction to the area where the ureter crosses the sacroiliac joint. The middle ureter starts over the iliac vessels and bony pelvis. And the pelvic or distal ureter (lower) courses from the iliac vessels to the bladder. The terminal portion of the ureter can be subdivided into the juxta vesical, submucosal parts, and iliac vessels.

What Is Distal Ureterectomy?

Cancer can be found in the lower (distal) part of one of the ureters. To treat cancer, distal ureterectomy is the treatment of choice. This surgery is done to remove the lower part of the ureter and a part of the bladder.

What Are the Types of Distal Ureterectomy Surgery?

The surgery can be done through various small incisions (laparoscopy). Or it can be done through one larger incision called open surgery. Laparoscopy cannot be utilized in all cases. In some cases, the surgeon can begin surgery using laparoscopy but can change to open surgery for safety reasons.

  • Laparoscopy - The surgery involves several small incisions in the abdomen. The scope is settled through one of the small incisions. The scope takes pictures from inside the abdomen to a video screen. Surgical tools are positioned through the other incisions. The surgeon uses a procedure called robotic laparoscopy. The robotic system provides a 3D picture of the body. It also helps the surgeon to perform hand movements.

  • Open Surgery - One bigger incision is made in the side of the abdomen. The surgeon watches and works through this incision.

What Is the Pre-surgical Procedure of Distal Ureterectomy?

Prepare for the surgery as told by the surgeon, and in addition -

  • Inform the physician about all the ongoing medicines. This encompasses prescription and over-the-counter medicines, herbs, vitamins, and other supplements. It also includes blood thinners, such as Clopidogrel, Warfarin, or daily Aspirin. Patients may need to avoid taking some or all of the drugs before surgery, as directed by the surgeon.

  • Avoid eating or drinking anything eight hours before the surgery. This includes foodstuffs such as tea, coffee, water, gum, and mints. (If advised to take medicines, take them with a little sip of water.)

What Is the Procedure of Distal Ureterectomy?

The surgery requires about two to three hours. Afterward, a stay in the hospital for one to three days is needed.

Before the Surgery

An intravenous line is started into a vein in the arm or hand. This line delivers fluids and medicines like antibiotics. Medicine to prevent blood clots is included too. To provide painless surgery, general anesthesia is given. This medicine leaves patients in a deep sleep state throughout the surgery. A tube is put into the throat to help to breathe. A thin tube (catheter) is placed into the bladder through the urethra. This drains the urine during the surgery and for a few days after the surgery.

During the Surgery

Thearea is scanned for cancer spread. The lower end of the ureter (distal part) and part of the bladder are discarded. Nearby lymph nodes may similarly be removed. The rest of the part of the ureter is then reinserted into the bladder and fastened into place.

A tall, flexible tube called a stent is set into the ureter. It enters the kidney into the bladder. It is maintained in place for 4 to 6 weeks after surgery to help grip the ureter open while it heals. The catheter is left in the bladder to drain urine as the bladder heals.

When the surgery is completed, all equipment is removed. The incision or incisions are fastened with stitches, staples, surgical glue, or strips of surgical tape. One or more tubes (drains) are positioned into the incision site. These drain fluid that builds up as recovery starts.

Recovering in the Hospital

After the surgery, patients will be supervised as they wake up from the anesthesia. They might feel sleepy and nauseous. If a breathing tube were used, the throat would be sore at first. Medicine will be given to manage pain.

The catheter in the urethra and any drains are liable to be removed before leaving the hospital. If not, instructions will be given on how to care for them at home.

Recovering at Home

After the hospital stay, patients will be released and the recovery time varies for each person. The surgeon will guide patients in their return to the normal routine. Until then, fulfill the instructions that the surgeon has given. Be sure to:

  • Take all medicines as and when prescribed.

  • Care for the incisions as instructed. Take care of any catheters or drains as directed.

  • Follow the physician's guidelines for showering. Do not take a bath, swim, use a hot tub, or do other activities that will fill in the incision with water until asked by the physician.

  • Do not do vigorous activity, as advised by the physician.

  • Do not drive until the physician allows it. When taking medications that cause sleepiness or drowsiness, avoid operating a motor vehicle.

  • Do not push during a bowel movement. If required, take stool softeners as directed by the provider.

  • The stent in the ureter will cause the desire to pass urine more often. There can be some burning and blood in the urine. This is normal and will stop once the stent is removed during a follow-up visit.

What Are the Risk Factors After the Distal Ureterectomy Surgery?

Seek immediate medical intervention if any of the following occurs:

  • Fever of 100.4° Fahrenheit (38 degree Celsius) or higher, or as directed by the physician.

  • Blood in the urine or large clots.

  • Swelling or leg -pain.

  • Pain that cannot be controlled with drugs.

  • Unable to urinate.

  • A large amount of drainage or bleeding from the incision.

  • Symptoms of infection at an incision site such as warmth, increased redness or swelling, worsening pain, or bad-smelling drainage

  • Vomiting.

What Are the Possible Complications of Distal Ureterectomy?

Possible risks of this surgery include -

  • Damage to the bowels, bladder, or other organs.

  • Kidney impairment.

  • Tumor appearing risks.

  • Risks of anesthesia.

  • Bleeding.

  • Infection.

  • Urine leakage from the ureter or bladder.

  • Stricture (narrowing) in the ureter.

  • Blood clots.

Conclusion

Ureters are a pair of the organ that carries urine from the kidneys to the bladder. The ureter is divided into three segments in which, the distal segment is more prone to cancer. In order to treat the cancer of the distal part of the surgery, called the distal ureterectomy is performed. The surgery can be done via laparoscopy or open surgery. The pre-surgical and post-surgical procedure of the surgery involves greater care and indications.

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Frequently Asked Questions

Partial ureterectomy refers to the partial removal of a portion of the ureter. It is performed as an alternative to a complete nephroureterectomy, which is performed to treat upper tract bladder cancer. However, complete kidney and ureter removal is performed to treat bladder cancer affecting the ureter.
During ureterectomy, a part of the bladder and the lower end of the ureter is removed. The lymph nodes present in that region are also removed. The remaining portion of the ureter is then attached to the bladder and sutured. A thin, long, and flexible tube called a stent is then inserted into the ureter.
The current procedural terminology (CPT) code for excision procedures on the ureter is 50650. The CPT code is a medical procedural code maintained by the American Medical Association. The CPT code for distal ureterectomy with ureteral reimplantation is 50948. It involves laparoscopic surgery, ureteroneocystostomy without cystoscopy, and placement of the ureteral stent.
In a ureterectomy with a bladder cuff, the bladder cuff is a separate procedure, which is not reported along with other procedures on the ipsilateral (same side) ureter. The CPT code for ureterectomy with bladder cuff is 50650. These CPT codes are formulated under the range of excision procedures on the ureter.
Ureteral stones can be seen in the right or left ureter. A distal ureteral stone is present in the distal end of the ureter, which means the stone is present at the region away from the point of origin of the ureter. A ureteral stone is commonly seen in the distal ureter, which can be small, medium, or large
The location of the stone differentiates a proximal stone and a distal stone. The proximal stones are present above the pelvic brim, and the distal stones are seen below the pelvic brim. A distal stone is seen at a portion of the ureter that is away from the point of origin of the ureter, whereas a proximal stone is seen close to the point of origin.
The pain of the distal ureter stone denotes the pain symptom caused by a distal ureter stone. A small ureteral stone does not cause pain. A large stone obstructs the flow of urine and causes severe pain, which may be accompanied by cramps in the lower abdomen. The cramps in the lower abdomen may also spread to the groin region.
Stone formation happens in the kidneys and is called kidney stones. Some stones in the kidneys may move into the ureter. The ureters are thin tubes that help transmit urine from the kidneys to the bladder. If a kidney stone descends from the kidney and gets obstructed in the ureter, it is referred to as a ureteral stone.
A ureteral stent can stay in place for several days to several months. The time duration of a ureteral stent is variable depending on the requirement. It is usually removed within 5 to 10 days after the procedure. About 50 percent of patients experience flank fullness during voiding and urgency due to the presence of a ureteral stent.
Stents are placed after kidney stone removal to prevent postoperative swelling from obstructing the ureter. A ureteral stent is removed within five to ten days after the procedure. If required, a ureteral stent may be left in place for a longer period. However, routine placement of ureteral stents after kidney stone removal is not followed.
Ureteroscopy with laser lithotripsy is performed for stones up to 2 cm (centimeters) or 0.787 inches in size located in the kidney or the ureter. A ureteroscopy is performed by passing a fiberoptic ureteroscope through the bladder to reach the ureter, allowing the visualization of the ureteral stone.
Ureteroscopy may cause complications like bleeding or injury to the ureter. It can also increase the chances of infection and may cause discomfort while voiding urine. If swelling is present in the ureter after the procedure, urination may be hard and painful. In rare cases, a major injury requiring extensive surgery may occur.
The urine in the bladder leaves the body through the ureters. The portion of the ureter that is close to the bladder is called the proximal ureter. The part of the ureter that lies away from its point of origin in the bladder and close to the region where the urine leaves the body is called the distal ureter.
A proximal stone is located above the pelvic brim. Proximal stones are usually located close to the point of origin of the ureter in the bladder. Proximal stones are variable in size. Small stones descend spontaneously, whereas large stones are removed by ureteroscopy or shock wave lithotripsy.
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