Contemporary role of ureterolysis in retroperitoneal fibrosis: treatment of last resort or first intent? An analysis of 50 cases.

OBJECTIVE: To determine the outcomes of open ureterolysis in a contemporary cohort of patients presenting with ureteric obstruction secondary to retroperitoneal fibrosis (RPF).

PATIENTS AND METHODS: We conducted a prospective analysis of 50 patients undergoing open ureterolysis and omental wrap between January 2012 and January 2016 in a single centre, managed by a multi-disciplinary RPF team. Patients had a minimum follow-up of 1 year. Indications were: nephrostomy-dependent drainage (n = 5); stent failure as evidenced by persistent hydronephrosis (n = 20); severe stent symptoms (n = 22); and patient choice/pre-emptive (n = 3). Outcome measures were stent-free rate; change in renal function post-ureterolysis; operating variables (operating time, blood loss, complications, length of hospital stay); and need for further intervention.

RESULTS: Of the 50 patients, 48 (96%) were stent-free at 3 months and 47/50 (94%) were stent-free at 12 months. The median (interquartile range [IQR]) changes in glomerular filtration rate, according to these indication groups, at 1 year were: overall +6 (-4 to +22)% (P < 0.05); stent failure +25 (+5 to +27)% (P < 0.001); stent symptoms +0 (-17 to +6)% (P = 0.834); nephrostomy-dependent drainage -10 (-19 to -2)% (P = 0.731); and pre-emptive 0 (0 to +8)% (P = 0.5). A total of 11/50 patients (22%) underwent additional procedures: nephrectomy, n = 7; uretero-ureterostomy, n = 1; aneurysm repair, n = 1; 1 Boari flap, n = 1; and ureteric re-implant, n = 1. Serious complications (Clavien III or IV) occurred in 12% of patients. The median (IQR) blood loss was 390 (20-1,200) mL and the median (IQR) length of hospital stay was 8 (3-21) days.

CONCLUSIONS: This study suggests that for patients with ureteric obstruction caused by RPF, contemporary ureterolysis performed by a high-volume specialist team can successfully render patients stent- or nephrostomy-free without compromising renal function. The results suggest that ureterolysis should be considered in all patients who present with ureteric obstruction caused by RPF that does not respond quickly to standard treatment.