Reoperative ureteral reimplantation: management of the difficult case.

Reoperative ureteral reimplantation can be difficult if the bladder and ureters are abnormal or the patient has undergone multiple operations. In some cases both ureters can be mobilized and reimplanted again with satisfactory result. That is impossible in others. A useful alternative is long tunnel reimplantation of the better ureter, with psoas hitch, and transureteroureterostomy of the other ureter. If neither ureter is suitable a tapered bowel segment can be used, but this must be done in a manner that prevents reflux. In those patients for whom none of the above choices are possible, cecal augmentation of the bladder offers yet another option, intussuscepting the ileocecal valve to prevent reflux. With these various approaches in the reconstructive armamentarium, urinary diversion should be avoidable in nearly all cases who present after previous failure of ureteral reimplantation.