Challenging ureteral reconstruction pays off

After years of being told it wasn’t possible, 49-year-old woman gets high-risk urologic surgery that rids her of needing a nephrostomy tube.
July 9, 2020
pamela, who had Ureteral reconstruction, with her granddaughter at a river.
Pamela Jacobsen with granddaughter Honor Grace. Photo courtesy of Pamela Jacobsen.

Pamela Jacobsen had undergone 103 surgeries. Many of them involved bowel-cancer treatments – and, later, fixes for damage done by those treatments. Other procedures targeted blood clots that increasingly formed in her veins. One surgery, though, was a particular drag on her life.

Her abdominal surgeries had led to scarring, and the scarring had blocked a ureter, one of two nearly foot-long tubes that connect the kidneys to the bladder. The workaround had involved a nephrostomy tube, or “nep tube.” The nep tube, inserted through the lower back into the center of her kidney, mimicked the job of the ureter. But rather than link kidney to bladder, the nep tube exited her back to connect the kidney to a bag she now had as a constant, unwelcome companion.

That surgery was in 2017. For two years, doctors told the Aurora resident she’d have that nep tube for the rest of her life. Jacobsen asked more than once whether there wasn’t a surgical fix. The answer was always the same: “Impossible. Can’t be done.”

Dr. Ty Higuchi
Dr. Ty Higuchi

Then a nurse at a local community hospital, one who had once worked at UCHealth University of Colorado Hospital on the Anschutz Medical Campus (UCH), suggested otherwise. Jacobsen should touch base with the UCHealth Urology Clinic – Anschutz Medical Campus, the nurse said. Physicians there handled cases similar to hers. Perhaps one of them could help.

The nurse was referring to Dr. Brian Flynn and Dr. Ty Higuchi. They worked with patients with blockages of the ureter caused by scarring from cancer, kidney stones, and other causes. Jacobsen sat in an exam room with Higuchi, a University of Colorado School of Medicine and UCHealth urologist and surgeon, less than two weeks later.

Is ureteral reconstruction the right choice

Before Jacobsen’s visit, Higuchi reviewed a long and winding medical history and looked over her many scans. The surgery, should she be a candidate for it, would involve a ureteral reconstruction. The operation involves identifying the section of ureter that’s blocked (a dye-sensing X-ray unit in the operating room helps with this), removing that section, and reconnecting the kidney to the bladder via the healthy ureter that remains. Often, the surgeon must stretch or surgically alter the bladder to compensate for the shorter ureter. It’s a painstaking procedure, but Higuchi and Flynn are skilled enough at it that they can perform it with minimally invasive da Vinci robotic surgery. The smaller incisions generally mean much faster recovery times.

Pamela at a park, smiling, after having had rreteral reconstruction.
After ureteral reconstruction, Pamela Jacobsen is free of her nephrostomy tube. Photo courtesy of Pamela Jocobsen.

With a case such as Jacobsen’s, robotic surgery wasn’t an option. She had had 25 bowel surgeries. There was a lot of scarring in her abdomen that introduced a high risk of bleeding. In typical cases, should Higuchi find that the surgically shortened ureter no longer quite reaches to the bladder, he can use a section of small intestine to fashion an extension to the ureter and anchor it to the bladder. That backup plan wouldn’t be an option for Jacobsen because previous surgeries had removed much of her small intestine. Plus she was a smoker, which surgeons have long known can result in slower healing.

Weighing pros and cons for ureteral reconstruction

On the other hand, Higuchi saw that Jacobsen had been hospitalized more or less monthly for the last two years, often for multidrug-resistant infections from the nep tube. These were dangerous infections that a ureteral reconstruction could end. Her nutrition was good, and she was only 49 – both positives. And living with a nep tube is hard.

“I couldn’t go swimming. No baths; no hot tubs. At night you’ve got to be careful or you’ll pull the stitches out,” she said. “Walking around with bags and tubes hanging out of me just pulls me down as a person.”

two women dress up at a fundraiser event.
Pamela Jacobsen, left, and Stacy Grant at Mother’s High Tea Event at the McNichols building. Photo courtesy of Pamela Jacobsen.

Higuchi was faced with a tough call on whether to perform the surgery. He described it as being an “an emotional-physical decision.”

“I think all surgeons have an overwhelming feeling that they want to help the patient,” he said. “But then you have the harder decision based on what you’re seeing and the objective inputs.”

In that UCHealth Urology Clinic exam room, Jacobsen told Higuchi a story that jibed with and augmented the one he had read in her medical record and seen in her scans. She then said, “I’ve heard there’s a doctor here who could do away with my nephrostomy tube.”

Choosing ureteral reconstruction

Higuchi had made his emotional-physical decision. “I can do that,” he said.

“You can do that?” Jacobsen asked.

“I can do that,” Higuchi said.

The news brought her to tears.

Jacobsen quit smoking, and on Halloween 2019, Higuchi went to work on Jacobsen’s 104th surgery. The two-and-a-half-hour procedure involved identifying the blockage and removing a roughly three-inch section of scar-choked ureter, shifting the bladder up, and connecting the bladder to the healthy ureter.

There were no complications, and in December, Jacobsen’s nep tube was removed for good.

“Kudos to Dr. Higuchi for doing what others could not,” Jacobsen said. “I am forever thankful. He gave me back some of the things that life with a nep tube took from me. I’m blessed to have found him.”

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.