Replacement of the ureter by small intestine: clinical application and results of the ileal ureter

Use of ileum as ureteral replacement in urological reconstruction

PURPOSE

We reviewed indications and outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction.

MATERIALS AND METHODS

Between December 1989 and September 2007, 105 patients underwent ileal ureter replacement, of whom 14 were excluded from study due to incomplete data. The remaining 91 patients (99 renal units) comprised the study cohort.

RESULTS

Mean patient age was 46.8 years and mean followup was 36.0 months. Indications for an ileal ureter were stricture following genitourinary surgery in 29 cases (31.9%), radiation induced stricture in 17 (18.7%), nonurological surgery iatrogenic injury in 16 (17.6%) and retroperitoneal fibrosis in 11 (12.1%). Only 4 patients (4.4%) had primary ureteral cancer. Long-term complications included anastomotic stricture in 3 patients (3.3%) and fistula in 6 (6.6%). Serum creatinine decreased or remained stable in 68 patients (74.7%) and hyperchloremic metabolic acidosis developed in 3. No patient complained of excessive urinary mucous production.

CONCLUSIONS

In 68.1% of patients indications for an ileal ureter included radiation induced stricture or iatrogenic injury. The ileal ureter is a reasonable option for long-term ureteral reconstruction with preserved renal function in carefully selected patients.

Ileal ureteric replacement with an ileo-psoas muscle tunnel antirefluxing technique for the treatment of long segment ureteric strictures

OBJECTIVES

To develop and report our initial experience with a novel antirefluxing technique for segmental ileal ureteric replacement for the treatment of long ureteric strictures.

PATIENTS AND METHODS

Between January 2000 and January 2007, 12 cases of ureteric strictures (nine bilateral and three unilateral) were treated using a novel surgical technique in which the ureter was replaced with a segment of ileum using an end-to-side anastomosis. An antireflux valve was constructed by fixing the distal part of upper ureter (4 cm) between the psoas muscle and ileal segment (the ileo-psoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis.

RESULTS

The 12 cases were followed-up for a mean (range) of 39.42 (12-64) months. There were no cases of pyelonephritis or signs of renal failure after surgery. There was dramatic improvement in hydronephrosis, as assessed by intravenous urography, in the 4-9 months after surgery. Cystography showed no evidence of ileo-ureteric reflux. Mild hyperchloraemic acidosis was detected in two patients and was successfully treated with oral alkalization.

CONCLUSIONS

In our initial experience, ileal ureteric replacement combined with the ileo-psoas tunnel antirefluxing technique is a highly effective procedure for the treatment of ureteric strictures.

Terminal Urothelium Differentiation of Engineered Neoureter After In Vivo Maturation in the “Omental Bioreactor”

OBJECTIVE

Long ureteric defects may theoretically be repaired with the use of tissue-engineered neoureter. However, attempts to construct such a neoureter in animal models have failed because of major inflammatory response. Avoidance of such inflammation requires a well-differentiated urothelium. We investigated whether omental maturation of a seeded construct in a pig model could achieve terminal differentiation of the urothelium to allow construction of a stricture-free neoureter.

MATERIAL AND METHOD

Bladder biopsies were taken to allow urothelial and smooth muscle cell cultures. These cultured cells were used to seed small intestinal submucosa (SIS) matrix. After 2 wk of cell growth, the in vitro SIS-seeded construct was shaped around a silicone drain and wrapped by the omentum to obtain neoureters. These neoureters were left in the omentum without any contact with urine, and then harvested 3 wk later for histologic and immunohistochemical studies.

RESULTS

Before implantation, the in vitro constructs were composed of a mono- or bilayer of undifferentiated urothelium overlying a monolayer of smooth muscle cells. After 3 wk of omental maturation, these constructs were vascularized and comprised a terminally differentiated multilayered urothelium with umbrella cells over connective tissue and smooth muscle cells, with no evidence of fibrosis or inflammation.

CONCLUSION

We obtained, for the first time, with this model of in vivo maturation in the omentum, a mature neoureter composed of a well-differentiated multilayered urothelium.

Continent cutaneous urinary diversion: long-term follow-up of more than 800 patients with ileocecal reservoirs

We report the clinical outcome of more than 800 patients, who underwent continent cutaneous urinary diversion with an ileocecal reservoir (Mainz-pouch I) in two urological tertiary referral centers at a mean follow-up of 7.6 years. Complications related to the continence mechanism (intussuscepted ileal nipple vs. submucosally embedded in situ appendix) and the antirefluxive uretero-intestinal anastomosis (submucosal tunnel vs. serosa-lined extramural tunnel) were recorded retrospectively. Stomal stenosis was observed in 23.5% of the patients with appendix stoma and in 15.3% of the patients with intussuscepted ileal nipple. The incidence of calculi was 10.8% in reservoirs with intussuscepted ileal nipple and 5.6% in reservoirs with appendix stoma. Eleven patients (eight with appendix, three with ileal nipple) required reoperation because of ischemic degeneration of the continence mechanism. The overall continence rate (day and night) was 92.8%. Anastomotic strictures of the afferent limb occurred in 6.5% of renal units (RUs) with a submucosal tunnel and in 5.0% of RUs with a serosa-lined extramural tunnel. Continent cutaneous urinary diversion with an ileocecal pouch is a highly satisfactory and safe option for patients, in whom orthotopic urinary diversion is impossible or contraindicated.

Comparison between ureteral replacements using a transverse tubularized colonic tube or ileal ureter: experimental study in dogs

INTRODUCTION

We report the comparison between ureteral replacements using a transverse tubularized colonic tube or ileal ureter in dogs.

MATERIALS AND METHODS

Ten canines were studied. Four underwent ureteral substitution with an ileal ureter; 5 with a single transverse tubularized colonic tube and 1 with a double colonic transverse tubularized tube. The animals were observed for a predetermined interval of 30 days. At 30 days, the animals underwent an intravenous pyelogram, cystogram, urine analysis, and serum electrolyte sampling, and the kidney, ureteral conduit, and bladder were examined grossly and histologically.

RESULTS

The pyelograms of both the ileal ureter and the transverse tubularized colonic tube showed prompt bilateral renal excretion. Grade 1 hydronephrosis was seen in 3 of 4 animals that received the ileal ureter and with 1 of 5 animals that received the colonic tube. Histological exam of the kidneys showed small focal areas of pyelonephritis in both groups without significant injury to the collecting tubules or glomeruli.

DISCUSSION

The transverse tubularized colonic tube is an effective form of ureteral replacement in the animal model. The advantages of using the colon include its proximity to the ureters, the minimal mobilization needed, position outside the radiation portals, and the short colonic segment necessary.

The Use of Bowel for Ureteral Replacement for Complex Ureteral Reconstruction: Long-Term Results

PURPOSE

Ileal and intestinal ureteral replacement remains a useful procedure for complex ureteral reconstruction. We examined the long-term safety and efficacy of this procedure, especially in regard to maintaining preoperative renal function and the avoidance of major complications.

MATERIALS AND METHODS

A total of 56 patients underwent intestinal ureteral substitution at our institution between 1979 and 2003, including 52 with an ileal ureteral replacement, 2 with colonic replacement alone and 2 with bilateral ureteral replacement, necessitating ileum and colon for 1 ureter each. The factors reviewed were indications for surgery, type of ureteral replacement, and the presence and type of complications. Followup data included excretory urogram or equivalent imaging results, and measurement of serum chloride, bicarbonate and creatinine before and after the procedure.

RESULTS

Overall the complication rate remained low. Mean followup was 6.04 years (median 3.2). Most postoperative complications, which occurred in 10 patients (17.9%), were minor in nature, including pyelonephritis, fever of unknown origin, neuroma, hernia, recurrent urolithiasis and deep venous thrombosis. Major complications occurred in 6 patients (10.5%), including anastomotic stricture, ileal graft obstruction, wound dehiscence and chronic renal failure. Overall patients did not experience worsening renal function after the procedure with equivalent median creatinine before and after the procedure (1.0 mg/dl).

CONCLUSIONS

During long-term followup major complications are rare and renal function remains preserved. Ileal and intestinal ureteral substitution remains a safe and efficacious procedure in patients with complex and difficult ureteral issues not amenable to more conservative measures.

Replacement of ureter by ileum

PURPOSE OF REVIEW

The challenge of bridging long defects of ureter has been reviewed with particular emphasis on the utilization of ileum.

RECENT FINDINGS

The application of the Yang-Monti principle can provide an ileal tube of adequate length and suitable cross-sectional diameter. An antireflux ileovesical anastomosis is also feasible.

SUMMARY

Although long-term results are still lacking, an ileal tube constructed on the basis of the Yang-Monti principle seems ideal for ureteric substitution.

Lower urinary tract reconstruction with ileum in the treatment of gynecologic malignancies

INTRODUCTION

Advanced or recurrent gynecologic malignancies can invade or obstruct the lower urinary tract. If extirpation is necessary for cytoreduction or repair of radiation sequelae, treatment has typically involved creation of either an ileal conduit or a cutaneous continent urinary diversion. As an alternative, a more limited resection with urinary tract reconstruction using ileum for interposition or augmentation may allow for the preservation of urethral voiding.

CASES

We describe the use of ileal segments for lower urinary tract reconstruction in the treatment of ten patients with advanced or recurrent gynecologic malignancies. The clinical history, surgical technique, and patient outcomes are reviewed.

DISCUSSION

These cases demonstrate that limited bladder or ureteral resection with reconstruction using ileal segments may offer select patients preservation of urethral voiding.

Ileal ureteric replacement in complex reconstruction of the urinary tract

OBJECTIVE

To report 10 years' experience with ileal ureteric replacement as a last resort in complex reconstruction of the urinary tract.

PATIENTS AND METHODS

From March 1991 to February 2002 ileal segments were used for partial or total substitution of the ureter in 43 patients (mean age 45.6 years) with structural or functional ureteric loss secondary to irradiation, surgical complications or various other pathological conditions. Ileum was either implanted into the native urinary bladder (in 14) or an intestinal reservoir (in 29). In the latter group the technique was used at the time of primary urinary diversion in eight, in a secondary approach for treating early or late complications in nine and in undiversion or conversion procedures in 12. The ileal ureter was implanted into the urinary reservoir using a serous-lined extramural tunnel or distal intussusception for reflux prevention (in 31). All patients were followed prospectively according to a standardized protocol.

RESULTS

There were no perioperative deaths; the mean (range) follow-up was 40.8 (1.5-109.5) months. In 41 patients with dilatation of the upper urinary tract before surgery there was a significant improvement radiographically in 34, no change in five and deterioration in two. The serum creatinine level decreased or remained stable in all. Reflux occurred in the 12 cases without and in three with an antireflux mechanism. Shortening of an elongated kinking ileal ureter became necessary because of recurrent severe metabolic acidosis and mucus obstruction in two; in one case mucus obstruction was treated endoscopically. There was pyelonephritis only in three patients with refluxing implantation into an intestinal reservoir.

CONCLUSION

Ileal ureteric replacement is a safe and reliable last resort even in difficult cases. Whenever feasible, antirefluxing implantation into intestinal urinary reservoirs is recommended.

Ileal ureter substitution: a contemporary series

OBJECTIVES

To review our contemporary experience with ileal ureter reconstruction. Despite advancements in surgical technology and technical expertise, ureteral injuries continue to occur. These injuries can be extensive, and ileal ureter reconstruction may be necessary.

METHODS

A total of 18 ileal ureter substitutions were performed in 16 adults (10 men and 6 women) by a single surgeon during a 6-year period. The mean patient age was 49.4 years (range 25 to 72). The mean follow-up was 18.6 months (range 7 to 59). All ileal ureter substitutions were performed in an isoperistaltic, refluxing fashion. Follow-up included clinical evaluation, nuclear renography, intravenous urography, and serum chemistry testing.

RESULTS

Postoperative nuclear renography demonstrated no relative loss of function of the affected renal unit and no evidence of functional obstruction. An unobstructed state was also confirmed with intravenous urography. No statistically significant metabolic changes were found in any patient, as assessed by serum chemistry testing. None of the patients had evidence of new stone formation. Two patients developed an isolated, symptomatic urinary tract infection during follow-up, and one has had recurrent urinary tract infections, a problem that was present preoperatively.

CONCLUSIONS

Ileal ureter substitution remains an effective treatment for patients with complex ureteral strictures or injuries. Stone activity does not appear to increase, and metabolic sequelae are uncommon in properly selected patients.

Bridging long ureteral defects using the Yang-Monti principle

PURPOSE

A new technique for replacing the ureter based on the Yang-Monti principle is introduced to overcome the drawbacks of the classic ileal ureter.

MATERIALS AND METHODS

Between March 2001 and June 2002 ureteral replacement by ileum was indicated in 10 patients, including 9 with long or multiple strictures due to bilharzial (6), tuberculosis (3) and a low grade lower ureteral tumor (1). The technique involved isolation of a 5 to 7.5 cm. ileal segment, which was further subdivided into 2 or 3 equal parts. Paramesenteric incision along the longitudinal axis of these segments followed by unfolding resulted in a 12 to 18 cm. ileal strip. Tubularization of this strip led to the formation of an ileal tube with a suitable caliber. The latter was implanted into the bladder by submucosal (nonrefluxing) ileovesicostomy.

RESULTS

Mean followup +/- SD was 9.6 +/- 2.4 months (range 6 to 13). Mean serum creatinine remained stable in all patients. Split kidney function (mercaptoacetyltriglycine clearance) was stable in 7 cases and improved in 3. Antegrade urography revealed dynamic unidirectional nonobstructed flow. Reflux was noted in only 1 case. Excretory urography and/or magnetic resonance urography showed excellent configuration of the substitute without evidence of dilatation or obstruction.

CONCLUSIONS

The new technique offers certain distinct advantages. A short bowel segment is included with the consequent absence of metabolic complications. It allows construction of an ileal ureter with a suitable cross-sectional diameter without the need for tailoring and makes possible the use of an antireflux technique.

Long-term results of ileum interposition for ureteral obstruction

OBJECTIVE

To present the long-term results of ileum interposition in the ureter for uni- or bilateral ureteral obstruction.

PATIENTS AND METHODS

Between 1981 and 2000, a total of 22 patients received an ileal segment interposition as a substitution for the ureter, of whom 18 were available for analysis. The mean age was 54 years (range 29-73). Patients were followed for a mean period of 65 months (range 2-196). Assessment included clinical examination, serum creatinine levels, renal ultrasonography, intravenous pyelography and isotopic renography. In eight patients, the ileal-ureteral substitution was the first reconstructive procedure. The other patients underwent up to four previous reconstructions of different types. Fourteen patients were treated for unilateral ureteral obstruction, four of whom had a functional or anatomical solitary kidney, the other four patients had bilateral obstruction.

RESULTS

In 16 patients renal function improved after ileal-ureteral substitution. One patient underwent a nephrectomy because of a decreased renal function due to an obstruction at the level of the uretero-ileal anastomosis. One patient had a nephrectomy because of recurrent macroscopic hematuria caused by multiple arterio-venous malformations. Overall, 15 patients (83%) had a good functioning kidney after a mean period of 65 months. In three patients an early reintervention was necessary because of bleeding, small bowel obstruction and urinary leakage from a pyelo-ileal anastomosis. Six patients required a reintervention in the long-term: two had a nephrectomy, three had a re-anastomosis between the renal pelvis and the proximal ileal segment, while the sixth patient underwent a PNL for a kidney stone. Recurrent urinary tract infections were seen in six patients, of whom three had to undergo a reintervention. Metabolic acidosis was detected in two patients and was treated with sodium bicarbonate substitution.

CONCLUSION

Ileal-ureteral substitution is a valuable procedure with good long-term results and an acceptable rate of secondary interventions in patients for whom other alternatives are not feasible.

Ureteroileoneocystostomy: the use of an ileal segment for ureteral substitution in gynecologic oncology

OBJECTIVE

The aim of this study was to assess the results of the use of an ileal segment to restore the functional integrity of the renal tract where lower ureteric resection is necessary in gynecologic oncology surgery.

METHODS

All patients in whom ureteroileoneocystostomy (UINC) was performed between March 1988 and December 2000 were identified and a retrospective review of their case notes was conducted.

RESULTS

A total of 12 UINC procedures were performed on eight patients. The primary diagnoses were ovarian cancer in six cases, endometrial stromal sarcoma in one case, and vaginal carcinoma in one case. The average age of the patients at the time of their first UINC procedure was 56 years. Bilateral UINC was performed at a single episode in one patient and unilateral UINC in seven patients. Subsequent obstruction necessitated repeat or revision of the original procedure in two cases and contralateral UINC in one case. Complications included one death at 38 days from aspiration pneumonia not directly related to UINC, one pelvic abscess causing ureteric obstruction, and three cases of recurrent urinary tract infection. Follow-up ranged from 38 days to 77 months following the initial UINC procedure, with a mean of 34 months. Aside from the single postoperative death, the procedure was successful in 82% (9/11) of anastamoses on the first occasion and 100% (2/2) of anastamoses at repeat or revision surgery. There were no cases of renal failure secondary to a failed UINC.

CONCLUSIONS

Ureteroileoneocystostomy is a safe and effective procedure that should be considered in cases where lower ureteric resection is necessary.

Alça intestinal invertida como substituto do ureter: estudo experimental em cães

OBJETIVO: Pesquisar a viabilidade da alça ileal invertida como substituto ureteral. MÉTODOS: Quarenta cães foram divididos em 5 grandes grupos de 8 animais, cada um subdividido em 2 subgrupos de acordo com a data do sacrifício (I - sacrifício em 12-15 dias de pós-operatório, e II - 60 dias de pós-operatório). Nos grupos A e B fez-se a substituição ureteral parcial com selo de íleo invertido, após abertura lateral do ureter direito com 2 (Grupo A) ou 4 cm (Grupo B) de extensão. Nos demais grupos fez-se a substituição do segmento completo do ureter usando-se um tubo de íleo invertido de comprimento equivalente ao segmento do ureter ressecado com 2cm (Grupo C) e 6cm (Grupos D e E) de extensão. A mucosa ileal foi removida por raspagem ou diérese. A permeabilidade ureteral foi testada por urografia excretora e por exploração anatômica com cateter após o sacrifício. As peças foram estudas histologicamente após preparação e coloração com hematoxilina-eosina. RESULTADOS: O número de animais com urografia normal após o seguimento foi: A-2, B-2, C-3, D-2 e E- 2. A histologia revelou que a serosa ileal se reveste com urotélio, não como decorrência de metaplasia, mas do crescimento a partir da borda da mucosa ureteral. CONCLUSÃO: Conclui-se que o íleo invertido não é um bom substituto ureteral.

Laparoscopic nephrectomy for autotransplantation

Proximal ureteral injuries often require extensive reconstruction to repair. Management options include nephrectomy, ileal ureter interposition, extensive spiral bladder flaps, or autotransplantation. We report a patient who sustained a proximal ureteral avulsion and underwent a less invasive repair by way of a laparoscopic nephrectomy and subsequent autotransplantation.

Versatility of the adult psoas hitch ureteral reimplantation

PURPOSE

The psoas hitch ureteral reimplant has been described in the literature as an excellent method to restore ureterovesical continuity in patients with ureteral defects of various etiologies. However, long-term data on the durability of this procedure are lacking. We retrospectively reviewed patients who underwent ureteral reconstruction using the psoas hitch reimplantation to determine long-term efficacy.

MATERIALS AND METHODS

Ureteral reimplantation in the adult is frequently performed in the setting of ureteral tissue loss secondary to resection or injury. The psoas hitch reimplantation is a simple, versatile technique that avoids the inclusion of intestinal segments and can be used in most patients requiring reimplantation. Indications for surgery and the long-term followup were examined in 20 patients undergoing reimplantation using the psoas hitch.

RESULTS

The indications for ureteral reconstruction included surgical injury in 13 cases, recurrent pyelonephritis with reflux in 1, obstruction secondary to cancer in 2, trauma in 1, retroperitoneal fibrosis in 1 and ureteral stricture in 2. At followup of 1 to 14 years (mean 6) 17 patients have not required further intervention for urological problems and have retained normal renal function. In the 2 patients with cancer ileal conduit was performed later and in 1 flank pain persisted despite negative urological evaluation.

CONCLUSIONS

Psoas hitch ureteral reimplantation can be used successfully for bridging various ureteral defects in difficult clinical situations. Adequate renal and bladder mobilization will allow reconstruction despite long ureteral defects.

Historical perspective of the use of bowel in urology

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

Ileal orthotopic bladder substitutes. What we have learned from 12 years' experience with 200 patients

The perfect bladder substitute has not been devised yet. The ileal orthotopic bladder substitute, however, provides adequate capacity, convenient voiding patterns, optimal continence rate, preservation of renal function, acid-base balance, and calcium metabolism. The authors describe important surgical details based on experience with more than 200 patients. To achieve a good functional result, patient selection, postoperative voiding reeducation, and meticulous follow-up are important.

Ileal ureter

Ureteral replacement with ileal bowel segments has become common in the armamentarium of the reconstructive urologist. The use of ileal bowel substitution, whether total or segmental, has provided yet another surgical alternative for renal preservation. The indications, surgical technique, and results with the ileal ureter are reviewed.

Management of complete ureteral replacement. Experiences and review of the literature

The common treatment for patients with extensive damage to the ureter is complete ureteral replacement, combining Boari flap-psoas bladder hitch and downward mobilization of the involved kidney, with complete ideal replacement of the ureter, renal autotransplantation, of elective nephrectomy. Three case reports serve to describe two options of reconstructive treatment for complete ureteral replacement. The operative techniques, their limits, their postoperative results, and the treatment alternatives are discussed with due regard to recent literature. In the case of ileal replacement we have used a very short ileal segment to reduce the absorption surface of the ileal mucosa. Reflux prevention of the ileal segment was performed by creating an invaginated distal ileum nipple which was additionally fixed at the Boari flap by a third stapler row (auto suture TASS) to prevent potential nipple-gliding.

Summary of 10 years' experience with an ileal low-pressure bladder substitute combined with an afferent tubular isoperistaltic segment

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

The ileopsoas tunnel, a new antireflux technique for ureteroileal reimplantation: an experimental study in dogs

A new antirefluxing ureteroileal anastomosis is described in which the implanted ureter is placed between the ileal segment and psoas muscle. The procedure was studied in eight experimental dogs, which were observed for 20 weeks. Radiologic and bacteriologic examinations, necropsy assessment and histopathologic results provided evidence that this ileo-psoas tunnel technique allows a unidirectional, non-obstructed flow of urine. The technique could be applied when ileal replacement of the ureter is necessary or in association with continent bladder replacement.

Lower pole calicostomy for the management of iatrogenic ureteropelvic junction obstruction

It is often possible to use endoscopic techniques for the management of iatrogenic upper ureteral or ureteropelvic junction obstruction. However, in some cases with severe stricture disease or significant ischemic injury open surgical reconstruction is necessary. We report our experience with ileal ureter-lower pole calicostomy for the management of these complex urological injuries. During the last 3 years we treated 3 patients with severe ureteral/ureteropelvic junction obstruction secondary to iatrogenic injuries, including ureteral avulsion during ureteroscopic stone extraction, ureteral laceration during dilation for diagnostic ureteropyeloscopy, and ureteral ligation with ureteropelvic junction disruption and large peri-pelvic urinoma. In all cases unsuccessful attempts at endoscopic management necessitated open repair. Lower pole heminephrectomy was performed in all patients to expose the lower pole calix and ileal ureter-lower pole calicostomy was created due to the injury of large segments of the ureter. Satisfactory results were demonstrated on postoperative excretory urography and by a lack of symptoms. Followup averaged 23 months (range 20 to 26) with stable renal function in all patients. We believe that ileal ureter-lower pole calicostomy represents an attractive alternative for the management of severe ischemic, iatrogenic upper ureteral or ureteropelvic junction obstruction when endoscopic maneuvers are not possible or ineffective.

Female urinary tract fistulas

Urinary tract fistulas in women are an uncommon complication of a variety of surgical procedures. However, such fistulas lead to significant patient and physician distress, and have important medicolegal implications. Successful repair of urinary tract fistulas requires careful preoperative evaluation and adherence to basic surgical principles. A variety of approaches and techniques may be used, and the choice of procedure is less important than achieving adequate resection of fibrosis with watertight, tension-free closure of well vascularized tissues in layers. Interposition grafts of omentum, muscle, peritoneum and labial fat may be used in recurrent, complicated or radiated fistulas, and add significantly to the rate of success. Overall, successful repair of urinary tract fistulas can be achieved in the majority of cases.

Bilateral ureterovaginal fistula treated by psoas hitch and uretero-appendicocystostomy

Reconstruction of bilaterally damaged ureters after pelvic surgery is challenging. We successfully treated such a patient with a uretero-appendicocystostomy on the right side and a psoas hitch on the left side.

Optimization of replacement of the ureter by ileum

Fifty patients for whom an ileal replacement of the ureter was indicated were prospectively randomized among 2 treatment groups according to the surgical technique used. In group 1 the standard operation was performed. In group 2 a tailored and valved (modified) ileal ureter was used. Patients were followed every 3 to 6 months for 12 to 28 months. Kidney functions were evaluated by 99m technetium diethylenetriaminepentaacetic acid scans and by determination of the 24-hour creatinine clearance. Urine cultures were obtained, and urine viscosity and flow rates were measured. A urographic study, including ascending cystography, was done every 6 months. Results indicated that the modified operation is functionally superior to the standard procedure. It provides efficient unidirectional flow of urine from the kidney to the bladder with less mucus secretion. This was ultimately reflected as better renal function when it was quantitated by renography and/or chemical clearance.

Ileal segment for ureteral substitution or for improvement of ureteral function

A total of 29 patients received an ileal segment interposition between the upper and lower urinary tract for partial or total ureteral substitution, or for ileal wrapping around a massively dilated, aperistaltic ureter. Indications for an operation included the presence of an extensively diseased or short ureter and an aperistaltic megaureter that had failed previous reconstructive attempts. Nine patients (group 1) underwent an ileal sleeve procedure in an attempt to increase the ureteral peristaltic activity and facilitate drainage. Among these patients 7 (78%) had a stable upper tract radiologically and normal serum creatinine (less than 1.6 mg./100 ml.), while 2 (22%) had deterioration of the renal function. Ten patients (group 2) had undergone a myriad of reconstructions that failed and then underwent complete ureteral substitution with ileum. Among them, renal function (as evidenced by excretory urography and serum creatinine) is stable in 7 (70%) and deteriorated in 3 (30%). In 10 patients (group 3) the ureters were partially replaced by ileum in addition to a bladder augmentation procedure. Of these patients 8 (80%) have stable renal function and 2 (20%) had renal failure. Over-all, 7 patients have different degrees of renal failure; among them 2 (6.9%) are on dialysis and 2 (6.9%) have received a transplanted kidney. In groups 2 and 3 the results with an antireflux operation indicated that among 6 ureteroileal reimplantations 5 (83%) were successful, among 12 intravesical intestinal nipples 6 (50%) failed to prevent reflux and there was no case of obstruction, while among 4 ileocecal intussusceptions 2 (50%) were successful and 2 failed. Mucous secretion produced temporary ureteral obstruction in 1 ureter (3.4%), which resolved without surgical intervention. Some of the aforementioned procedures were done in the past and in some situations a different reconstructive technique would be considered presently. The surgical complexity and magnitude of the procedures justify their performance only in difficult clinical situations as an alternative to urinary diversion or renal autotransplantation.

Traumatic disruption of the ureteropelvic junction managed by ileal interposition

The use of ileal interposition in the management of a patient with delayed diagnosis of traumatic disruption of the ureteropelvic junction is presented. The unusual presentation of this problem, potential options in reconstructing the ureter and successful outcome are discussed.

Nonrefluxing ileal ureteral replacement using the intussuscepted ileal nipple: laboratory studies

A new technique for nonrefluxing ureteral replacement using ileum has been developed. Five adult mongrel dogs were operated using this nonrefluxing ileal ureteral technique. Subsequent reoperation showed in every case the preservation of renal function, a nonrefluxing system and no evidence of pyelonephritis or hydronephrosis. Based on the intussuscepted ileal nipple used in the Kock continent ileostomy, this technique has application in candidates for urinary undiversion, situations of ureteral loss due to trauma and fibrosis, and in patients with tuberculous strictured ureters.

Urinary tract re-functionalization after long-term diversion. A 20-year experience with 177 patients

From 1969 to 1990, previously diverted urinary tracts were 'undiverted' in 177 patients whose ages ranged from 1 to 31 years. Fifty-six of the patients (32%) had been diverted for 10 years or longer. There were 67 female and 110 male patients. Forty-four patients had only one kidney and in two of those patients it was a previous renal transplant. One patient was anephric at the time of reconstruction, having had two unsuccessful transplants. Most of the diversions had been considered permanent. Types of diversions that were reversed include ileal loop, colon conduit, loop ureterostomy or pyelostomy, end ureterostomy, cystostomy or vesicostomy, long-term nephrostomy, and ureterosigmoidostomy.

Colocalicostomy. A solution to an obliterated renal pelvis

A thirty-nine-year-old paraplegic with an ileal conduit urinary diversion and long ureteral strictures bilaterally required urinary tract reconstruction to establish effective internal drainage. Reported techniques proved infeasible. Therefore, the right kidney with its small intrarenal pelvis was opened by anatrophic nephrotomy and anastomosed to a segment of transverse colon in two layers. The left kidney could not be anastomosed directly to the colon segment, so it was anastomosed end-to-side to an isolated jejunal segment. Colocalicostomy should be considered in the repair of an obliterated renal pelvis or an isolated, obstructed lower-pole calix.

Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation

A total of 18 patients underwent an operation for extensive ureteral loss from 1980 to 1986. The indications included recurrent calculi, retroperitoneal fibrosis, surgical trauma and tumor. Of the patients 10 had construction of an ileal ureter (4 had bilateral reconstruction), 6 had creation of a psoas hitch with a Boari bladder tube and 2 were treated by autotransplantation. Mean duration of followup was 4.8 years. The procedure was successful in 17 patients. There were no apparent differences among the groups. Selection criteria and potential complications are discussed with regard to each technique. These procedures provide an excellent means for reconstruction of the urinary tract in patients who have failed other treatments.

Renal function after autotransplantation with direct pyelocystostomy. Long-term follow-up

The function of 20 human autologous kidney grafts was studied for 4 to 8 years (mean 5 1/2) after autotransplantation with a direct pyelocystostomy. The indications for the operation were low-grade, low-stage tumour of the renal pelvis and/or ureter, frequently recurrent renal stones and remaining outflow obstruction after pyeloplasty for hydronephrosis. The wide pyelocystostomy implies reflux of urine from the urinary bladder to the renal pelvis but no significant changes were found in glomerular or tubular function, studied with 51Cr-EDTA clearance, 131I-Hippuran renography, analysis of beta 2-microglobulin and total protein excretion in urine, and determination of concentration ability after administration of desmopressin. No increase in the severity or frequency of urinary tract infections was observed.

En bloc excision of lower ureter and internal iliac vessels for locally advanced upper rectal and rectosigmoid cancer. Use of ileal segment for ureteral repair

Eight patients who received en bloc excision of the ureter and internal iliac vessels for locally advanced upper rectal and rectosigmoid cancer were reported. Indications, techniques, functional results of the ileal ureter, and prognosis of these patients are discussed. Although three patients died of recurrent tumor--one of transperitoneal spread and two of liver metastasis--none of them developed local recurrent growth. As a replacement for the resected ureter, ileal substitution was applied in all eight patients--unilateral in six patients and bilateral in two. Serum creatinine and electrolyte patterns were within the normal range in all patients. A voiding cystogram showed no reflux to the anastomosed ureter, and a mild reflux to the ileal segment. The patients had excellent prognoses with regard to local control and also satisfactory functional results with the ileal ureter. The authors recommend that this procedure be applied to patients with locally advanced cancer such as those in this series.