Robotic Buccal Ureteroplasty: a Review of the Current Literature

Laparoscopic ureteroplasty with oral mucosal graft for ureteral stricture: Initial experience of eighteen patients

OBJECTIVE

To investigate the feasibility and clinical efficacy of laparoscopic ureteroplasty with oral mucosal graft for ureteral stricture and describe the initial experience of eighteen operations.

METHODS

A retrospective analysis was performed on the clinical data of 18 patients who underwent laparoscopic ureteroplasty with oral mucosal graft for long segment or complex ureteral stricture admitted to the Second Affiliated Hospital of Anhui Medical University from July 2018 to June 2021. After the stricture ureter segment was freed during the operation, the ureteral stenosis segment was longitudinally cut. The required oral mucosa is removed according to the length of the stenosis. Oral mucosal grafts were harvested and placed in the ureter as an anterior onlay with omental wrapping.

RESULTS

Ureteral repair was performed laparoscopically in all cases, with no conversion to open surgery and no serious complications. The median length of ureteral stenosis was 3 cm (range, 2-7 cm), the mean operative time was 205.8 ± 33.4 min, indwelling time of the drainage tube was 4.9 ± 1.6 days, and the median length of postoperative stay was 7 days (range, 4-14 days). The double J tube was removed three to six weeks postoperatively. One of the eighteen patients had restenosis after surgery, and the other patients showed no deterioration of the severity of the obstructive uropathy after follow-up imaging examination.

CONCLUSION

Laparosopic ureteroplasty with oral mucosal graft is a simple, safe and efficient option for the treatment of ureteral stricture. Although the results of the initial experience are encouraging, a large cohort study with longer follow-up period is need to be done.

Ureteral reconstruction for complex strictures: a review of the current literature

PURPOSE

Frequently employed procedures for ureteral reconstruction include balloon dilation, pyeloplasty and ureteral re-implants. However, these procedures do not work for complex ureteral disease. The goal of this literature review is to report on techniques and success rates for the following techniques: buccal graft ureteroplasty, appendiceal interposition, transureteroureterostomy, ileal ureter and autotransplantation.

METHODS

A comprehensive literature search for English-language original and review articles was conducted using PubMed. The following terms were queried: "ureteral reconstruction", "buccal graft", "appendiceal interposition", "ileal ureter", "transureteroureterostomy", "autotransplantation".

RESULTS

Procedures involving the buccal mucosa or appendix offer minimally invasive techniques and low morbidity with good short-term success. Drawbacks to appendiceal interposition include the availability and length of appendix, and 10-20% of patients may have insufficient appendix upon intra-operative assessment. Transureteroureterostomy is typically limited to extensive exonerations due to concerns of injury to the contralateral kidney, even with reported success rates > 90%. Ileal ureter may carry a risk of metabolic acidosis in patients with renal insufficiency along with bowel-related complications. Ileal ureter and autotransplantation are reserved for the most severe cases due to their high morbidity but do offer options for the complex patient.

CONCLUSION

Ureteral stricture disease not amenable to pyeloplasty, ureteroureterostomy or ureteroneocystostomy offers a challenge to urologist. Careful patient selection with pre-operative assessment of renal and bladder is vital to a successful operation with minimal complications.

Open ureteroplasty with buccal mucosa graft for long proximal strictures: A good option for a rare problem

Purpose

To report a single surgeon experience with one year follow-up after open ureteroplasty with buccal mucosa graft (OUBMG) in the rare situation of long segment proximal ureteral strictures.

Materials and Methods

Four patients with long segment proximal ureteral stricture underwent OU-BMG between February and July 2017. Functional outcome was assessed by pre- and postoperative serum creatinine, ultrasound and renal scintigraphy as well as patient reported outcomes.

Results

Four patients with an average stricture length of 4 cm underwent OU-BMG between February and July 2017. No major postoperative complications occurred. Retrograde uretero-pyelography 6 weeks postoperatively revealed a watertight anastomosis followed by immediate emptying of the renal pelvis and ureter in all four patients. Ureteroscopy at this time showed a wide lumen with well-vascularized pink mucosa. After a mean follow-up time of 12.5 (12–14) months, postoperative serum creatinine was unimpaired. Renal scintigraphy revealed no signs of renal obstruction. With regard to intraoral surgery, no difficulties with mouth opening or intraoral dryness or numbness were reported.

Conclusions

For patients with long segment ureteral strictures OU-BMG is a safe technique with excellent surgical and functional outcomes. Hence, the application of this technique should be encouraged and regarded as one of the standard options in case of this rare problem.

[Management of ureteral injuries]

Ureteral injuries account for less than 3% of genitourinary injuries. Most of them are caused iatrogenically during abdominal surgery. The symptoms are often non-specific and do not aid in diagnosis. The later the injury is detected, the more often complications occur. Therefore, in such situations it is important to consider the possibility of ureteral injury and initiate further diagnostic steps as soon as possible. A variety of diagnostic tests are available. In addition to the direct inspection of the ureters and retrograde ureteropyelography, computed tomography (CT) urography is routinely used. Based on the time of diagnosis as well as the extent and the localization of the injury, the further procedure can be determined. For minor injuries, the insertion of a ureteral splint is usually the treatment of choice. In the case of higher grade damage, operative reconstruction by one of several possible surgical procedures is indicated.