Ureteral substitution

Appendix interposition for total left ureteral reconstruction

INTRODUCTION

Appendix interposition has been described as an option for surgical reconstruction of partial and total ureteral defects both in children and adults. However, to our knowledge, appendix interposition for a total left ureteral reconstruction has never been described.

CASE REPORT

We report the first case of total left ureteral reconstruction with cecal appendix to connect the renal pelvis of a native kidney to the urinary bladder in a 3-month-old child with ureteral necrosis following pyeloplasty.

RESULTS

Postoperative recovery was uneventful. Postoperative intravenous pyelogram showed good flow of dye from the pelvis past the appendicular graft into the bladder. After 6 months, the child was asymptomatic, within the normal growth curve for height and weight.

CONCLUSION

Total ureteral reconstruction with cecal appendix is a feasible technique in young children. Surveillance for late operative complications is required, since this is the first case of total left ureteral reconstruction with appendix to connect the renal pelvis of a native kidney to the urinary bladder.

The appendix as ureteral substitute: a report of 10 cases

BACKGROUND

Ureteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter.

METHODS

A retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix.

RESULTS

Ten patients were identified, operated in 2002-2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n=1), congenital ureteric stenosis (n=5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n=3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n=1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16months (1-72 months), all the patients were well except one whose kidney function had deteriorated.

CONCLUSIONS

Total or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.

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.

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.

Neointimized Gore-Tex graft for ureteral prosthesis in the dog

OBJECTIVES

To determine the feasibility of replacing a ureteral segment with a neointimized Gore-Tex graft.

METHODS

Seven adult mongrel dogs underwent a two-stage operative procedure. The first procedure involved arterializing the graft to stimulate spread of a luminal neoendothelium by transmural capillary growth. Eight weeks after the initial procedure, a segment of the ipsilateral ureter was replaced with a segment of the neointimized graft.

RESULTS

Histologic evaluation of a portion of the graft removed during the second procedure demonstrated transmural neocapillary ingrowth in all grafts; however, there was no neoendothelial growth on the luminal surface. In 5 dogs the graft was occluded with blood clot and was not suitable for a ureteral prosthesis. In 2 dogs the graft was patent and was successfully incorporated into the urinary system. After 1 year of observation, both of these dogs maintained a patent ureter and had no evidence of hydronephrosis on intravenous urogram.

CONCLUSIONS

These data demonstrate that a Gore-Tex graft can be used as a ureteral prosthesis in the dog. The importance of preliminary arterialization, however, remains to be determined.

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.

Surgical management of urinary incontinence in children

The field of continent reconstruction continues to expand rapidly, as new innovations are introduced by imaginative surgeons. Today, review of previous experience and knowledge of physiology permit creation of solutions to previously insoluble problems. It must be stressed that long-term results are not available for many of these procedures, but with careful follow-up, the outlook is promising.

Combined Boari bladder flap-psoas bladder hitch procedure in ureteral replacement

Uncomplicated injuries to the ureter are commonly treated with end-to-end ureteroureterostomy or reimplantation into the bladder. The Boari bladder flap and the psoas bladder hitch have been used separately when distal ureteral replacement is required. In cases of more extensive ureteral damage extending above the pelvic rim, more complex procedures have been performed. These procedures (transureteroureterostomy, intestinal replacement or renal autotransplantation) often represent a considerable surgical challenge and may be associated with numerous complications. Combining the principles of the psoas bladder hitch and Boari flap affords the clinician a means of traversing extensive ureteral defects with standard surgical techniques. We report herein patients with ureteral damage who have undergone replacement of various lengths of ureter with combined psoas hitch/Boari flap procedures. The technique is suitable for traversing ureteral defects at least to the lower pole of the kidney. An obvious advantage is that the replacement utilizes only normal urinary tract, it does not endanger ipsilateral kidney nor contralateral ureter or kidney and can be employed in patients with decreased renal function. In our experience ureteral replacement with the combination of the psoas bladder hitch and Boari bladder flap is an excellent method which is surgically simpler and safer than the other methods described for more extensive ureteral injuries.

Bladder reconstruction in rabbits with glutaraldehyde-stabilized amniotic membranes

Glutaraldehyde-treated human amniotic membranes were used to repair rabbit bladders after supratrigonal cystectomies. The membranes maintained the integrity of the bladders until healing and reepithelialization occurred. There was no significant loss of bladder capacity or decreased renal function postoperatively. Calcification did not occur on the membranes but was noted on chromic sutures retaining the membranes in 7 of 27 bladders. These findings suggest that glutaraldehyde-stabilized amnion is well tolerated by the urothelium and may serve as a suitable material for replacement of genitourinary tissues.

Radiology of urinary undiversion

Many patients with urinary diversions are now considered candidates for "undiversion". Radiographic evaluation prior to undiversion of the urinary tract includes cystography to determine bladder capacity and sensation, urinary continence, and the presence of reflux. Urography, loopography, and/or ureterography (antegrade and/or retrograde) are necessary to completely visualize the remaining urinary structures. Surgical techniques involved in the reconstruction are briefly discussed to facilitate an understanding of the often unusual radiographic appearance of the undiverted urinary tract. Stentograms and cystography are recommended for early postoperative evaluation to exclude urinary leakage or significant obstruction. Percutaneous ureteral perfusion studies are often useful in the long-term follow-up of these patients.

Simplified nonrefluxing ileovesical anastomosis. Experimental study and clinical application

A simplified ileovesical anastomosis is herein described. It prevents vesicoileal reflux and allows for unimpeded efflux of urine into the bladder. The technique involves implanting 3 inches of distal ileum into a denuded muscular bed in the bladder. Vesical mucosa grows over the ileum creating an effective valvular mechanism. Experimental work done on the canine bladder and the use of this technique in 2 patients is described.

Ileal conduit undiversion: experience with tunneled vesical implantation of tapered conduit

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Bivalve nephrolithotomy in kidneys with ileal ureter

We describe the surgical management of 2 patients with staghorn stones in kidneys previously operated upon and an ileal ureter. Bivalve nephrolithotomy was accomplished in situ using local hypothermia and anatrophic nephrotomy. This approach seemed to be the most suitable in these cases because other procedures could have been difficult and risky for the pelvioileo-anastomosis.

Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.