Strategies for open reconstruction of upper ureteral strictures

Reconstruction of the Ureter Using the Boari Flap and Psoas Hitch Techniques in a Patient With Damage to the Proximal Part of the Ureter: A Case Report

Although the Boari flap technique is commonly described in the literature as a method for primarily distal and middle ureteral injuries, it can also be used for reconstructing the proximal segment of the ureter. In this case study, we present a patient who underwent gynecological surgery with subsequent damage to the proximal ureter, and who underwent ureteral reconstruction using methods such as kidney mobilization, Boari flap, and psoas hitch. The postoperative period was uncomplicated, and after a six-month follow-up, the reconstructed ureter is functioning well, and the patient is in good health.

Mechanical characterization of porcine ureter for the evaluation of tissue-engineering applications

Introduction: Clinics increasingly require readily deployable tubular substitutes to restore the functionality of structures like ureters and blood vessels. Despite extensive exploration of various materials, both synthetic and biological, the optimal solution remains elusive. Drawing on abundant literature experiences, there is a pressing demand for a substitute that not only emulates native tissue by providing requisite signals and growth factors but also exhibits appropriate mechanical resilience and behaviour. Methods: This study aims to assess the potential of porcine ureters by characterizing their biomechanical properties in their native configuration through ring and membrane flexion tests. In order to assess the tissue morphology before and after mechanical tests and the eventual alteration of tissue microstructure that would be inserted in material constitutive description, histological staining was performed on samples. Corresponding computational analyses were performed to mimic the experimental campaign to identify the constitutive material parameters. Results: The absence of any damages to muscle and collagen fibres, which only compacted after mechanical tests, was demonstrated. The experimental tests (ring and membrane flexion tests) showed non-linearity for material and geometry and the viscoelastic behaviour of the native porcine ureter. Computational models were descriptive of the mechanical behaviour ureteral tissue, and the material model feasible. Discussion: This analysis will be useful for future comparison with decellularized tissue for the evaluation of the aggression of cell removal and its effect on microstructure. The computational model could lay the basis for a reliable tool for the prediction of solicitation in the case of tubular substitutions in subsequent simulations.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation

OBJECTIVE

To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option.

METHODS

We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed.

RESULTS

One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis.

CONCLUSION

Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Total intracorporeal laparoscopic ileal ureter replacement in a single position for ureteral stricture based on membrane anatomy

PURPOSE

The aim of this study was to present our initial experience and prove the feasibility of total intracorporeal laparoscopic ileal ureter replacement (TILIUR) in a single position for ureteral stricture based on membrane anatomy.

MATERIALS AND METHODS

Between January 2021 and April 2023, six patients underwent TILIUR in a single position for ureteral strictures based on membrane anatomy. All patients with a past medical history underwent radical hysterectomy with bilateral pelvic lymph node dissection as well as extensive ureteral stricture due to radiotherapy. The procedure is performed completely laparoscopically. Dissection of the digestive system as well as ureteral stricture or renal pelvis is based on membrane anatomy. The surgery is performed in a single position.

RESULTS

TILIUR in a single position for ureteral stricture based on membrane anatomy was successfully performed without open conversion in all patients. Among the 6 patients, 3 patients underwent combined ileal ureter replacement (IUR) and abdominal wall ostomy, 2 underwent unilateral IUR, and 1 underwent bilateral IUR. The mean length of the ileal substitution was 22.83 cm (range: 15-28). The average operative time was 458 ± 72.77 min (range 385-575 min), and the average intraoperative blood loss was 158 mL (range 50-400 mL). The median postoperative hospital stay was 15.1 d (range: 8-32). The median duration of postoperative follow-up was 15 months (range: 3-29 months). The success rate was 100%.

CONCLUSIONS

TILIUR in a single position may be a promising option for ureteral stricture based on membrane anatomy in selected patients. Moreover, it has a positive effect on patients with renal insufficiency and urinary incontinence. Although IUR is difficult and risky, proficient surgeons can perform the procedure safely and effectively.

Oral mucosal graft ureteroplasty versus ileal ureteric replacement: a meta-analysis

OBJECTIVES

To describe outcomes of oral mucosal graft ureteroplasty (OMGU) and ileal ureter replacement (IUR) and determine the relative merits of both procedures.

METHODS

Databases (including PubMed, Embase and Cochrane) were interrogated for eligible trials that assessed outcomes of OMGU or IUR from 2000 to 30 July 2022. The variables analysed were reconstruction success rates, stricture length, hospital stays, perioperative complications and long-term complications.

RESULTS

A total of 23 single-arm studies were included. The pooled reconstruction success rates for OMGU and IUR were 94.9% (95% confidence interval [CI] 91.0%-97.7%) and 85.8% (95% CI 81.0%-90.0%), respectively. Stricture length of patients in the OMGU and IUR groups were 3.73 (95% CI 3.17-4.28) and 11.55 (95% CI 9.82-13.29) cm, respectively. The maximal stricture length repaired by OMGU was 8 cm. The hospital stays were 5.85 (95% CI 3.88-7.82) and 11.55 (95% CI 6.93-16.17) days in the OMGU and IUR groups, respectively. The incidences of low-grade postoperative complications were 13.6% (95% CI 6.9%-20.3%) and 27.3% (95% CI 19.5%-35.1%), high-grade postoperative complications were 4.6% (95% CI 1.8I-8.5%) and 13.0% (95% CI 9.4%-17.1%), and long-term complications (occurred at > 3months) were 9.0% (95% CI 1.7%-20.0%) and 35.4% (95% CI 25.8%-45.6%) in the OMGU and IUR groups, respectively.

CONCLUSION

An OMGU is an effective, minimally invasive, and safe alternative to IUR for the management of long ureteric strictures. OMGU was the preferred treatment for long ureteric strictures, especially obstructed ureter segments of ≤8 cm.

Ileal ureteral replacement for the management of ureteral avulsion during ureteroscopic lithotripsy: a case series

INTRODUCTION

To describe our initial experience with ileal ureteral replacement (IUR) for the management of ureteral avulsion (UA) during ureteroscopic lithotripsy.

METHODS

Between September 2010 and April 2021, ten patients received ileal ureteral replacement for ureteral avulsion during ureteroscopic lithotripsy. Anterograde urography and computed tomography urography (CTU) were applied to evaluate the lesion. Follow-up was performed with magnetic resonance urography and renal ultrasound as well as clinical assessment of symptoms. We retrospectively analysed the clinical data of ten patients treated with ileal ureteral replacement for the treatment of ureteral avulsion.

RESULTS

Four patients underwent open ileal ureteral replacement, two underwent laparoscopic ileal ureteral replacement, and four underwent robotic-assisted ileal ureteral replacement. The mean operative time (OT) was 310 min (range 191-530). The mean estimated blood loss (EBL) was 193 mL (range 10-1000). The mean length of the ileal graft was 21 cm (range 12-25). The median postoperative hospital time was 13 days (range 7-19). All surgeries were effectively completed, and no case required open conversion in laparoscopic and robotic-assisted surgeries. There was no obvious hydronephrosis according to contrast-enhanced computed tomography 3-dimensional reconstruction images without serious complications or progressive hydronephrosis during a median follow-up duration of 51 months (range 5-131), and the success rate was 100%.

CONCLUSIONS

Our initial results and experience showed that ileal ureteral replacement for the management of ureteral avulsion during ureteroscopic lithotripsy is safe and feasible.

Laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures: our experience

BACKGROUND

This study was designed to evaluate the feasibility of laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures of the middle and lower ureters. By observing its curative effect and prognosis, we can provide a safer and reliable treatment option for patients with middle and lower ureteral injury.

METHODS

In this study, of the eight cases under study, five were diagnosed with long-segment ureteric strictures, one had long-segment ureteric avulsion, one was diagnosed with ureteral rupture caused by surgical injury of appendicitis, and the remaining one underwent ureterostomy after ureteral injury. The location of ureteral injury was in the middle lower segment. All eight patients underwent laparoscopic ureteral reimplantation with a Boari flap from January 2018 to October 2021. In this study, two patients were treated with a Boari bladder flap with psoas hitching. All procedures were performed by the same surgeon with over 20 years of experience in urological surgery.

RESULTS

The mean length of ureteric avulsion or ureteric strictures was 7.94 cm (range, 4-15 cm). Laparoscopic ureteral reimplantation with a Boari flap was performed successfully between 120 and 240 min. The mean duration of postoperative hospital stay was 6 days, and no major complications related to the procedure in the perioperative period occurred. Postoperative follow-up showed no obvious hydronephrosis on computed tomography urography or urinary ultrasound in all eight patients. Postoperative reexamination did not reveal any significant hydronephrosis, urinary tract infection, or ureteral reflux, and none of the postoperative renal functions were abnormal.

CONCLUSIONS

Laparoscopic ureteral reimplantation with a Boari flap is safe and feasible for experienced physicians. In our case, the length/width ratio of bladder flap is more than 4:1, with good blood supply and no obvious complications, it provides a longer alternative length.

Bilateral ileal ureter substitution for patients with ureteral strictures secondary to gynecological tumors radiotherapy: a multi-center retrospective study

Background

The selection of treatment for bilateral ureteral strictures caused by radiotherapy in patients with gynecological tumors often brings great challenges to urologists. This study was designed to analyze the characteristics of radiation-induced ureteral strictures and summarize the surgical experience of bilateral ileal ureter substitution.

Methods

We retrospectively collected the medical records of 18 patients between June 2010 and June 2019 who had a radiation-induced bilateral ureteral strictures. Time interval from radiotherapy to the discovery of ureteral stricture was categorized into short-term (less than 12 months) and long-term (over 12 months) groups. All patients received reverse “7” bilateral ileal ureteral substitution. Surgical success was defined as no restenosis, relief of symptoms, and improved/stabilized hydronephrosis.

Results

The patients had been suffered from ureteral stricture for a median of 12 [2–106] months. The mean length of the left and right ureteral stricture was 9.6±2.6 and 8.8±3.2 cm, respectively. The mean length of the ileal graft was 29.1±7.4 cm. The mean operative time was 308.4±70.2 min, and the mean estimated blood loss was 254.7±166.2 mL. The postoperative hospital stays in the short-term group was significantly shorter than that in the long-term group (14.0 vs. 20.6 days, P=0.049). During a median follow-up time of 24.1 (4.5–71.9) months, the success rate was 94.4%. Eight minor complications and two major complications occurred in 7 patients.

Conclusions

Bilateral ileal ureter substitution can be an effective strategy for radiation-induced ureteral stricture in patients with gynecological tumors.

The emerging role of robotics in upper and lower urinary tract reconstruction

PURPOSE OF REVIEW

Developments in robotic reconstructive urology have introduced novel treatments for complex upper and lower urinary tract disease. Short-term and mid-term data demonstrates excellent outcomes and minimal morbidity, suggesting the advanced instrumentation and visualization of robotics represent a new treatment paradigm in patients that are historically difficult to treat. Here we review recent developments in the robotically assisted surgical management of urethral and ureteral strictures.

RECENT FINDINGS

The minimally invasive approach, enhanced precision and reach, and near-infrared fluorescence imaging capabilities of robotic platforms have proven to be valuable additions in reconstructive urology where perfusion is often compromised, or anatomy is distorted. These benefits are leveraged heavily in recent descriptions of robotic-assisted posterior urethroplasty and ureteroplasty. Short-term to mid-term follow-up data for these procedures show excellent patency rates with low morbidity and complication rates when compared with open approaches. Long-term data for these procedures are not yet available.

SUMMARY

The role of robotics in reconstructive urology is being actively investigated. Initial findings demonstrate excellent results with low morbidity in the treatment of upper and lower urinary tract disease. Long-term data will ultimately determine the role of robotics in the reconstructive armamentarium.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents

OBJECTIF

Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US).

MATERIAL

We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion.

RESULTS

22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4μmol/l respectively, P=0.67), nor urinary diversion.

CONCLUSION

KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers.

LEVEL OF EVIDENCE

3.

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience

OBJECTIVE

To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center.

METHODS

Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded.

RESULTS

Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries.

CONCLUSIONS

Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures

Background

To summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures.

Methods

This study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference.

Results

All surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients.

Conclusions

With the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy

PURPOSE

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios.

METHODS

From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures.

RESULTS

A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2-6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P < 0.001). At a mean follow-up of 12.8 months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches.

CONCLUSION

Laparoscopic and robotic onlay flap/graft ureteroplasty can be safe and feasible to repair long proximal/middle ureteral strictures while robotic procedures showed higher efficiency, faster recovery but higher cost. Our algorithmic strategies may provide beneficial references for their standardization and dissemination into clinical care.

A new technique for ureteral reconstruction using lingual mucosa grafts in a beagle model

PURPOSE

To investigate the feasibility of ureteral reconstruction using lingual mucosa graft (LMG) and evaluate the histological changes of the engrafted LMG in beagles.

METHODS

Twelve male beagle dogs were randomly divided into groups A, B and C (n = 4). A ventral ureteral defect was created by excising half of the ureteral wall. The length of the defect was 3 cm, 6 cm, and 10 cm in groups A, B, and C, respectively. The LMGs were harvested and employed to repair the ureteral defects in onlay fashion. Two dogs per group were sacrificed after 6 months, with additional two dogs per group sacrificed after 12 months. Intravenous urography (IVU) and macroscopic examination were performed to evaluate renal function and ureteral patency. Histological changes in the engrafted LMGs during the tissue incorporation process were assessed by histological analysis.

RESULTS

There were no postoperative complications. Only one dog in group C developed a mild stricture near the proximal anastomosis. In the remaining 11 animals, IVU showed normal renal function and a wide ureteral caliber without stricture or fistula. The diameter of the LMG-reconstructed ureter was greater than that of the proximal and distal ureter (each p value < 0.01). The LMGs survived in situ with newly formed capillaries. The epithelium of the lingual mucosa resembled the urothelium in postoperative 12 months.

CONCLUSION

This new technique for ureteral reconstruction using LMGs is feasible. This approach is a promising alternative clinical treatment for curing long ureteral strictures.

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.

Appendiceal Onlay Flap Ureteroplasty for the Treatment of Complex Ureteral Strictures: Initial Experience of Nine Patients

Purpose: To evaluate the onlay technique using the appendix for ureteral reconstruction and describe the initial experience of nine operations performed by one surgeon. Methods: Nine patients with complex ureteral strictures who underwent appendiceal onlay flap ureteroplasty since May 2019 were recruited from our RECUTTER database. There were seven men and two women, with a mean age of 38.9 years; four patients underwent robot-assisted laparoscopic surgery, and five patients underwent traditional laparoscopic surgery. All patients had iatrogenic injuries of the ureter after treatment of stone disease. Seven patients had proximal ureteral strictures, and two had midureteral strictures. The mean stricture length of the nine patients was 3.9 (range 3-4.5) cm. Nephrostomy was performed in seven patients before they presented to our center, and the other two patients had indwelling Double-J ureteral stents. Results: All nine operations were effectively completed without open conversion. The mean operation time was 182 (range 135-220) minutes, the mean estimated blood loss was 71 (range 20-100) mL, and the mean length of postoperative hospital stay was 9 (range 6-12) days. No postoperative complications of high grade (Clavien-Dindo III and IV) occurred within 30 days of surgery. All the patients had their Double-J ureteral stents and nephrostomy tubes removed after complete ureteroscopy and upper urinary tract urodynamic examination or CTU, which showed that the anastomosis healed well and that the urinary tract was unobstructed, respectively. The objective success rate was 100% (all the patients had endoscopic and radiographic resolution of their ureteral strictures). The subjective success rate was 88.9% (one patient developed recurrent back discomfort and a 0.5 cm calculus was found in her renal pelvis). Conclusions: Appendiceal onlay flap ureteroplasty is a viable and effective technique for treating complex proximal and middle ureteral strictures at the right side.

Intestinal interposition for complex ureteral reconstruction: A comprehensive review

Long ureteral defects have remained a challenge to urologists for a long time. Bowel interposition, including ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance, even though it is a complicated procedure and associated with some potential complications. Mucus obstruction and metabolic disorders are common complications of intestinal substitution. To circumvent these troubles, modified techniques, such as tapering the bowel graft, intestinal onlay flap and the Yang-Monti procedure, are used. In particular, Yang-Monti ileal ureter replacement is a highly effective option for ureteral reconstruction, and the incidence of complications would be significantly reduced in select patients. After being combined with the Boari flap or psoas hitch technique, the length of intestinal segment used can also be significantly reduced. Most recent long-term results suggest that ileal ureter replacement with antireflux anastomosis seems to be remarkably free of complications, and we highly praise the distal nipple valve technique. Appendiceal interposition is available for patients with normal appendix, and usually this procedure is limited to reconstructing the right ureter. Appendiceal onlay ureteroplasty has emerged as a feasible and effective option to manage patients with complex proximal and mid-ureteral strictures of the right side. The colon is rarely used for ureteral reconstruction because of its large caliber and mucous surface area. However, a reconfigured colon segment is a good substitute to reconstruct long-segment ureteral defects, and long-term follow up confirmed minimal complications and improved renal function. This review provides a comprehensive perspective on complex ureteral reconstruction and replacement using intestinal segments, in particular, ileal ureter replacement.

Post ureteroscopic stone surgery ureteral strictures management: a retrospective study

PURPOSE

To share experience in managing ureteral strictures following ureteroscopic lithotripsy.

METHODS

Ninety five patients diagnosed as ureteral strictures after ureteroscopic lithotripsy between January 2013 and January 2018 were included. 53 received endourological treatment, 34 underwent reconstruction, 6 underwent nephrectomy for severe renal impairment, and 2 chose routine ureteral stent replacement. Therapeutic success was defined as absence of clinical symptoms and radiologic relief of obstruction.

RESULTS

The follow-up time ranged from 13 to 57 months, with a median time of 24. It lasted more than 13 months in all patients, exception for 2 nephrectomies. Two patient groups including 69 endourological procedures and 37 reconstructions were used to compare therapeutic effects and complications. The overall success rate was 60.9% (42/69) in endourological intervention vs. 97.3% (36/37) in reconstruction (p < 0.001), while 74.4% (29/39) patients with stricture less than 1 cm and 68.8% (33/48) patients with mild-to-moderate hydronephrosis achieved success in endourological group. All except 1 failure appeared within the first year postoperatively. Subgroup analyses for endourological procedures revealed significant differences in the success rate of different stricture lengths and hydronephrosis (p = 0.004 and p = 0.043). Multivariate Cox regression analysis indicated that reconstruction was significantly related to a more successful outcome, compared with endourological procedures (HR 0.052, 95% CI 0.007-0.394, p = 0.004).

CONCLUSION

Reconstruction performs better than endourological procedures in surgical outcome. Endourological procedure provides an acceptable success rate in patients with stricture shorter than 1 cm and slight hydronephrosis. Most stricture recurrence appeared within the first year postoperatively.

Feasibility of Boari Bladder Flap Procedure in Patients With Heterotrophic Renal Transplant

OBJECTIVES

Our goal was to investigate the safety and efficacy of the Boari bladder flap procedure in patients who received either allogeneic or autotransplant of kidneys.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of all patients with either allogeneic or autotransplant of kidneys who also underwent Boari bladder flap procedures between January 2007 and January 2018. Boari bladder flap was preferred in management of ureteral com-plications after allogeneic renal transplant or it was combined with renal autotransplant when ureteral length was not sufficient to allow ureterovesical anastomosis in patients with ureteral injury.

RESULTS

Boari bladder flap procedures were performed in 14 patients who had undergone heterotrophic renal transplant. Nine patients had undergone allogeneic renal transplant, and 5 patients had renal auto-transplant. The mean age of patients was 41.7 ± 13.4 years. The 5 patients with renal autotransplant procedures had simultaneous Boari flap procedures due to ureteral avulsion during retrograde ureter-orenoscopic surgery for urolithiasis. For the entire cohort, mean preoperative and postoperative (at month 1) serum creatinine levels were 1.42 ± 0.71 and 1.13 ± 0.43 mg/dL, respectively. At last visit, the mean creatinine level was 1.94 ± 1.88 mg/dL.

CONCLUSIONS

The Boari bladder flap procedure can be a safe and relevant choice in the management of challenging complications after heterotrophic (either allogeneic or autotransplant) renal transplant, allowing minimally invasive urologic surgery, no need for use of bowel segments, and no potential risk for the contralateral kidney.

Preputial Graft Ureteroplasty for the Treatment of Complex Ureteral Stricture: A New Surgical Technique and Review of Literature

Objectives: To present our first experience and 12-month outcomes of the novel technique of onlay preputial graft ureteroplasty (PGU) for complex ureteral stricture.

Methods: In December 2016, open onlay PGU was made on a male patient who have proximal stricture of the right ureter. The length of upper ureteral stricture was 50 mm. A 60 mm in length and 15 mm in width preputial graft was harvested from the ventral side of the penis and placed in the ureter as a ventral onlay for ureteroplasty. Operative time, intraoperative, and postoperative complications were recorded properly. Follow-up was performed via clinical assessment of symptoms, renal ultrasound, MR urography, and nuclear scan renography.

Results: The new technique was effectively performed without any intraoperative and postoperative complications. Residual hydronephrosis in the right side was found through ultrasonography 3, 6, and 12 months and MR urography 6 months postoperatively. But complaint of the patient's pain passed completely.

Conclusions: Within our knowledge, we present the first experience with onlay PGU for proximal ureteral stricture. Twelve-month results indicate that the new technique appears to be an excellent option for proximal ureteral stricture. Our experience is encouraging, and it will find wider application in the complex ureteral lesion.

Clinical reappraisal and state of the art of nephropexy

The diffusion of minimally invasive techniques for renal surgery has prompted a renewed interest in nephropexy which is indicated to prevent nephroptosis in symptomatic patients and to mobilize the upper ureter downward in order to bridge a ureteral defect. Recent publications have been reviewed to present the state of the art of the diagnosis and management of these two challenging conditions and to try to foresee the next steps. The evaluation of patients with mobile kidney can be made relying on diagnostic criteria such as ultrasound with color Doppler and measurement of resistive index, conventional upright X-ray frames after a supine uro-computerized tomography scan and both static and dynamic nuclear medicine scans, always with evaluation in the sitting or erect position. Laparoscopic nephropexy emerges as the current treatment option combining both objectively controlled repositioning of the kidney and resolution of symptoms with minimal invasiveness, low morbidity, and short hospital stay. The use of robotics is presently limited by its higher cost, but may increase in the future. Downward renal mobilization and nephropexy is a safe and versatile technique which has been adopted as a unique strategy or more often in combination with other surgical maneuvers in order to cope with complex ureteral reconstruction.

Left ureteral appendiceal interposition: exercise caution and do not be mislead by postoperative radiological obstruction

Postoperative imaging after appendiceal ureteral interposition may be difficult to interpret, misguiding the urologist towards intervention. We present a case in which radiological obstruction was not endorsed by a 99TcDTPA nephrogram, with favorable outcome after conservative treatment.

Use of the Ileum for Ureteral Stricture and Obstruction in Bilateral, Unilateral, and Single-kidney Cases

OBJECTIVE

To investigate the functional outcomes of ileal ureter replacement for complex ureteral loss, including bilateral and single ureter stricture, as a result of various etiologies.

METHODS

In 2013-2016, 31 patients underwent ileal ureter replacement surgery. The data for their assessments included etiology, combined surgical procedures, ureteral replacement type, postoperative complications, and changes in renal function.

RESULTS

The 31 study patients had a median age of 56.0 (range 18-65) years and were followed for a median of 23.6 (range 6.5-43.2) months. There were 14 bilateral, 12 unilateral, and 5 single-kidney cases. The main indication for surgery was ureteral defects after gynecological surgery and radiation in 24 patients (77.4%). The mean operation time was 370.6 minutes and the median hospital stay was 25.2 (range 6-79) days. Various types of ileal arrangement were performed to cover bilateral ureter loss. After 30 days past surgery, 24 patients (77.4%) were in a stable state and 5 (16.1%) had decreased serum levels of creatinine. Short-term complications greater than grade 3 on the Clavien scale occurred in 10 patients (33.3%), and long-term complications occurred in 27 (87.1%). However, all cases were well relieved by conservative care, and surgical intervention was needed in only 1 case. Apart from 2 patients who died because of the progression of cervical cancer, all patients had stent-free status at 22.4 months.

CONCLUSION

Ileal ureter replacement is a useful reconstructive surgery for complex ureteral loss, such as bilateral and single-kidney cases resulting from various etiologies.

Robotic Buccal Ureteroplasty: a Review of the Current Literature

PURPOSE OF REVIEW

This study aimed to provide an overview of the literature on buccal mucosal ureteroplasty for ureteral stricture disease, with a specific focus on the application of the robotic platform to buccal ureteroplasty.

RECENT FINDINGS

In our review, we highlight the results of Zhao et al. from the New York University School of Medicine Department of Urology, as well as our own results from Temple University Hospital. Zhao et al. published the first series of four patients who underwent robotic buccal ureteroplasty. Mean stricture length was 3.0 cm, and at a mean follow-up of 15 months, all repairs remained patent. We also describe our results in 10 patients who underwent robotic buccal ureteroplasty at Temple University Hospital. Median stricture length was 3.0 cm, and at a median follow-up of 5 months, all repairs remain patent. Robotic buccal ureteroplasty offers a promising option for repair of complex ureteral strictures.

Biofabrication and biomaterials for urinary tract reconstruction

Reconstructive urologists are constantly facing diverse and complex pathologies that require structural and functional restoration of urinary organs. There is always a demand for a biocompatible material to repair or substitute the urinary tract instead of using patient's autologous tissues with its associated morbidity. Biomimetic approaches are tissue-engineering tactics aiming to tailor the material physical and biological properties to behave physiologically similar to the urinary system. This review highlights the different strategies to mimic urinary tissues including modifications in structure, surface chemistry, and cellular response of a range of biological and synthetic materials. The article also outlines the measures to minimize infectious complications, which might lead to graft failure. Relevant experimental and preclinical studies are discussed, as well as promising biomimetic approaches such as three-dimensional bioprinting.

Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results

INTRODUCTION

Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects.

METHODS

We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates.

RESULTS

Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup.

CONCLUSIONS

Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model

OBJECTIVE

To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures.

MATERIALS AND METHODS

Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated.

RESULTS

All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003).

CONCLUSIONS

Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction

OBJECTIVE

To evaluate renal mobilization with downward nephropexy as an adjunct maneuver to facilitate various methods of reconstruction of the upper urinary tract with limited ureteral length.

MATERIALS AND METHODS

We retrospectively reviewed all upper urinary tract reconstructive procedures performed from 2007 to 2015 to identify those requiring downward renal mobilization with nephropexy. Data including concomitant maneuvers, stricture location, prior surgeries, and intraoperative details were analyzed. Success rates, defined by resolution of symptoms and avoidance of further intervention, and complications were evaluated.

RESULTS

Of 92 patients undergoing ureteral reconstruction during the study period, 18 (19.6%) involved renal mobilization with downward nephropexy to gain additional ureteral length (5/7 [71.4%] of ureterocalycostomies, 8/26 [30.1%] of Boari flap bladder reconfigurations, 4/12 [33.3%] of ureteroureterostomies, and 1/12 [8.3%] of ileal ureters). Two-thirds of patients (12/18, 66.7%) had undergone unsuccessful prior open, laparoscopic, or endoscopic reconstruction attempts. Renal mobilization was performed open in 15/18 (83.3%) cases and laparoscopically in 3/18 (16.7%). After renal mobilization, the average distance of downward movement achieved was 3.3 cm (range 3-5 cm). With a mean follow-up of 50.4 months (range 3-87 months), overall success rate defined as ureteral patency was 88.9%, with 2/18 patients (11.1%) requiring a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis.

CONCLUSION

Downward renal mobilization and nephropexy is a safe and versatile technique that can be effectively combined with many other reconstructive maneuvers.

Laparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stricture: initial experience and 9-month follow-up

PURPOSE

We present our initial experience and 9-month outcomes of the novel technique of laparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stricture.

MATERIALS AND METHODS

In June 2015, transperitoneal laparoscopic onlay lingual mucosal graft ureteroplasty was performed on a male patient with proximal stricture of the left ureter. The patient complained with left frank pain. Severe hydronephrosis and proximal ureteral dilatation were noted through ultrasonography and CT scan. The length of upper ureteral stricture was 30 mm including 10-mm occlusion. A 46 mm in length and 15 mm in width lingual mucosa graft was harvested from the ventral of the tongue and placed in the strictured ureter as a ventral onlay for laparoscopic ureteroplasty. Operative time, intraoperative, and postoperative complications were well recorded. Follow-up was performed with renal ultrasound, CT scan, and nuclear scan renography as well as clinical assessment of symptoms.

RESULTS

The new technique was performed successful without intraoperative and postoperative complications. Neither hydronephrosis nor proximal ureteral dilatation in the left side was found through ultrasonography 3, 6, 9 months and CT scan 6 month postoperatively. The left renal function, glomerular filtration rate, had a recovery from 9.6 ml/min preoperatively to 14.0 ml/min at 6-month follow-up, and the patient has no complaints about the donor site and flank pain.

CONCLUSIONS

To our knowledge, we present the initial experience with laparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stricture. With 9-month outcomes, the new technique appears to be an excellent option for proximal ureteral stricture.

Long-term Outcome of Ileal Ureteric Replacement With an Iliopsoas Muscle Tunnel Antirefluxing Technique for the Treatment of Long-segment Ureteric Strictures

OBJECTIVE

To investigate the long-term outcome of ileal ureteric replacement using a proximal antirefluxing technique for the treatment of long-segment ureteric strictures.

PATIENTS AND METHODS

Between January 1997 and December 2013, 41 patients with a long ureteral stricture or defect and 3 patients with unilateral mid-lower ureteral cancer (20 bilateral and 24 unilateral, 28 males and 16 females) were treated by ureteral substitution using a proximal antirefluxing technique. The distal part of the upper ureter (4 cm) was fixed between the psoas muscle and the ileal segment (the iliopsoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis. A successful outcome was defined as the absence of major complications, worsening baseline renal function, metabolic derangements, or obstruction.

RESULTS

One patient with unilateral mid-lower ureteral cancer died 3 years postoperatively because of metastasis, and the remaining 43 patients were followed for 12-180 months (mean 69 months). Intravenous urography showed that the hydronephrosis improved significantly or disappeared after 6-12 months in 34 patients, with improvement in 9 patients. Cystography showed no evidence of ileoureteral reflux. Seven patients needed long-term oral alkalization to prevent hyperchloremic acidosis.

CONCLUSION

In our experience, outcomes following subtotal ureteric replacement are encouraging. The ileal ureter replacement by the proximal antirefluxing technique appears to be a reliable procedure for treating long-segment ureteral stricture and preservation of renal function.

Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction after failed endoscopic intervention: A technical report

Objective

Complex ureteral obstruction is refractory to conventional urological intervention. This report describes a case of laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction.

Methods

Right-side multiple ureteral stones and complicating ureteral obstruction failed an initial attempt of ureteroscopy lithotripsy with simultaneous percutaneous nephroscopy in a 23-year-old male. Laparoscopic ureterolysis with ureteroscopy and percutaneous nephroscopy was used simultaneously to dissect the periureteral adhesions with the patient placed in the Galdakao-modified supine Valdivia position. The ureter was incised to allow the insertion of a ureteral catheter through the twisted ureter, and a guide wire was advanced into the pelvis using ureteroscopy. A double-J stent was placed into the right-side ureter using antegrade percutaneous nephroscopy.

Results

The laparoendoscopic procedure lasted 330 min with an estimated bleeding volume of 100 mL. The patient underwent an uneventful postoperative course, and postoperative follow-up radiography confirmed good positioning of the double-J stent. The double-J stent was removed 3 months after operation. The patient remained asymptomatic within a 13-month follow-up period.

Conclusion

Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy is an effective and safe treatment option for complex ureteral obstruction.

Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients

OBJECTIVE

To evaluate the long-term outcomes of robotic-assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction performed at a tertiary referral centre.

MATERIALS AND METHODS

Data from 250 consecutive patients undergoing RAL UUT reconstruction, including pyeloplasty with or without stone extraction, ureterolysis, uretero-ureterostomy, ureterocalicostomy, ureteropyelostomy, ureteric reimplantation and buccal mucosa graft ureteroplasty, were collected at a tertiary referral centre between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months.

RESULTS

Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure, with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications, none greater than Clavien grade 3.

CONCLUSION

Robotic-assisted laparoscopic UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons.

Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.