Nondismembered ureteroplasty for congenital midureteral stenosis: a new application of an old technique

Robot-Assisted Laparoscopic Heineke-Mikulicz Ureteroplasty for Congenital Mid-Ureteral Stricture and Ipsilateral Distal Megaureter Repair in a Child

Background: Congenital mid-ureteral stricture (CMUS) is a rare diagnosis almost exclusively repaired with ureteroureterostomy in infancy or early childhood. Case Report: We describe a unique case of a 2-year-old child with both a CMUS and ipsilateral obstructed megaureter, which was addressed in a single operative setting using a robotic Heineke-Mikulicz nondismembered ureteroplasty for the CMUS and a dismembered tapered extravesical ureteral reimplant for the obstructed megaureter. Conclusion: Compared with ureteroureterostomy, a nondismembered ureteroplasty for CMUS minimizes the risk of ureteral vascular compromise and can be particularly beneficial in cases where the affected ureter requires additional reconstruction. Use of robot-assisted technology for complex ureteral reconstruction in the pediatric population is safe and effective.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

[Clinical characteristics and outcomes of congenital midureteral stricture detected by fetal ultrasonography]

OBJECTIVES

Congenital midureteral stricture (CMS), which develops from obstructive lesion between pyeloureteral junction and ureterovesical junction, is relatively rare and its clinical condition and therapeutic strategy have not yet been established. We analyzed the clinical characteristics and surgical outcomes of CMS.

PATIENTS AND METHODS

From November 2006 to December 2012, out of 137 patients presented with congenital hydrohephrosis, we identified 4 pediatric patients diagnosed with CMS at our institutions. We retrospectively investigated clinical characteristics and surgical outcomes in these 4 patients.

RESULTS

Three boys and one girl were identified in this study. All patients were detected hydronephrosis by fetal ultrasonography. The median age at the diagnosis of CMS was 1 year and 11 months. Three patients had obstructive lesion in left side and 1 patient in right. CMSs were located at the level of L4 in 2 patients, and at the level of L5 and S1 in each 1. Split renal function was decreased less than 45% in 3 of 4 patients. Ipsilateral pyeloureteral junction obstruction and ipsilateral hypoplastic kidney were identified in 2 and 1 patient, respectively. One patient developed urosepsis and underwent nephrostomy. Partial ureterectomy and ureteroureterostomy, pyeloplasty were performed in 3 and 1 patient, respectively. Extrinsic obstruction was detected in just 1 patient intraoperatively. In all patients, there were no protruded lesion and atrophied, fibrotic and ischemic muscles were not detected in pathological finding. Neither urinary tract infection nor recurrence of obstructive lesion was detected in all patients at the mean follow-up period of 3 years and 1 month.

CONCLUSION

We analyzed the clinical characteristics of 4 pediatric patients with CMS. In order to prevent critical infection and maintain renal function, it could be considered that surgical intervention is undertaken just after making the diagnosis of CMS.