Feasibility of Intracorporeal Robotic-Assisted Laparoscopic Appendiceal Interposition for Ureteral Stricture Disease: A Case Report

Ureteral reconstruction with appendiceal interposition graft following resection of retroperitoneal leiomyosarcoma

Ureteral defects can be repaired using a variety of different techniques that depend on the length and position of the defect. Here we describe a case where a long, upper-ureteral defect was successfully reconstructed using an appendiceal interposition graft. A 60-year-old female patient underwent resection of a right-sided retroperitoneal leiomyosarcoma that was encasing the entire upper ureter and obstructing the right kidney. The mass was resected en bloc, leaving behind an 11 cm ureteral defect. The defect was successfully reconstructed with an appendiceal interposition graft. Appendiceal interposition grafts are a feasible and effective approach for ureteral reconstruction in adults following oncologic resection. We describe various technical aspects that optimize the success of ureteral reconstruction.

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.

The Clinical Study of Bladder Flap Ureteroplasty (Psoas Hitch) in the Treatment of Lower Ureteral Injuries and Strictures (19 Cases)

Objective

The aim of this study was to investigate the efficacy and safety of bladder flap ureteroplasty (psoas hitch) in the treatment of lower ureteral injuries and strictures.

Methods

19 patients with lower ureteral injuries and strictures scheduled for a bladder flap ureteroplasty (psoas hitch) in our hospital from January 2020 to January 2021 were recruited. The outcome measures included treatment efficacy and safety.

Results

The operative time, intraoperative bleeding, catheter extubation time, hospital stay, extubation time of ureteral stent, and follow-up time were (125.36 ± 15.38) min, (75.37 ± 11.09) ml, (7.25 ± 1.04) d, (8.76 ± 1.11) d, (46.34 ± 7.66) d, and(19.27 ± 1.27) months, respectively. No serious perioperative adverse reactions were observed, and all the symptoms of patients were relieved.

Conclusion

Bladder flap ureteroplasty (psoas hitch) is safe and effective for the treatment of lower ureteral injuries, with advantages such as less intraoperative bleeding and trauma and rapid recovery, so it is worthy of promotion. This was a retrospective study supervised by the Ethics Committee of Hebei Yanda Hospital.This trial is registered with no. hebYD076.

Stentless repair of left urethral defect with appendiceal interposition: A case report

INTRODUCTION AND IMPORTANCE

Various methods have been described in the repair of ureteral defects. Here, it is aimed to present the repair performed with appendiceal interposition without any double J stent for the left ureteral defect in a patient who was operated on urgently due to obstruction with metastatic and locally advanced colon tumor.

CASE PRESENTATION

An 82-year-old male patient was taken to an emergency operation with the diagnosis of ileus. A tumor involving the left ureter was detected in the sigmoid colon, and a 6 cm defect occurred in the left ureter after resection. This defect was repaired with appendiceal interposition without double J stent placement. Hydroureteronephrosis and stricture were not observed in the patient's 2nd and 8th-month follow-up imaging.

CONCLUSION

The appendix interposition for left ureter reconstruction is a safe and feasible option. Also, this procedure can be done without any ureteral stent.

The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

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.

Appendiceal Interposition for Ureteral Stricture Disease: Technique and Surgical Outcomes

OBJECTIVE

To report our initial experience with ureteral appendiceal interposition (UAI) in a series of adult patients undergoing ureteral reconstruction for ureteral stricture.

METHODS

We retrospectively collected data of patients who underwent UAI for ureteral stricture disease from December 2015 to March of 2020. Success of surgery was defined as one that required no subsequent procedural intervention for recurrent ureteral stricture disease, or loss of kidney function.

RESULTS

Eleven patients underwent UAI for ureteral stricture. Etiologies for stricture disease included radiation exposure, nephrolithiasis, and iatrogenic injury. Median follow-up was 363 days. Three patients had Clavien-Dindo class III complications during their hospitalization. No patient required repeat intervention due to recurrent ureteral stricture disease. On imaging, 9 patients had no obstruction on Lasix renal scan postoperatively, or improvement in hydronephrosis on CT scan. Two patients with poor renal function preop continued to show poor function after surgery.

CONCLUSION

The use of the appendix is a safe and feasible option for ureteral reconstruction in appropriately selected adult patients when primary ureteral repair is not possible.

A Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter

BACKGROUND

Iatrogenic ureteral injuries are devastating complications potentially resulting in irreversible impairment of renal function and/or infectious sequelae. Only few data are available on the management of such injuries to the abdominal ureter.

OBJECTIVE

To report the etiology, perioperative outcomes, and treatment failure rate of different reconstructive surgical interventions for iatrogenic injuries to the abdominal ureter in a contemporary case series.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed consecutive patients who underwent reconstructive surgery for iatrogenic injuries to the abdominal ureter at our academic centers between July 2013 and April 2019. All interventions were performed via either an open or a robot-assisted approach by a single expert surgeon.

SURGICAL PROCEDURE

Different surgical reconstructive procedures, such as Boari bladder flap, ureteroureterostomy, ileal replacement, and pyeloureteroplasty, have been adopted.

MEASUREMENTS

Outcome measures were the etiology of iatrogenic injuries, rate of postoperative complications, and rate of treatment failure, defined as upper urinary tract obstruction requiring permanent urinary drainage.

RESULTS AND LIMITATIONS

Nineteen patients were included. Injuries were consequent to endourological procedures in nine (47.4%), gynecological procedures in two (10.5%), colonic surgery in two (10.5%), vascular surgery in two (10.5%), and other surgeries in four (21.1%) cases. Boari bladder flap was performed in 12 (63.2%), ureteroureterostomy in two (10.5%), ileal substitution in two (10.5%), and pyeloureteroplasty in three (15.8%) cases. Only four (21.1%) procedures were performed robotically. Major postoperative complications were recorded in three (15.8%) patients. After a median follow-up of 16 (interquartile range 12-24) mo, treatment failure was observed in two (15.8%) cases. We accept the limitations of a small retrospective single-surgeon series with preference-based management choice.

CONCLUSIONS

In our series, endourological procedures were the most frequent cause of iatrogenic injuries to the abdominal ureter requiring reconstructive surgery. A Boari bladder flap was the preferred option to bridge extensive ureteral defects. Despite the complexity of such procedures, major postoperative complications were infrequent and treatment failure rate was low.

PATIENT SUMMARY

We report on a contemporary series of patients with disparate iatrogenic injuries to the abdominal ureter requiring complex reconstructive surgery. Despite the difficulty of such procedures, we found that major postoperative complications were infrequent and treatment failure rate was low.

Ureteral substitution with appendix

OBJECTIVE

To study the long-term results of ureteral reconstruction with the appendix in patients with long ureteral strictures.

METHODS

From 1998 to 2019, 26 patients were operated with substitution of extended defects of the ureter with the appendix. There were 22 women and four men (mean age 44.7 ± 11.3 years). One patient had stricture of the lumbar ureter because of a gunshot wound. He underwent substitution of the upper third of the right ureter with the appendix. In the other cases, we carried out substitution of the pelvis part of the ureter with appendix, in four cases from the left side. In the last 22 cases, a novel surgical technique for better appendicovesical anastomosis was carried out: a flap was dissected from the dome of the cecum to increase the diameter of anastomosis.

RESULTS

The postoperative follow-up period was from 1 to 21 years. A stricture of uretero-appendical anastomosis developed in four patients (15.4%). Resection of stricture and re-anastomosis was carried out in one case. In another two cases associated with similar complications, endoureterotomy and ureteral stenting were carried out. One patient was managed with percutaneous nephrostomy. Kidney function was restored in all patients. Good short-term results were achieved in 22 patients (84.6%) and long-term (from 1 to 21 years) results in 25 patients (96.2%).

CONCLUSIONS

In patients with long ureteral stricture, the use of the appendix can help to restore the function of the upper urinary tract.

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.

[Advances in surgical repair of ureteral injury]

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

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.