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Ali-El-Dein B, El-Hefnawy AS, D' Elia G, El-Mekresh MM, Shokeir AA, Gad H, Bazeed MA. Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney. Urology 2021; 152:153-159. [PMID: 33359492 DOI: 10.1016/j.urology.2020.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney. PATIENTS AND METHODS Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome. RESULTS Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted. CONCLUSION Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m2 is considered relative contraindication.
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Affiliation(s)
- Bedeir Ali-El-Dein
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Ahmed S El-Hefnawy
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Gianluca D' Elia
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohsen M El-Mekresh
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ahmed A Shokeir
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hosam Gad
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mahmoud A Bazeed
- Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Xiong S, Zhu W, Li X, Zhang P, Wang H, Li X. Intestinal interposition for complex ureteral reconstruction: A comprehensive review. Int J Urol 2020; 27:377-386. [PMID: 32189401 DOI: 10.1111/iju.14222] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/11/2020] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Shengwei Xiong
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Weijie Zhu
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Xinfei Li
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
| | - Peng Zhang
- Department of Urology, Emergency General Hospital, Beijing, China
| | - He Wang
- Department of Medical Imaging, Peking University First Hospital, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Beijing, China.,Institute of Urology, Peking University, Beijing, China.,National Urological Cancer Center, Beijing, China
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Mogorovich A, Selli C, De Maria M, Manassero F, Durante J, Urbani L. Clinical reappraisal and state of the art of nephropexy. Urologia 2018; 85:135-144. [PMID: 29637838 DOI: 10.1177/0391560317749191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Andrea Mogorovich
- 1 Division of Urology, Department of Translational Research, University of Pisa, Pisa, Italy
| | - Cesare Selli
- 1 Division of Urology, Department of Translational Research, University of Pisa, Pisa, Italy
| | - Maurizio De Maria
- 1 Division of Urology, Department of Translational Research, University of Pisa, Pisa, Italy
| | - Francesca Manassero
- 1 Division of Urology, Department of Translational Research, University of Pisa, Pisa, Italy
| | - Jacopo Durante
- 1 Division of Urology, Department of Translational Research, University of Pisa, Pisa, Italy
| | - Lucio Urbani
- 2 Department of Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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Ubrig B, Janusonis J, Paulics L, Boy A, Heiland M, Roosen A. Functional Outcome of Completely Intracorporeal Robotic Ileal Ureteric Replacement. Urology 2017; 114:193-197. [PMID: 29180072 DOI: 10.1016/j.urology.2017.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess perioperative, clinical, and functional outcomes following completely robotic ileal ureter. METHODS We retrospectively reviewed 7 consecutive patients undergoing completely intracorporeal ileal ureteric replacement between November 2015 and May 2017. One patient had a solitary kidney. A 4-arm technique was used. In 5 patients, additional psoas hitch procedure was performed. Patients had retrograde filling and removal of the ileal stent and transurethral catheter at an average of 14 days postoperatively. Renal ultrasonography, serum analysis, and diuretic renography were performed at follow-up 3 months postoperatively. RESULTS Mean operative time was 328 ± 66.3 minutes and median estimated blood loss was 100 mL (range 50-200); mean length of the ileal substitute was 20.4 cm (range 18-24). No case was converted to open surgery. In 1 patient, there was a prolonged insufficiency of the pyeloileal anastomosis, requiring prolonged stenting. Apart from that, there were no major complications and no open surgical or endoscopic reinterventions. On 3-month follow-up, all patients presented symptom-free, with no signs of obstruction on ultrasound and significantly improved glomerular filtration rate, creatinine levels, and differential renal function (P = .02, 0.03, and 0.046, respectively). Five patients had a diuretic halftime <10 minutes, 2 had a halftime between 10 and 20 minutes. CONCLUSION Completely intracorporeal robotic ileal ureteric replacement results in full functional restoration of the upper tract in cases of long defects of the mid and upper ureter.
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Affiliation(s)
- B Ubrig
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany
| | - J Janusonis
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany
| | - L Paulics
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany
| | - A Boy
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany
| | - M Heiland
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany
| | - A Roosen
- Department of Urology, Augusta-Kliniken, Witten/Herdecke University, Bochum, Germany; Ludwig-Maximilians-University, Munich, Germany.
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Kranz J, Brandt AS, Anheuser P, Reisch B, Steffens J, Roth S. [Ureteral stricture as a late complication of radiotherapy : Possible treatment options]. Urologe A 2016; 56:322-328. [PMID: 28004123 DOI: 10.1007/s00120-016-0294-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.
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Affiliation(s)
- J Kranz
- Klinik für Urologie und Kinderurologie, St. Antonius-Hospital Eschweiler, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland.
| | - A S Brandt
- Klinik für Urologie und Kinderurologie, Helios Klinikum Wuppertal, Wuppertal, Deutschland
| | - P Anheuser
- Klinik für Urologie, Albertinen-Krankenhaus Hamburg, Hamburg, Deutschland
| | - B Reisch
- Klinik für Urologie und Kinderurologie, St. Antonius-Hospital Eschweiler, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland
| | - J Steffens
- Klinik für Urologie und Kinderurologie, St. Antonius-Hospital Eschweiler, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland
| | - S Roth
- Klinik für Urologie und Kinderurologie, Helios Klinikum Wuppertal, Wuppertal, Deutschland
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Takeuchi M, Masumori N, Tsukamoto T. Ureteral reconstruction with bowel segments: experience with eight patients in a single institute. Korean J Urol 2014; 55:742-9. [PMID: 25405017 PMCID: PMC4231152 DOI: 10.4111/kju.2014.55.11.742] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 09/23/2014] [Indexed: 11/18/2022] Open
Abstract
Purpose Although replacement of the ureter with a bowel segment is indicated for large ureteral defects, it is still a challenging technique for urologists. We present our experience and outcome of ureteral reconstruction using bowel segments. Materials and Methods Ureteral reconstruction with bowel segments was performed in eight patients in our institute between 1969 and 2009. We investigated the position and length of the ureteral defect and methods of reconstruction as well as the patients' backgrounds, postoperative complications, and clinical outcomes. Results Five patients underwent ureteral replacement with isolated ileal segments alone. In one patient, the ureter was reconstructed by using the Yang-Monti procedure with the ileum. A colon segment was used in two patients who required bladder augmentation for tuberculous contracted bladder at the same time. Metabolic acidosis occurred in three patients having a solitary kidney and the ureter had to be replaced by a relatively long intestinal segment. Two patients who received preoperative radiation therapy were required to undergo additional operations. Long-term cancer-free survival was achieved in one patient who underwent ileal substitution for low-grade renal pelvic cancer. Conclusions Although ureteral replacement with a bowel segment is a challenging and useful procedure, attention must be paid to the possibility of metabolic acidosis, which is likely to occur in patients having a solitary kidney with renal insufficiency or in patients requiring a long intestinal segment for reconstruction. In addition, preoperative radiation therapy for the pelvic organs may cause postoperative complications.
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Affiliation(s)
- Motoi Takeuchi
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Taiji Tsukamoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Lazica D, Ubrig B, Brandt A, von Rundstedt F, Roth S. Ureteral Substitution With Reconfigured Colon: Long-Term Followup. J Urol 2012; 187:542-8. [DOI: 10.1016/j.juro.2011.09.156] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Indexed: 11/25/2022]
Affiliation(s)
- D.A. Lazica
- Department of Adult and Pediatric Urology, University of Witten/Herdecke, HELIOS-Hospital Wuppertal, Wuppertal, Germany
| | - B. Ubrig
- Department of Adult and Pediatric Urology, University of Witten/Herdecke, HELIOS-Hospital Wuppertal, Wuppertal, Germany
| | - A.S. Brandt
- Department of Adult and Pediatric Urology, University of Witten/Herdecke, HELIOS-Hospital Wuppertal, Wuppertal, Germany
| | - F.C. von Rundstedt
- Department of Adult and Pediatric Urology, University of Witten/Herdecke, HELIOS-Hospital Wuppertal, Wuppertal, Germany
| | - S. Roth
- Department of Adult and Pediatric Urology, University of Witten/Herdecke, HELIOS-Hospital Wuppertal, Wuppertal, Germany
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Abstract
Ureteral injuries are caused by iatrogenic reasons in about 75% of cases. Among urological procedures ureterorenoscopy (URS) is mainly described as the reason for ureteral injury, although complication rates of URS are generally low. Injuries of the ureter are divided into five grades by the AAST. Grades I-II are referred to as partial and grades III-V as complex ureteral injuries. To avoid higher complication rates there should be no delay in confirmation of diagnosis and initiation of therapy. Correct therapy depends on grade of injury. Partial ureteral injuries are treated by endoscopic inlay of a ureteral stent for approximately 14-21 days. In complex injuries endoscopic ureteroureterostomy could be attempted but leads to rather poor long-term results depending on the length of devascularization of the injured ureter.Procedures with and without use of bowel for ureteral reconstruction and replacement have been described. The type of operative procedure should be selected based on location and degree of ureteral injury. Besides ureteral reconstruction, autotransplantation of the affected kidney can be required in individual cases.
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Janek S, Hinkel A, Noldus J. [Singular ileum interposition with bilateral implantation of the ureters after Wertheim-Meigs surgery]. Urologe A 2007; 46:920-2. [PMID: 17541539 DOI: 10.1007/s00120-007-1366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ileum or colon interpositions are qualified procedures for functional ureteral replacement in case of extended ureteric lesions. In most cases, a unilateral interposition is sufficient. Rarely, it is necessary to perform bilateral procedures. We report the case of a 41-year-old female patient with bilateral ureter implantation into a singular ileum segment.
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Affiliation(s)
- S Janek
- Urologische Klinik, Marienhospital Gelsenkirchen, Akademisches Lehrkrankenhaus der Universität Essen, Essen
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Castellan M, Gosalbez R. Ureteral replacement using the Yang-Monti principle: Long-term follow-up. Urology 2006; 67:476-9. [PMID: 16527561 DOI: 10.1016/j.urology.2005.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 08/11/2005] [Accepted: 09/08/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To present the long-term results for 2 patients with ureteral replacement using reconfigured transversely tubularized bowel segments according to the Yang-Monti principle. METHODS Between May 1999 and November 2001, 2 patients underwent ureteral replacement at our institution using a reconfigured ileal segment in one and colon in the other. The first patient was a 33-year-old man who had lost 6 cm of the proximal left ureter after two attempts to repair a ureteral stricture. A reconfigured small bowel tube was interposed between the proximal and distal ureteral stumps after excision of the left ureteral stricture. The second patient was a 66-year-old woman with a poorly functioning right kidney and total bilateral ureteral strictures resulting from radiotherapy for metastatic cervical cancer. She underwent complete left ureteral substitution with a double Monti sigmoid tube in association with a Boari flap. RESULTS With a follow-up of 5.75 and 3.25 years, both patients were clinically doing well with a stable split renal function on mercaptotriglycylglycine renal scan and no evidence of obstruction. The man had required exploratory laparotomy 4 weeks postoperatively to correct a small bowel obstruction secondary to a bowel kink. CONCLUSIONS The transverse tubularized bowel tube is an effective technique for partial and complete ureteral replacement with sustained, good, long-term results. Reconfigured tubes of small or large bowel seem to promote an equally efficient urine transport mechanism that persists unaltered for long periods.
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Affiliation(s)
- M Castellan
- Division of Pediatric Urology, Miami Children's Hospital, Miami, Florida 33155, USA.
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Castillo OA, Litvak JP, Kerkebe M, Olivares R, Urena RD. EARLY EXPERIENCE WITH THE LAPAROSCOPIC BOARI FLAP AT A SINGLE INSTITUTION. J Urol 2005; 173:862-5. [PMID: 15711294 DOI: 10.1097/01.ju.0000152157.25984.ae] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We present our initial experience with the laparoscopic Boari flap for long ureteral strictures. MATERIALS AND METHODS Nine patients underwent a laparoscopic Boari flap procedure at our institution. Eight patients had 4 to 7 cm distal ureteral strictures on excretory urogram and retrograde pyelogram, and 1 had transitional cell carcinoma in the distal right ureter. We analyzed our intraoperative parameters with regard to operative time and intraoperative complications. The operative results assessed were hospital stay, renal function, symptomatic improvement and radiological studies. The patient with ureteral transitional cell carcinoma was excluded from analysis because ureteral stricture etiology differed from that in the other 8. RESULTS Mean operative time was 156.6 minutes. Mean estimated blood loss was 124 cc. There were no intraoperative complications. Mean hospital stay was 3 days. At a mean followup of 17.6 months all patients were symptom-free and had an unobstructed ureterovesical anastomosis on followup excretory urogram. One surgical postoperative complication resolved laparoscopically. CONCLUSIONS The laparoscopic Boari flap is a feasible alternative surgical technique in patients with long distal ureteral strictures. Larger series with longer followup are needed to validate these results vs the standard open technique.
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Affiliation(s)
- Octavio A Castillo
- Section of Urology, Clinica Santa Maria and Department of Urology, Facultad de Medicina Oriente, Universidad de Chile, Santiago, Chile
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Abstract
PURPOSE A new technique for replacing the ureter based on the Yang-Monti principle is introduced to overcome the drawbacks of the classic ileal ureter. MATERIALS AND METHODS Between March 2001 and June 2002 ureteral replacement by ileum was indicated in 10 patients, including 9 with long or multiple strictures due to bilharzial (6), tuberculosis (3) and a low grade lower ureteral tumor (1). The technique involved isolation of a 5 to 7.5 cm. ileal segment, which was further subdivided into 2 or 3 equal parts. Paramesenteric incision along the longitudinal axis of these segments followed by unfolding resulted in a 12 to 18 cm. ileal strip. Tubularization of this strip led to the formation of an ileal tube with a suitable caliber. The latter was implanted into the bladder by submucosal (nonrefluxing) ileovesicostomy. RESULTS Mean followup +/- SD was 9.6 +/- 2.4 months (range 6 to 13). Mean serum creatinine remained stable in all patients. Split kidney function (mercaptoacetyltriglycine clearance) was stable in 7 cases and improved in 3. Antegrade urography revealed dynamic unidirectional nonobstructed flow. Reflux was noted in only 1 case. Excretory urography and/or magnetic resonance urography showed excellent configuration of the substitute without evidence of dilatation or obstruction. CONCLUSIONS The new technique offers certain distinct advantages. A short bowel segment is included with the consequent absence of metabolic complications. It allows construction of an ileal ureter with a suitable cross-sectional diameter without the need for tailoring and makes possible the use of an antireflux technique.
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Affiliation(s)
- Bedeir Ali-el-Dein
- Department of Urology, Urology and Nephrology Center, Mansoura University, Egypt
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