Transureteroureterostomy: 25-year experience with 100 patients

Application of the "Yang-Monti principle" in children with iatrogenic ureteral injuries

BACKGROUND

Iatrogenic ureteral injuries in children are rare, due to its retroperitoneal position. The Yang -Monti ileal substitution serves as a good surgical option in such injuries associated with long segment defects of the ureter.

OBJECTIVES

To review our experience using the Yang Monti principle of ileal ureter substitution in children with long segment ureteric defects and analyse its intermediate term outcomes.

STUDY DESIGN

This was a prospective study, conducted from 2014 to 2019. All children with iatrogenic ureteral injuries with delayed presentations, undergoing the Yang Monti principle of ileal ureter substitution, were included (as illustrated in summary image). These injuries were divided into upper, mid, and distal ureteral injuries and were diagnosed based on a standardized protocol. At follow up, findings of the CT urogram, functional isotope renogram, and renal functions were the key points monitored. The demographic, clinical profile, operative, post-operative complications and follow up data were collated and analyzed.

RESULTS

22 children were diagnosed with iatrogenic ureteral injuries. Of these, 14 children with delayed presentations underwent the Yang Monti principle of ileal ureter substitution. The primary pathology was gangrenous appendicitis (9 cases), calculus cholecystitis (3 cases) and torsion ovary (2 cases). Laparoscopic procedures were the commonest approach for the injury (10). The average age was 11.5 years, with a male predominance. The right ureter was affected in 12 cases. The average time to detection was 7 days. All children underwent an ultrasound guided nephrostomy tube insertion at presentation and the mid ureter (9) was most affected. The mean length of ureteric injury was 3.75 cm. Intra operatively, one ileal segment (2), two ileal segments (11) and three ileal segments (1) were used according to the length of the ureteric defect. Complications were urinary tract infections (2), adhesions (3) and leak (2) which were conservatively managed with no redo surgeries. The median follow up period was 4 years. At follow up CT urogram and isotope diuretic renogram were normal, with preserved renal functions and no metabolic complications in all.

DISCUSSION & CONCLUSION

In children associated with iatrogenic ureteral injuries of long lengths, the "Yang Monti ileal substitution" serves as a good and simple option with lesser complications permitting the preservation of the renal function at follow up.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Transureteroureterostomy revisited: long-term surgical outcomes

PURPOSE

Transureteroureterostomy is a treatment alternative for ureteral obstruction when more conventionally reconstructive techniques are not feasible. We report on long-term outcomes of patients treated with transureteroureterostomy.

MATERIALS AND METHODS

A retrospective chart review of all patients treated with transureteroureterostomy from January of 1985 to February of 2007 was performed.

RESULTS

We identified 63 patients who underwent transureteroureterostomy at our institution. Average treatment age was 31.5 years (range 1 to 83). Transureteroureterostomy was performed for 21 (33%) malignant and 42 (67%) benign indications. Reconstructions were 30 right-to-left (47.6%) and 33 left-to-right (52.4%) with 21 concurrent urinary diversions. There were 16 patients (25.4%) who received radiation before transureteroureterostomy. Postoperative complications occurred in 15 (23.8%) patients and were more common in those undergoing diversion for malignancy. Mean followup was 5.8 years (range 0.1 to 22.2) and 5 patients were lost to followup. Of the 56 patients with followup imaging the transureteroureterostomy was patent in 54 (96.4%) and obstructed in 2 (3.6%). Mean preoperative and recent calculated glomerular filtration rate for this cohort were 62.8 (range 13 to 154) and 71.8 (range 22 to 141) ml per minute, respectively (p = 0.04). Stone disease developed in 8 patients, and was treated with percutaneous nephrolithotomy (2), spontaneous passage (2), ureteroscopy (1) and surveillance (3). Subsequent urological intervention was required for obstruction or revision in 6 (10.3%) patients.

CONCLUSIONS

We demonstrated the long-term safety and effectiveness of transureteroureterostomy with sustained improvement of renal function compared to preoperative status. Recurrent stricture, distal obstruction and stone disease occur in a small percentage of patients, and can be treated in most with minimal intervention.

Successful transureteropyelostomy after heminephrectomy of a bilateral hydronephrotic horseshoe kidney: a case report

INTRODUCTION

Horseshoe kidney is a rare congenital malformation that is found in approximately 0.25% of the general population and usually remains asymptomatic.

CASE PRESENTATION

We report a successful transureteropyelostomy after heminephrectomy of the non-functional right moiety in a 25-year-old man with horseshoe kidney who had a combined 50% functional loss and hydronephrosis due to multiple distal ureteral strictures on the functionally remaining left side. Continuous ureteral stenting of the remaining part of the former horseshoe kidney was avoided during a follow-up of 2 years.

CONCLUSION

Urologists are often faced with technically difficult cases that are not responsive to standard operative procedures, and this case illustrates an individual surgical approach in a clinical situation.

Transureteroureterostomy allows renal sparing radical resection of advanced malignancies with rectosigmoid invasion

BACKGROUND

In case of advanced colorectal cancer or other malignancies with pelvic involvement, tumor invasion of the ureter may afford partial ureteral resection for curative multivisceral resection. One preferable approach for the primary reconstruction of the urinary tract to preserve the ipsilateral kidney and maintain normal urinary function is transureteroureterostomy, i.e. termino-lateral anastomosis of both ureters.

MATERIALS AND METHODS

Between June 2001 and August 2004, 15 multivisceral en bloc resections including a distal tumor-infiltrated ureteral segment were performed. Reconstruction was achieved by transureteroureterostomy with or without additional insertion of double J stents. Clinical outcome and especially complications of the urinary tract were monitored within the follow-up-period until August 2005.

RESULTS

Post-operative course was uncomplicated in 12 cases and double J stents were removed after ultrasound control on the 14th post-operative day. Percutaneous nephrostomy was post-operatively necessary in three patients who were initially operated without insertion of double J catheters: two suffered from leakage of the transureteroureterostomy and one patient had bilateral hydronephrosis due to stenosis of the transureteroureterostomy. After 6 weeks, percutaneous nephrostomy could be removed and urine flow was uncomplicated in all three patients.

CONCLUSION

For patients with advanced colorectal cancer or other pelvic malignancy, transureteroureterostomy is a favourable technique for definitive reconstruction of the urinary tract whenever tumor resection affords partial ureteral resection. Intra-operative insertion of double J stents into both ureters is highly recommended to prevent leakage or stenosis of the anastomosis.

Laparoscopic Transureteroureterostomy: A Novel Approach

PURPOSE

We describe the feasibility and short-term results of laparoscopic transureteroureterostomy in children.

MATERIALS AND METHODS

We performed transperitoneal laparoscopic transureteroureterostomy with a 4-trocar technique in 3 children with a mean age of 63 months (range 18 to 105). Diagnoses were unilateral ureteral obstruction after cross-trigonal reimplantation for vesicoureteral reflux (1 patient), unilateral refluxing megaureter (1) and ureteral injury after bladder diverticulectomy (1). Cystoscopy, retrograde pyelogram and stent placement in the recipient ureter were performed at the beginning of each case. The anastomoses were carried out with running 6-zero reabsorbable sutures at the level of the pelvic bream. An abdominal drain and Foley catheter were left indwelling for 1 to 3 days.

RESULTS

All cases were performed successfully. Postoperative course was uneventful except for a transient urinary leak, and patients were discharged home on postoperative day 2 to 4. At a mean followup of 6 months all patients were clinically well, with normal kidney function and blood pressure, and no significant hydronephrosis.

CONCLUSIONS

Based on our initial experience, laparoscopic transureteroureterostomy is safe and effective, and is associated with little blood loss, minimal analgesia requirements, fast recovery and excellent cosmetic results. We believe that in selected cases in which transureteroureterostomy is the chosen technique a laparoscopic approach is advantageous.

Ureteral reconstruction for retroperitoneal tumors in children

PURPOSE

Removal of solid tumors of the pelvis and abdominal cavity may require resection of an involved ureteral segment. Ureteral stricture can also be a result of intense therapy. We present our experience with urinary reconstruction in this situation.

METHODS

A retrospective review of pediatric oncology patients with solid abdominal/pelvic tumors who underwent a ureteral reconstructive procedure was done. Institutional review board wavier was obtained for the review. Patient data were collected on diagnosis, procedures performed, renal function, and follow-up.

RESULTS

Thirteen patients were identified: 8 male and 5 female. The mean age at surgery was 10.1 years. The most common reason for surgery was en bloc tumor resection (n = 8) followed by ureteral strictures (n = 3). The Boari flap, Leadbetter-Politano reimplantation, and psoas hitch were the most common procedures preformed. Follow-up studies included measurements of serum urea nitrogen/creatinine levels as well as renal scans to assess functional status; 2 patients had elevated serum urea nitrogen/creatinine levels at follow-up. The mean follow-up time was 18 months; 4 patients died-none was secondary to renal complications. There were no local tumor recurrences.

CONCLUSIONS

Abdominal and pelvic tumors frequently involve the ureter, and their removal should not necessitate acceptance of poor surgical margins. Complete surgical resection of tumor including involved ureteral segments can prolong survival in patients with extensive abdominopelvic cancers. In another group of patients, ureteral strictures arise secondary to therapy and reconstruction may preserve renal function.

Comparison of Ileal Conduit and Transureteroureterostomy with Ureterocutaneostomy Urinary Diversion

INTRODUCTION

We compare the postoperative early and late complications of patients who had undergone ileal conduit (IC) urinary diversion and transureteroureterostomy (TUU) with ureterocutaneostomy (UC) urinary diversion during the same interval and by the same surgeons.

MATERIALS AND METHODS

Between 1992 and 2004, we performed TUU with UC urinary diversion in 27 men and 7 women (group I) and ileal conduit urinary diversion in 57 men and 10 women (group II). The mean age of the TUU with UC diversion and the ileal conduit patients was 57+/-11.2 (range 51-76) and 64+/-12.6 (range 54-76) years, and the mean follow-up was 37 (range 14-52) and 56 (range 14-72) months, respectively. The 6F or 8F stents were used routinely.

RESULTS

Of 34 TUU with UC cases 8 (23.52%) had early postoperative complications and 2 (5.88%) had early reoperation rates, whereas 11 (16.42%) of 67 ileal conduit cases had early postoperative complications and 4 (5.97%) had early reoperation. The mean hospital stay was 7 (range 5-25 day) and 11 (range 7-34 day) days for each group, respectively. Of the TUU and UC cases, 6 (17.64%) had late complications and 3 had (8.82%) late reoperation, whereas 14 conduit cases (20.89%) had late complications and 6 had (8.9%) late reoperation. Early postoperative complications were defined as those that occurred before hospital discharge or within 30 days from the date of surgery and late complications were defined as those occurring greater than 30 days from the date of surgery as previously described. In group I, the mean operative time was 170 min (range 120-325) compared with 260 min (range 170-473) in group II. The mean blood loss in group I was 474 ml (range 250-1,400) and 589 ml (range 300-1,700) in group II (p>0.05).

CONCLUSIONS

Our results suggest that patients undergoing a TUU and UC diversion have no additional risk of reoperation and the TUU with UC urinary diversion is a safe procedure with postoperative early and late complications.

Principles of ureteric reconstruction

The principles of ureteric reconstruction are not different from those of reconstructive urology in the rest of the urinary system. The importance of ensuring good vascular supply, complete excision of pathological lesions, good drainage and a wide spatulated and tension-free anastomosis of mucosa to mucosa remain paramount. Although time of diagnosis is the most single most adverse factor affecting outcome, the majority of ureteric injuries still present postoperatively, and delays in diagnosis are the rule rather than the exception. Successful management requires early and definitive intervention using endoscopic means or percutaneous drainage and stenting where possible. Failing this, a number of open surgical options to foreshorten the course of the ureter should be implemented. Most ureteric injuries below the pelvic brim can be treated easily with a ureteroneocystostomy using a bladder elongation procedure or a Boari flap. Mid and upper ureteric injuries above the pelvic brim, however, can be repaired with a spatulated ureteroureterostomy if the defect is small. In those with extensive ureteral loss, measures such as mobilizing the kidney, transureteroureterostomy, renal autotransplantation and ureteral substitution using small bowel may be required. Artificial ureteral substitutes may be an alternative in selected cases.

Transureteroureterostomy in childhood and adolescence: long-term results in 69 cases

PURPOSE

We analyzed a series of 69 transureteroureterostomies to evaluate long-term results and specify current indications.

MATERIALS AND METHODS

Between 1969 and 1998 transureteroureterostomy was performed in 32 females and 37 males with a mean age of 8.6 years. Surgery was done to avoid repeat or difficult ureteral reimplantation after multiple failed procedures in 22 cases and to create a continent ureteral conduit for intermittent catheterization in 23. Other indications included undiversion in 8 cases, ureterocystoplasty in 6, diversion in 4, the Kropp procedure in 3, massively dilated megaureter in 2 and ureteral necrosis in 1. Of the 69 patients 6 were lost to followup and 63 were followed at least 1 year (median 6).

RESULTS

A total of 63 patients were regularly monitored by clinical observation and morphological investigation, including ultrasound, excretory urography and cystography. In 50 cases (79.4%) results were good with no upper urinary tract dilatation. All initially normal donor ureters remained normal. Of 51 initially dilated donor ureters 40 (78.4%) improved or returned to normal, while 20 of 27 initially dilated recipient ureters (74.1%) improved or returned to normal. Serious complications in 3 cases (4.3%) involved anastomotic leakage, ischemic stenosis of the common ureteral trunk and progressive deterioration of function in 1 kidney requiring nephrectomy 3 years postoperatively. Reoperation was successful in the former 2 cases.

CONCLUSIONS

With careful attention to technique transureteroureterostomy represents a safe and reliable procedure with well-defined indications in pediatric urology.

Laparoscopic transureteroureterostomy: demonstration of its feasibility in swine

PURPOSE

To evaluate the feasibility of laparoscopic transureteroureterostomy (TUU) in a porcine model.

MATERIALS AND METHODS

Nine female pigs had bilateral ureteral stents placed 3 weeks prior to surgery. At surgery, a left-to-right laparoscopic TUU was performed. Ureteral stents were placed across the anastomosis in seven cases. Six weeks after surgery, the stents were removed. After an additional 3 weeks, an excretory urogram, retrograde ureteropyelogram, and ureteroscopic examination of the anastomosis were performed. Serum creatinine assay and urine cultures were performed at regular intervals. Antibiotic prophylaxis was used for 1 week after each procedure.

RESULTS

Of the nine animals, eight underwent successful laparoscopic TUU. Excretory urograms revealed prompt function and washout in all these cases. One animal developed an anastomotic stricture; in this animal, the ureters had remained nondilated after initial stent placement. Serum creatinine values remained within the normal range for all animals undergoing successful surgery. Additional complications included one urinary tract infection and one postoperative ileus, which were treated without difficulty. The operative time ranged from 2.5 to 6 hours, with shorter procedures later in the series.

CONCLUSIONS

Laparoscopic TUU is practical in the porcine model. It may prove to be an alternative to an open TUU in patients with lower ureteral lesions when ureteroneocystostomy is not feasible.

Lower ureteral reconstruction

Lower ureteral reconstruction is commonly performed in instances of congenital anomalies and ureteral injury. Keys to a successful outcome are an understanding of ureteral anatomy, familiarity with the principles of tissue handling, and the knowledge of various techniques of repair. This article presents some important and useful reconstructive techniques that can be considered in the management of patients with congenital anomaly or lower ureteral injury.

Transureteroureterostomy and terminal loop cutaneous ureterostomy in advanced pelvic malignancies

Transureteroureterostomy was combined with terminal loop cutaneous ureterostomy, without complications, in 8 patients with advanced pelvic malignancy and a poor prognosis. Urinary diversion was palliative in all patients and followed pelvic exenteration in 4, debulking of pelvic tumor in 2 and radical cystectomy in 1, while 1 had inoperable bladder cancer. All patients had at least unilateral hydroureteronephrosis preoperatively. In each case a postoperative excretory urogram revealed significant improvement of the hydroureteronephrosis and the serum creatinine improved or stabilized. No patient had ureteral stomal stenosis or retraction. Mean survival was 5 months, with the longest survival being 1 year. Transureteroureterostomy in conjunction with terminal loop cutaneous ureterostomy is an effective technique of urinary diversion in selected patients with a poor prognosis and advanced pelvic malignancy, decreasing operative time while avoiding the morbidity associated with a ureterointestinal operation or nephrostomy.

Transureteroureterostomy with cutaneous ureterostomy: a 25-year experience

We reviewed 67 patients who underwent transureteroureterostomy with cutaneous ureterostomy for benign (32) and malignant (35) disease in regard to the indications for and complications of the procedure. The most common complications included urine leakage at the ureteroureterostomy, stomal stenosis and calculus formation. Renal function improved or remained stable in 75% of the patients. Transureteroureterostomy with cutaneous ureterostomy is a viable alternative diversion technique in a select group of patients.

Surgical management of urinary incontinence in children

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

The expanded role of transureteroureterostomy in pediatric urology

Transureteroureterostomy was used in 31 patients as a component in urinary undiversions, salvage procedures for failed reimplants/reconstructions and diversions with a sigmoid antirefluxing conduit or end cutaneous ureterostomy, as well as an adjunct to reimplantation procedures complicated by an abnormal bladder that precluded reimplantation of more than 1 ureter. Reconstruction in 29 patients involved procedures that changed the drainage of the recipient ureters for various reasons, including obstruction, reflux, undiversion and diversion. A neurogenic bladder was present in 26 patients and an additional 4 patients had a significant bladder pathological condition. Both ureters were dilated in 17 patients, while 1 was dilated in another 6. This series illustrates the versatility and confirms the success of transureteroureterostomy in high risk, complicated reconstructive urological procedures in children.

Transuretero-ureterostomy--a review of its use in modern paediatric urology

Transuretero-ureterostomy (TUU) was performed on 55 patients with a mean age of 10 years at operation and a mean follow-up of 4 years. The indications for this procedure are described and, if followed, it is safe and easily performed. The indications for its use may be as a primary procedure for unilateral ureteric pathology, as a salvage procedure, after failed ureteric reimplantation or as part of a urinary undiversion. There have been no deaths and only one patient later required a nephroureterectomy.

Transureteroureterostomy with cutaneous ureterostomy for permanent urinary diversion

Transureteroureterostomy with cutaneous ureterostomy was used for permanent urinary diversion in 18 patients. No early complications occurred, but late complications arose in two patients. Because of its simplicity, this procedure should receive more frequent consideration for permanent urinary diversion. A low complication rate can be achieved by adherence to certain technical principles.