Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients

Ileal ureter replacement and ileocystoplasty for the treatment of bilateral ureteral strictures and bladder contracture: technique and outcomes

BACKGROUND

The aim of this study was to explore the feasibility of ileal ureter replacement and ileocystoplasty for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture.

METHODS

A retrospective review of clinical data from seven patients who underwent bilateral Ileal Ureter Replacement and ileocystoplasty from April 2019 to February 2023 was conducted. The surgeries were performed using open, laparoscopic, and robot-assisted laparoscopic approaches. Baseline characteristics, perioperative, and mid-term results of the patients were collected. Follow-up period of 3-28 months. A detailed description of the technique was reported.

RESULTS

The mean age of the patients was 52.86±6.06 years. The average duration of surgery was 365±28.54 minutes, and the estimated intraoperative blood loss was 357.14±184.06 mL. The mean length of harvested ileum was 37.86±8.40 cm. The preoperative serum creatinine level was 88.02±18.05 μmol/L, postoperative day 1 creatinine level was 90.7±12.93μmol/L, postoperative 3-month creatinine level was 93.77±33.34 μmol/L, and the mean creatinine level at the last follow-up was 94.89±27.89μmol/L. The postoperative bladder capacity was 249.43±32.50 mL on average. The average length of hospital stay was 26.57±15.46 days. No complications of Clavien-Dindo grade 3 or higher were observed. During the follow-up period, no patients experienced deterioration of renal function after surgery.

CONCLUSIONS

Bilateral ileal ureter replacement and ileocystoplasty are effective surgical technique for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture caused by radiation therapy.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Ileal Ureter Utilization in Patients With Previous Urinary Diversions

OBJECTIVE

To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions.

METHODS

A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications.

RESULTS

Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy.

CONCLUSION

Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

Single ileal segment in a cat-tail configuration for bilateral ureteric strictures

Introduction

Management of bilateral long length ureteric strictures is difficult with few options for reconstruction. In this report, we describe our experience with the use of a single, 15- 20 cm ileal segment for reconstruction of bilateral long length (involving more than 2/3^rd ureter) ureteric strictures.

Patients and Methods

A retrospective analysis of 5 cases operated between 2015 and 2020for bilateral long length ureteric strictures, using a single segment ileal interposition in a cat tail configuration was performed. We evaluated renal function, surgical success, incidence of urinary tract infection and complications of the procedure. Surgical success was defined as an asymptomatic patient with no hydronephrosis and/or prompt drainage of the kidney on radiological investigations.

Results

The average age of presentation was 42.8 ± 7.4 years (33-53) years). All the cases were secondary to a gynaecological intervention. The mean creatinine prior to surgery was 0.81 ± 0.36 mg % (range 0.5 -1.4 mg%). Mean duration of follow-up was 28.6 ± 20.6 months (Range 10 - 56 months). Mean hospital stay was 14.4 ± 3.36 days (range 12-20 days). Two patients developed ileus and one patient developed deep venous thrombosis in the post-operative period. One patient developed pyelonephritis within one month of surgery. There was no deterioration of renal function with the mean serum creatinine at last follow-up being 0.9 ± 0.36 mg% (range 0.6 - 1.5 mg%).

Conclusion

The use of an ileal segment in cat-tail configuration for bilateral simultaneous ileal replacement is a feasible and safe option. The medium-term result states that it is effective in the preservation of renal function and provides a good conduit for drainage.

28 years of functioning of the ileal ureter - own experience and systematic review

A SHORT INTRODUCTION

Irreversible ureteral damage is a rare and challenging problem for pediatric urologists. Ileal replacement has become one of the limited surgical options for ureteral reconstruction. Only a few papers have examined the results of the ileal ureter and renal function outcomes. Furthermore, there are even fewer papers showing patients with the intestinal ureter, which is used to drain urine from a solitary kidney in early childhood.

AN OBJECTIVE

To perform a systematic review and analyze available cases of the long-term function of the "neoureter" and differences in the surgical approach. To present the case of a 29-year-old female with a history of ileal replacement of the ureter in a solitary kidney which was performed in this patient at the age of 14 months.

STUDY DESIGN

PubMed and Scopus were used to search for eligible articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were strictly followed. Based on the titles, abstracts, and full-text reviews, 77 articles were analyzed, of which only 23 were directly related to pediatric cases of our interest. Medical records of the female patient, who has been treated in our center since 1991, were retrospectively described and reviewed.

RESULTS

Of 23 papers, we identified 75 cases of children who underwent ureteral substitution. The outcomes of the procedure are satisfactory and acceptable. The presented case of the female patient shows a good therapeutic option.

CONCLUSION

Ileal ureteral reconstruction is a safe and effective therapeutic option (even in a long-term follow-up). Despite many problems and complications, it allows preservation of renal and bladder function and social dryness.

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.

Complex Ureteral Reconstruction in Kidney Transplantation

OBJECTIVES

Despite advances in surgical techniques and organ preservation, transplant ureteric strictures remain a common complication in kidney transplantation. A variety of endourological and surgical techniques have been utilized; however, there is a lack of consensus on the optimal modality in dealing with these complex cases.

MATERIALS AND METHODS

We present challenging ureteral reconstruction cases after failed attempts at ureteral dilatation, failed conventional open repairs, and/or with bladder dysfunction.

RESULTS

All renal allografts were salvaged by successful use of bladder Boari flap and intestinal segment interpositions/diversions.

CONCLUSIONS

Operative repair remains the most durable and successful approach, and minimally invasive options should be reserved for nonsurgical candidates, with consideration of a single attempt in patients with early, distal, short (<2 cm), nonischemic strictures.

Minimally invasive ileal ureter replacement: Comparative analysis of robot-assisted laparoscopic versus conventional laparoscopic surgery

BACKGROUND

This study is an initial comparative analysis of perioperative and intermediate-term functional outcomes between patients who underwent robot-assisted laparoscopic (RALS) or conventional laparoscopic surgery (LS).

MATERIALS AND METHODS

A total of 25 patients who underwent ileal ureter replacement (10 RALS and 15 LS) were followed by functional cine magnetic resonance urography (MRU) combined with a modified Whitaker test. Also, the characteristics, perioperative data and functional outcomes of the patients were compared.

RESULTS

The estimated blood loss, postoperative hospital stay and time to oral intake were significantly lower in the RALS group. At the median 14-month follow-up, all the patients showed improved renal function and were symptom-free, with no signs of leakage or stenosis observed by cine MRU combined with a modified Whitaker test.

CONCLUSIONS

RALS with an extracorporeal bowel resection is feasible and appears to be safe, with quick postoperative recovery and encouraging outcomes.

Ileal ureter replacement: Early morbidity and long-term results

INTRODUCTION

Ileal ureter is a technique that consists of replacing the ureter by a segment of ileum to treat a long ureteric lesion or a lesion involving the lumbar ureter. The primary objective of our study was to assess the early perioperative morbidity of ileal ureter according to the Clavien-Dindo classification. The secondary objectives were to assess the morbidity and the medium- and long-term outcome of renal function.

MATERIALS AND METHODS

Single-centre retrospective study, collecting data from patients operated between February 2005 and October 2019. All patients who underwent ileal ureter replacement surgery in our unit were included in this analysis. The ureteric defect was longer than five centimetres and involved the pelvic and/or iliac and/or lumbar ureter. All ileal ureter replacements were performed by open surgery using isoperistaltic ileal grafts.

RESULTS

Twenty-one patients (11 women and 10 men) underwent total or subtotal, unilateral or bilateral ileal ureter replacement, corresponding to 25 kidneys. The grade III early postoperative complication rate was 9.5% (two cases) mainly consisting of bleeding. No grade IV or V complications were observed. With a mean follow-up of 85 months, long-term morbidity essentially consisted of infectious complications. No patients developed anastomotic strictures. Mean serum creatinine was 116.3μmol/L preoperatively, 105.6μmol/L one month postoperatively and 112.2μmol/L at last follow-up. Renal function was generally preserved or even improved, except for patients with preoperative renal failure.

CONCLUSION

Ileal ureter replacement is a surgical alternative associated with low morbidity and satisfactory long-term functional results.

LEVEL OF EVIDENCE

3.

Ileal Ureteral Substitution After "Panureteral Damage: A Devastating Complication of Forgotten Double-J Stent"

Background: Forgotten ureteral stent is frequently observed in urologic practice. It has serious consequences such as encrustation, stone formation, fragmentation, ureteral damage, and sepsis. Panureteral damage by forgotten stent is a major complication requiring complex reconstructive surgery. Case Presentation: We report a case of 66-year-old man with forgotten ureteral stent for 10 years, which caused panureteral damage. Ileal ureteral substitution was done and kidney was salvaged. Conclusion: Prolonged forgotten stent can cause panureteral fibrosis and requires complex surgical procedure such as ileal ureteral substitution.

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.

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.

Technical considerations and outcomes for ileal ureter replacement: a retrospective study in China

BACKGROUND

Ileal ureter replacement is an alternative treatment for various length ureter defects. We present our experience and outcome of ileal ureter replacement in China.

METHODS

We retrospectively collected data of patients who underwent ileal ureter replacement between January 2010 and January 2015. We reviewed the medical history, indications for surgery, operative data, perioperative data, and outcomes. Besides, follow-up data included symptom, urine routine test, serum creatinine, serum electrolyte status, and radiographic test.

RESULTS

There were 23 patients who underwent ileal ureter replacement by the same surgeon. Twenty patients were performed unilateral ileal ureter replacement, two patients underwent a combination of ileal ureter replacement and Boari flap-psoas hitch, and one received bilateral ileal ureter replacement. Among these patients, the main cause leading to surgical treatment was iatrogenic injuries (n = 15), especially urinary surgery procedure (n = 11). The median follow-up time was 45 months. There were 6 early complications and 6 late complications after operation. Only one patient suffered from small bowel-related complication and was cured by conservative treatment. Only the patient who underwent bilateral ileal ureter replacement had metabolic acidosis. And 22 patients (95.7%) had a good renal function.

CONCLUSIONS

Ileal ureter replacement is an efficacious and safe procedure for the therapy of long ureteral defects. With appropriate technical considerations, the complication rate may decrease.

RUG technique: replacement of the ureter with gonadal vein. A cadaveric study

BACKGROUND

Ureteral defect lesions may result from retroperitoneal fibrosis, radiation damage, tumors, or surgical procedures; the management of long-segment ureteral defects is a challenge for urologists. Total or partial replacement of the ureter is sometimes required, with consequent ileal interposition, but this technique may lead to several complications, such as severe urinary infections. In a few cases, nephrectomy may be required. Starting from the above considerations, we can postulate the RUG technique (replacement of the ureter with gonadal vein), using the gonadal vein (GoV) as an autologous graft to substitute the ureter. For this reason, we decided to test this novel idea on an experimental model.

METHODS

We tested the above technique on a cadaveric model, performing complete procedure (RUG #1), segmental replacement of the ureter (RUG #2), and ureteroplasty with a GoV patch (RUG #3). All the procedures involved an open approach. After RUG #3, the treated segment of the ureter was sampled for histologic analysis.

RESULTS

Four RUGs were performed (two RUG #1, one RUG #2, one RUG #3). All anatomic structures were easily identified, and all procedures were completed successfully. The dimensions of the ureters were comparable to those of the GoV in all cases, as usual. Histologic analysis demonstrated perfect adherence of the two anastomosed structures.

CONCLUSIONS

The RUG technique resulted in an adequate, safe and easy-to-perform surgical alternative.

Laparoscopic Yang-Monti Ureteral Reconstruction in Children

OBJECTIVE

To investigate the clinical outcome of surgical treatment for long ureteral defect in children, we evaluated our experience of managing 6 children with the long defect utilizing laparoscopic ureteral reconstruction technique using Yang-Monti technique.

MATERIALS AND METHODS

Six children with long ureteral defect who underwent laparoscopic Yang-Monti ureteral reconstruction between January 2013 and March 2016 were reviewed. The diagnosis and outcomes of long ureteral defects were reviewed based on clinical and imaging data. We assessed preoperative clinical data and outcomes, and analyzed the experience of laparoscopic Yang-Monti ureteral reconstruction.

RESULTS

The mean age of the patients was 8.5 years. The etiology of the ureteral defect was failed pyeloplasty in 4 patients, failed pyeloplasty and ureteral reimplantation in 1, and trauma in 1. The mean defect length was 5.83 cm. All operations were performed successfully with no serious intraoperative complications and no conversion. The average operative time was 314 minutes, the average intraoperative blood loss was 25 mL, the average drain removal was 3.83 days, the average start of oral feeding was 5.17 days, and the average postoperative hospital stay was 7.17 days. Six patients suffered Clavien I and II complications postoperatively and were managed conservatively. Two patients suffered Clavien III complications postoperatively and were managed by replacing stent. A diuretic T_1/2 showed the improvement of differential renal function without urinary obstruction in all patients.

CONCLUSION

Laparoscopic Yang-Monti ureteral reconstruction is safe and feasible in children with an excellent outcome.

Anterior Pelvic Reconstruction with Ileum after Cancer Treatment

Ileum has been used to reconstruct the lower urinary tract in 15 patients (10 women, five men) after treatment for bladder or gynaecological cancer. Seven patients had previously received radical pelvic irradiation. Four methods were used: group 1 (five patients): bladder patch after partial cystectomy or bladder augmentation after clam cystotomy for bladder contracture; group 2 (four patients): bladder replacement after subtotal (supratrigonal) cystectomy; group 3 (two patients): ureteric replacement for lower ureteric obstruction or fistula, and group 4 (four patients): complete replacement of bladder and lower ureters after anterior pelvic exenteration, with creation of neovagina from caecum in the two female patients.

Review of the results indicates that ileum provides a versatile and safe material for anterior pelvic reconstruction in cancer patients, even after previous pelvic irradiation.

Use of ileum for complex ureteric reconstruction: Assessment of long-term outcome, complications, and impact on renal function

Introduction:

Defect in ureteral continuity can be due to various etiologies. The surgical options for management of complex long-segment ureteric defects are limited. Use of ileum is indicated in these cases; however, the technique is challenging and outcomes need to be assessed in detail.

Material and Methods:

It is an observational study conducted over 4 years. After preoperative optimization, ureteric reconstruction was performed using standard techniques of ileal interposition in cases of unilateral and bilateral long-segment ureteric defects. Patients were followed up at regular interval to assess outcomes and see for complications.

Results:

A total of 14 patients were studied. Two most common indications for performing ileal ureter were iatrogenic injury and radiation-induced strictures (5–5 cases). Most common site of ureteric involvement was lower and midureter seen in 6 cases. The mean length of the ileum used was 11.2 cm. Mean preoperative nadir creatinine level was 1.57 mg/dL in this study. Average postoperative creatinine level at 4-week follow-up was 1.75 mg/dL and 1.45 mg/dL and 1.37 mg/dL, at 3 and 12 months, respectively. The most common short-term complication was paralytic ileus and long-term complication was recurrent urinary tract infection UTI. There was no mortality.

Conclusion:

Ileal ureter is found to be relatively easy and safe surgery even in patients with borderline high creatinine. There was no worsening of renal function attributable to the conduit in this study. In patients with limited surgical options, it is a suitable alternative, rather than keeping patient on permanent percutaneous nephrostomy or regular stent change. Metabolic acidosis and mucous-associated complications such as pain, infection, and stone formation can be minimized by adherence to strict protocol.

[Results of conservative surgical management of ureteral injuries]

INTRODUCTION

The ureter is a retroperitoneal organ. Ureteral injuries are rare, with a prevalence of 0.083% of surgical interventions over 10 years. The objective of this study was to evaluate the surgical management of ureteric injuries according to the time of discovery, their size and their location. We also evaluated the results of this management on the renal repercussion as well as the predictive factors of the severity of the ureteric injuries.

MATERIAL AND METHODS

This was a monocentric retrospective study carried out on the basis of a systematic review of the CHU surgery files.

RESULTS

The average follow-up was 30 months. The average hospital stay was 8 days. Thirty-four patients (73.9%) underwent initial endoscopic management by attempting a double J probe. Only 20 patients received this double J probe and only 11 patients (55%) did not recidivate the ureteral injury with a median duration of maintenance of the double J probe of 90 days (28-240). Thirty-five patients received open surgical management (76.1%). We found 57% ureterovesical reimplantations (n=20), corresponding to pelvic ureteral injuries (n=32). We also found 20% of nephrectomies. No patient had recurrence of the ureteral injury. Eight patients had secondary dilatation of the pyelocalicious cavities (28.57%). The success of surgical treatment was therefore 57%.

CONCLUSION

The management of surgically treated ureter injuries provides good results but remains relatively diversified due to the different lesion levels. It was effective in 57% of cases including nephrectomies as failure of treatment.

LEVEL OF EVIDENCE

4.

Ileal Ureter Replacement Combined With Boari Flap-Psoas Hitch to Treat Full-Length Ureteral Defects: Technique and Initial Experience

OBJECTIVE

To evaluate the feasibility of ileal ureter replacement combined with Boari flap-psoas hitch procedure for the management of full-length ureteral defects (>20 cm).

METHODS

Three patients diagnosed with full-length ureteral defect were treated with our technique performed by a single surgeon between January 2015 to January 2016. All the patients had borderline renal function preoperatively. In each case, the ureteral reconstruction was performed by combining ileal ureter replacement with Boari flap-psoas hitch. Data on indications for surgery, intraoperative and postoperative outcomes, and changes in renal function were collected.

RESULTS

Surgery was performed successfully with an operation duration between 210 and 250 minutes. The mean estimated blood loss was 230 mL. The mean length of hospital stay was 11 days, and no major complications (grade ≥3) occurred. Postoperative follow-up showed radiological resolution of hydronephrosis and improved renal function in all 3 patients.

CONCLUSION

Ileal ureter replacement combined with Boari flap-psoas hitch is a feasible option for bridging full-length ureteral defects. This technique minimizes the length of ileal graft required as well as limitations concerning patient selection. Larger series with longer follow-up to confirm the value of the technique are warranted.

Long-term results of ileal ureteric replacement: a 25-year single-centre experience

OBJECTIVE

To report the long-term outcomes of ileal ureteric replacement (IUR) in complex reconstruction of the urinary tract.

PATIENTS AND METHODS

From 1991 to 2016, IUR was performed in 157 patients with structural or functional ureteric loss. In 52 patients, bilateral IUR became necessary. Implantation sites where either the native urinary bladder (n = 79) or intestinal reservoirs (n = 78). In the latter group, the technique was used at the time of primary urinary diversion (n = 34), in a secondary approach (n = 29), and in undiversion or conversion procedures (n = 15). Anti-refluxive implantation was performed in 37 patients. In eight patients the ileal ureter was implanted into the cutis as an ileal conduit. All patients were followed prospectively according to a standardised protocol.

RESULTS

The mean follow-up was 54.1 months. In 114 patients with dilatation of the upper urinary tract before surgery a significant improvement of the dilatation was confirmed in 98 patients. Serum creatinine levels decreased or remained stable in 147 of the 157 patients. Reflux was present in all cases without and in six cases with an anti-reflux mechanism. In six patients, operative revision became necessary because of severe metabolic acidosis, mucus obstruction or stenosis of the ileal ureter.

CONCLUSIONS

To our knowledge, this is the world's largest single-centre series of IUR reported to date. Long-term follow-up confirms that this approach is a safe and reliable solution, even under complex conditions. Anti-refluxive implantation is recommended for intestinal reservoirs, whereas reflux prevention seems to be of minor importance when the native bladder is chosen as the site of implantation.

Ureteral Reconstruction With Ileum: Long-term Follow-up of Renal Function

OBJECTIVE

To assess long-term renal preservation and surgical outcomes in patients undergoing ureteric substitution with ileum. This has been a mainstay of reconstruction options for lengthy ureteral defects.

METHODS

Consecutive patients aged 18 or older undergoing ileal ureters at our institution were retrospectively reviewed (from 1989 to June 2013). Patients with <6 months of follow-up were excluded. Demographic, surgical, and renal functional outcomes were reviewed. Renal function was assessed by the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease Study equations.

RESULTS

Of the 108 patients meeting the inclusion criteria, 86 (79.6%) had single-renal unit reconstruction and 22 had bilateral reconstruction. Eighty-four (77.8%) had radiation-induced stricture and 24 had iatrogenic or trauma-induced strictures. The median follow-up was 51 months (interquartile range: 22-112). Short-term complications included Clavien grade I (16 [14.8%]), Clavien grade II (3 [2.8%]), Clavien grade III (9 [8.3%]), and Clavien grade IV (3 [2.8%]). Long-term complications included fistula in 6 patients (5.6%), renal failure requiring dialysis in 2 patients (1.9%), hyperchloremic metabolic acidosis in 4 patients (3.7%), and incisional hernia in 11 patients (10.2%). Nine patients (8.3%) had small-bowel obstructions; 3 (2.8%) required adhesiolysis. Four patients (3.7%) had an anastamotic stricture. Nineteen patients (17.6%) had worsening renal function. Cox proportional hazards regression found that those with bilateral repair were at 3.7 times increased risk of worsening renal function (P = .02).

CONCLUSION

Ureteral substitution with ileum provides an effective and versatile long-term reconstructive option with minimal renal function compromise in properly selected patients. Bilateral reconstruction may contribute to worse long-term renal function.

[Ureteral stricture as a late complication of radiotherapy : Possible treatment options]

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.

Ureteral reconstruction with abdominal wall muscle flap: experimental study in rabbits

The authors detail the experimental development of a technique for the reconstruction of the ureter using a tubular shape, muscle flap of the abdominal wall. the preliminary results indicate the feasibility of this surgical technique.

[Management of ureteral strictures and hydronephrosis]

Patients who develop hydronephrosis due to an acute cause often have colic-like pain but hydronephrosis secondary to a chronic cause is often asymptomatic. Ureteral obstruction can be due to a variety of intrinsic and extrinsic causes, such as trauma, radiation, iatrogenic injury, urolithiasis, malignancies and congenital causes. Management planning is dictated by the underlying cause, patient comorbidity and life expectancy. Malignant ureteral obstructions can be managed with segmental metal stents with advantages in the quality of life and provide an alternative to long-term treatment with a DJ stent. Endoscopic balloon dilatation and endoureterotomy are options for benign ureteral strictures up to 2 cm in length. For longer benign strictures there are a number of reconstructive techniques, which can also be performed by laparoscopic or robot-assisted approaches at specialized centers.

Partial substitution of the ureter using a double short segments of the ileum following the Monti procedure

The partial substitution of the ureter using a pediculated double short segments of the ileum is a technique used to re-establish ureteral transit and preserve the renal unit, following the resection of extensive ureteral lesions. Standard surgical procedure for an ileoureteroplasty consists of isolating an ileal duct of equal or greater length than the ureteral defect and interposing it in the urinary tract in an isoperistaltic direction. Monti described a surgical technique that allows for the creation of catheterizable stomas in continent urinary diversions, using the Mitrofanoff principle. These passageways were created from one or several 2.5 cm long ileal sections by means of their detubulization and transverse retubulization.

Intestinal seromuscular tunneling: a novel method for ureteral replacement--an experimental design

BACKGROUND

Long-segment ureteral injuries may have different etiologies. Although multiple procedures have been previously used for ureteral replacement, none of them had optimum results, and replacement of long segments of injured ureter is still a challenging surgical problem. In this article, we have hypothesized that it may be possible to use intestinal seromuscular tunneling as a novel method for ureteral replacement.

METHODS

This experimental study was conducted on eight dogs. After cutting the ureter at about its mid-part and ligating the distal part, a 10-cm tunnel was made in the seromuscular layer of small intestine using a metallic probe, and a catheter was passed through it. Proximal and distal ends of the tunnel were anastomosed to proximal end of ureter and urinary bladder, respectively. After 8 weeks, the dogs were killed, and their whole urinary system was sent for histopathologic examinations.

RESULTS

No complication was noted during the post-op period. Histopathologic examinations confirmed that the seromuscular tunnel was well patent, lined by pseudostratified transitional epithelium and without any inflammatory reaction.

CONCLUSION

Our study shows that ureteral replacement by intestinal seromuscular tunneling is anatomically possible at least in animal model. However, more well-designed prospective studies are needed to confirm its long-term functional results.

Ureteral reconstruction with bowel segments: experience with eight patients in a single institute

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.

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

CONTEXT

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

OBJECTIVE

To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.

EVIDENCE ACQUISITION

A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.

EVIDENCE SYNTHESIS

Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.

CONCLUSIONS

Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Long-term functional outcomes after ileal ureter substitution: a single-center experience

OBJECTIVES

To assess the indications and outcomes of ileal ureter replacement for ureteral reconstruction, which remains a technique of choice in certain cases, notably when the ureter has been injured.

METHODS

A retrospective review of the data from patients treated with ureteroileoplasty from 1980 to 2010 was performed. The following data were analyzed: age, etiology of ureter injury, and pre- and postoperative creatinine levels. Follow-up visits occurred at 3 and 6 months postoperatively and at least annually thereafter.

RESULTS

A total of 17 patients with a median age of 43 years were included. The main etiology of the ureteral defect was an iatrogenic ureteral injury after a urologic procedure (n=6). The mean length of hospital stay was 12.4±8 days (range 7-26). Four major complications (grade 3) and 5 minor complications (grade 2) developed. The median follow-up time was 174 months. The mean creatinine level before surgery, at 1 month after surgery, and at the last follow-up visit was 1.3±0.3 mg/dL (range 0.6-3.4), 1.4±0.4 mg/dL (range 0.6-3.6), and 1.8±0.6 mg/dL (range 0.7-4.7), respectively. By the end of the follow-up period, 15 patients still had ileal ureters. Of these, 3 required dialysis.

CONCLUSIONS

The indications for an ileal ureter have evolved in recent years. The ileal ureter appears to remain a reasonable option for ureteral reconstruction to preserve long-term renal function.

A review of ureteral injuries after external trauma

INTRODUCTION

Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management.

LITERATURE REVIEW

Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%.

CONCLUSION

The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.

Appendix interposition for total left ureteral reconstruction

INTRODUCTION

Appendix interposition has been described as an option for surgical reconstruction of partial and total ureteral defects both in children and adults. However, to our knowledge, appendix interposition for a total left ureteral reconstruction has never been described.

CASE REPORT

We report the first case of total left ureteral reconstruction with cecal appendix to connect the renal pelvis of a native kidney to the urinary bladder in a 3-month-old child with ureteral necrosis following pyeloplasty.

RESULTS

Postoperative recovery was uneventful. Postoperative intravenous pyelogram showed good flow of dye from the pelvis past the appendicular graft into the bladder. After 6 months, the child was asymptomatic, within the normal growth curve for height and weight.

CONCLUSION

Total ureteral reconstruction with cecal appendix is a feasible technique in young children. Surveillance for late operative complications is required, since this is the first case of total left ureteral reconstruction with appendix to connect the renal pelvis of a native kidney to the urinary bladder.

A case of staghorn stones in a kidney with an ileal ureter treated by percutaneous nephrolithotomy

BACKGROUND

A 59-year-old man was admitted to hospital for investigation of a 1-year history of intermittent hematuria. He had undergone ileal ureteral replacement for left renal stones 36 years earlier.

INVESTIGATIONS

Renal ultrasonography, physical examination, abdominal plain radiography, intravenous urography, CT urography, measurement of serum levels of creatinine, urea and electrolytes, renal scintigraphy, urinalysis and urine culture.

DIAGNOSIS

Staghorn calculi in the left kidney, with a high-lying anastomosis between the renal pelvis and the proximal ileal segment.

MANAGEMENT

The patient underwent percutaneous nephrolithotomy via a middle-calyx access for the large staghorn stones. After surgery, no residual calculi were found and the patient was discharged with an uneventful postoperative course. At 1 month, renal scintigraphy showed normal bilateral kidney function. The patient received potassium citrate supplementation and was followed up with 6-monthly imaging studies. At the last report, he had been stone-free for 7 months.

Use of ileum as ureteral replacement in urological reconstruction

PURPOSE

We reviewed indications and outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction.

MATERIALS AND METHODS

Between December 1989 and September 2007, 105 patients underwent ileal ureter replacement, of whom 14 were excluded from study due to incomplete data. The remaining 91 patients (99 renal units) comprised the study cohort.

RESULTS

Mean patient age was 46.8 years and mean followup was 36.0 months. Indications for an ileal ureter were stricture following genitourinary surgery in 29 cases (31.9%), radiation induced stricture in 17 (18.7%), nonurological surgery iatrogenic injury in 16 (17.6%) and retroperitoneal fibrosis in 11 (12.1%). Only 4 patients (4.4%) had primary ureteral cancer. Long-term complications included anastomotic stricture in 3 patients (3.3%) and fistula in 6 (6.6%). Serum creatinine decreased or remained stable in 68 patients (74.7%) and hyperchloremic metabolic acidosis developed in 3. No patient complained of excessive urinary mucous production.

CONCLUSIONS

In 68.1% of patients indications for an ileal ureter included radiation induced stricture or iatrogenic injury. The ileal ureter is a reasonable option for long-term ureteral reconstruction with preserved renal function in carefully selected patients.

Ileal ureteric replacement with an ileo-psoas muscle tunnel antirefluxing technique for the treatment of long segment ureteric strictures

OBJECTIVES

To develop and report our initial experience with a novel antirefluxing technique for segmental ileal ureteric replacement for the treatment of long ureteric strictures.

PATIENTS AND METHODS

Between January 2000 and January 2007, 12 cases of ureteric strictures (nine bilateral and three unilateral) were treated using a novel surgical technique in which the ureter was replaced with a segment of ileum using an end-to-side anastomosis. An antireflux valve was constructed by fixing the distal part of upper ureter (4 cm) between the psoas muscle and ileal segment (the ileo-psoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis.

RESULTS

The 12 cases were followed-up for a mean (range) of 39.42 (12-64) months. There were no cases of pyelonephritis or signs of renal failure after surgery. There was dramatic improvement in hydronephrosis, as assessed by intravenous urography, in the 4-9 months after surgery. Cystography showed no evidence of ileo-ureteric reflux. Mild hyperchloraemic acidosis was detected in two patients and was successfully treated with oral alkalization.

CONCLUSIONS

In our initial experience, ileal ureteric replacement combined with the ileo-psoas tunnel antirefluxing technique is a highly effective procedure for the treatment of ureteric strictures.

Ureteric injury after lumbosacral discectomy: a case report and review of the literature

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.

The appendix as ureteral substitute: a report of 10 cases

BACKGROUND

Ureteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter.

METHODS

A retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix.

RESULTS

Ten patients were identified, operated in 2002-2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n=1), congenital ureteric stenosis (n=5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n=3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n=1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16months (1-72 months), all the patients were well except one whose kidney function had deteriorated.

CONCLUSIONS

Total or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.