Ileal replacement of the ureter in solitary kidney

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.

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.

Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation

A total of 18 patients underwent an operation for extensive ureteral loss from 1980 to 1986. The indications included recurrent calculi, retroperitoneal fibrosis, surgical trauma and tumor. Of the patients 10 had construction of an ileal ureter (4 had bilateral reconstruction), 6 had creation of a psoas hitch with a Boari bladder tube and 2 were treated by autotransplantation. Mean duration of followup was 4.8 years. The procedure was successful in 17 patients. There were no apparent differences among the groups. Selection criteria and potential complications are discussed with regard to each technique. These procedures provide an excellent means for reconstruction of the urinary tract in patients who have failed other treatments.

Ileal segment replacement of ureter. I. Effects on kidney of refluxing vs nonrefluxing ileovesical anastomosis

Unilateral partial ureteral obstruction was induced in 32 dogs followed by total ileal replacement of the obstructed ureter. The morphologic and functional effects on the kidney using a freely refluxing versus a nonrefluxing ileovesical anastomosis were compared, as well as the effect of total tapering of the reimplanted ileal segment. The tapered ileovesical anastomosis proved more reliable for prevention of reflux than the nontapered technique. Reflux prevention does not appear necessary for maintaining renal morphology and function when bladder function is normal and the observation period short. Total tapering of the ileal segment did not prove to be advantageous in protecting against hyperchloremic acidosis in this short-term canine study.

Ileal segment replacement of ureter. II. Dynamic characteristics of refluxing, nonrefluxing, and totally tapered ileal ureter

The pressure characteristics and cinefluoroscopic appearances of a refluxing, nonrefluxing, and totally tapered ileal " neoureter " were compared in 22 dogs with normal bladder function. The totally tapered ileal segment with a reflux preventing ileovesicostomy simulates normal ureteral peristalsis most closely on cinefluoroscopic evaluation. Pressure gradients across the ileovesical junction though were similar in refluxing and nonrefluxing ileovesicostomies , as well as in totally tapered ureters.

Renal autotransplantation for recurrent renal colic

Renal autotransplantation as an alternative to ileal interposition has been done successfully in patients with repetitive episodes of renal colic. Urinary tract continuity has been re-established by anastomosis of a Boari tube directly to the renal pelvis. This has resulted in easy egress of recurrent calculi without pain. Furthermore, the musculature of the Boari tube seems to be adequate for prevention of vesicorenal reflux. The procedure has been devoid of electrolyte and mucous urinary retention problems associated with ileal interpositionand it is advocated as an alternative in the management of such patients when medical therapy fails.

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

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.