Robot-Assisted Laparoscopic Excision and Ureteroureterostomy for Congenital Midureteral Stricture

A case of mid-ureteral stricture with ipsilateral atrophic kidney in a young adult

Introduction

Most congenital ureteral strictures occur at the ureteropelvic or ureterovesical junction in children. Mid-ureteral stricture is very rare and can cause congenital hydronephrosis. Only a few studies have reported on coexisting mid-ureteral stricture with ipsilateral atrophic kidney in young adults.

Case presentation

A 16-year-old girl presented with repeated urinary tract infection. Computed tomography revealed a right atrophic kidney and hydroureter. Retrograde pyelography showed a mid-ureteral stricture. Laparoscopic nephroureterectomy was performed, and histological examination revealed mid-ureteral stricture with hyperplasia of the fibrous connective tissue and an atrophic kidney.

Conclusion

Mid-ureteral stricture in a young adult is extremely rare. Appropriate imaging studies including retrograde pyelography are necessary for accurate diagnosis of mid-ureteral stricture.

A ureteral stricture disease score and classification system: correlation with upper urinary tract reconstructive surgery complexity

Background

To develop an original and standardized ureteral stricture disease (USD) score and classification system for quantifying ureter stricture characteristics, assessing complexity of the minimally invasive upper urinary tract reconstructive (UUTR) surgical procedure, formulating preoperative plans, and offering objective comparisons of surgical techniques between different institutions and surgeons.

Methods

We retrospectively reviewed a test set of 64 patients and a validation set of 170 patients who underwent minimally invasive UUTR surgery from January 2018 to January 2021. Three factors were selected to be included in the USD score and classification system: (I) stricture etiology (E, 1–2 points); (II) stricture segment (S, 0–3 points); and (III) length of stricture (L, 1–5 points). The UUTR surgery involves low-complex surgeries (cystoscopy with ureteral dilation and stent placement, ureteropyeloplasty, end to end repair, ureteral reimplantation) and high-complex surgeries (onlay repair (buccal mucosae, lingual mucosae, appendix mucosae), Boari flap repair and ileal ureter replacement). Estimated blood loss and operative time were used as surrogate indicators of surgical complexity.

Results

The interrater reliability of the USD score and classification system was 0.908. A linear relationship between the USD score and estimated blood loss was observed (rs =0.676, P<0.001). The USD score was also correlated with operative time (rs =0.638, P<0.001). A significant difference in USD scores was found between the high and low complexity surgery groups (4 vs. 7, P<0.001). Variability of UUTR surgery is based on USD classification system, but with regularity to conform to.

Conclusions

The USD score and classification system is a concise, easily applicable, and validated scale to delineate the clinically significant features of ureter stricture that correlate with the complexity of the UUTR surgical procedure. The use of this score and classification system can facilitate preoperative plan and comparison of USD treatments in clinical practice and urological literature. Research with large sample is needed to further examine and modify the use of the system.

Congenital midureteral stenosis in children: a 13-year retrospective study based on data from a large pediatric medical center

Background

Midureteral stenosis is very rare in children and can cause congenital hydronephrosis. We report our experience treating children with congenital midureteral stenosis at our center, focusing on the differences in preoperative diagnosis and treatment compared with other congenital obstructive uropathies.

Methods

We retrospectively reviewed the medical records of 26 children diagnosed with congenital midureteral stenosis at our center between January 2007 and December 2020, such as preoperative examination methods, intraoperative conditions, and postoperative follow-up results.

Results

Of the 1625 children treated surgically for ureteral narrowing, only 26 (1.6%) were diagnosed with midureteral stenosis, including 15 infants and 11 children. Eighteen (69.2%) were boys, 13 (50%) were affected on the left side, and 23 (88.5%) had isolated ureteral stenosis. Overall, 13 (50%) of the children presented with prenatal hydronephrosis, and 13 (50%) presented with abdominal pain or a mass. All the children had undergone urinary ultrasound and intravenous urography preoperatively; the diagnostic rate of ultrasound was 92.3%. Only 7 (26.9%) children had undergone pyelography. All the children had undergone surgery. The ureteral stenotic segment was less than 1 cm long in 25 (96.2)% of the children. The mean follow-up duration was 22 months (range: 6–50 months). One child developed anastomotic strictures. Urinary tract obstruction was relieved in the other children without long-term complications.

Conclusions

Congenital midureteral stenosis is rare, accounting for 1.6% of all ureteral obstructions, and its diagnosis is crucial. Urinary ultrasound has a high diagnostic rate and should be the first choice for midureteral stenosis. Retrograde pyelography can be used when the diagnosis is difficult, but routine retrograde pyelography is not recommended. Congenital ureteral stenosis has a relatively short lesion range, largely within 1 cm. The treatment is mainly resection of the stenotic segment and end-to-end ureteral anastomosis, with a good prognosis.

Management for Ureteral Stenosis: A Comparison of Robot-Assisted Laparoscopic Ureteroureterostomy and Conventional Laparoscopic Ureteroureterostomy

Background: To describe and analyze our experience of robotic-assisted laparoscopic ureteroureterostomy (RALU) and conventional LU for the repair of ureteral stenosis and compare the differences of safety and efficacy between RALU and LU. Materials and Methods: Patients who underwent RALU or LU for ureteral stenosis were retrospectively analyzed. Baseline characteristics, details of stenosis, surgery and some laboratory tests, and follow-up data were collected and analyzed. Results: Among 126 patients presented with ureteral stenosis, 65 patients underwent RALU and 61 patients underwent LU. All operations were completed successfully without conversion to open surgery. Both groups were comparable in baseline characteristics and details of stenosis. The mean operative time, suturing time, and hospitalization time of patients in RALU group were significantly less than those in LU group. The mean operative time of the RALU group was 126.34 minutes, whereas the mean operative time of the LU group was 176.57 minutes (P < .001). The average suturing time of RALU and LU was 26.88 and 70.43 minutes, respectively (P < .001). The mean hospitalization time of RALU and LU was 4.01 and 5.02, respectively (P < .001). RALU presented a lower degree of leukocytes rise than LU (P < .001). The mean follow-up time was 29.52 months. Conclusions: RALU and LU both are safe and feasible for ureteral stenosis with a low incidence of complications. Compared with LU, RALU may be a better choice with shorter operative time, suturing time, postoperative hospitalization time, and slighter inflammation. Further clinical studies of high quality are needed to confirm the priority of RALU.

Laparoscopic repair of congenital midureteric strictures in infants and children

PURPOSE

Congenital midureteric strictures (CMUS) are an uncommon cause of obstructive uropathy. There are only a few case reports of laparoscopic management of CMUS. We present our experience with laparoscopic repair of CMUS in 7 children.

PATIENTS AND METHODS

The records of all children (n=7, 5 infants) undergoing laparoscopic reconstruction for CMUS were reviewed. Preoperative imaging included ultrasound (US) and diuretic renography (DR) in all children. Intravenous urography or magnetic resonance urography was performed in 3 children when a dilated ureter was seen on the ultrasound. Retrograde pyelography was performed in 6 children before definitive surgery. All children underwent transperitoneal laparoscopic excision of the stricture with ureteroureterostomy. Follow-up included clinical examination and US in all children, with DR in 5 children.

RESULTS

Over a 3-year period, 7 children underwent laparoscopic repair of CMUS. Six children had antenatally diagnosed hydronephrosis, while one child presented with infected hydronephrosis, underwent nephrostomy and was later referred to us. The diagnosis of CMUS was suspected preoperatively in 4 children; in 3 children, diagnosis of CMUS was confirmed on retrograde pyelography. Laparoscopic repair was successfully completed in all children; there were no significant intraoperative or postoperative complications. At a median follow-up of 18months, all children are asymptomatic, with US (7) and DR (5) confirming significant reduction in the hydronephrosis and improved drainage. The cosmetic results have been excellent.

CONCLUSION

To our knowledge, this is the first report of laparoscopic repair of CMUS in children. Laparoscopic repair of CMUS can be safely and successfully performed even in small infants, with good results.

Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction after failed endoscopic intervention: A technical report

Objective

Complex ureteral obstruction is refractory to conventional urological intervention. This report describes a case of laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction.

Methods

Right-side multiple ureteral stones and complicating ureteral obstruction failed an initial attempt of ureteroscopy lithotripsy with simultaneous percutaneous nephroscopy in a 23-year-old male. Laparoscopic ureterolysis with ureteroscopy and percutaneous nephroscopy was used simultaneously to dissect the periureteral adhesions with the patient placed in the Galdakao-modified supine Valdivia position. The ureter was incised to allow the insertion of a ureteral catheter through the twisted ureter, and a guide wire was advanced into the pelvis using ureteroscopy. A double-J stent was placed into the right-side ureter using antegrade percutaneous nephroscopy.

Results

The laparoendoscopic procedure lasted 330 min with an estimated bleeding volume of 100 mL. The patient underwent an uneventful postoperative course, and postoperative follow-up radiography confirmed good positioning of the double-J stent. The double-J stent was removed 3 months after operation. The patient remained asymptomatic within a 13-month follow-up period.

Conclusion

Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy is an effective and safe treatment option for complex ureteral obstruction.

[Clinical characteristics and outcomes of congenital midureteral stricture detected by fetal ultrasonography]

OBJECTIVES

Congenital midureteral stricture (CMS), which develops from obstructive lesion between pyeloureteral junction and ureterovesical junction, is relatively rare and its clinical condition and therapeutic strategy have not yet been established. We analyzed the clinical characteristics and surgical outcomes of CMS.

PATIENTS AND METHODS

From November 2006 to December 2012, out of 137 patients presented with congenital hydrohephrosis, we identified 4 pediatric patients diagnosed with CMS at our institutions. We retrospectively investigated clinical characteristics and surgical outcomes in these 4 patients.

RESULTS

Three boys and one girl were identified in this study. All patients were detected hydronephrosis by fetal ultrasonography. The median age at the diagnosis of CMS was 1 year and 11 months. Three patients had obstructive lesion in left side and 1 patient in right. CMSs were located at the level of L4 in 2 patients, and at the level of L5 and S1 in each 1. Split renal function was decreased less than 45% in 3 of 4 patients. Ipsilateral pyeloureteral junction obstruction and ipsilateral hypoplastic kidney were identified in 2 and 1 patient, respectively. One patient developed urosepsis and underwent nephrostomy. Partial ureterectomy and ureteroureterostomy, pyeloplasty were performed in 3 and 1 patient, respectively. Extrinsic obstruction was detected in just 1 patient intraoperatively. In all patients, there were no protruded lesion and atrophied, fibrotic and ischemic muscles were not detected in pathological finding. Neither urinary tract infection nor recurrence of obstructive lesion was detected in all patients at the mean follow-up period of 3 years and 1 month.

CONCLUSION

We analyzed the clinical characteristics of 4 pediatric patients with CMS. In order to prevent critical infection and maintain renal function, it could be considered that surgical intervention is undertaken just after making the diagnosis of CMS.

Pure laparoscopic and robot-assisted laparoscopic reconstructive surgery in congenital megaureter: a single institution experience

To report our experience of pure laparoscopic and robot-assisted laparoscopic reconstructive surgery in congenital megaureter, seven patients (one bilateral) with symptomatic congenital megaureter underwent pure laparoscopic or robot-assisted laparoscopic surgery. The megaureter was exposed at the level of the blood vessel and was isolated to the bladder narrow area. Extreme ureter trim and submucosal tunnel encapsulation or papillary implantations and anti-reflux ureter bladder anastomosis were performed intraperitoneally by pure laparoscopic or robot-assisted laparoscopic surgery. The clinical data of seven patients after operation were analyzed, including the operation time, intraoperative complications, intraoperative bleeding volumes, postoperative complications, postoperative hospitalization time and pathological results. All of the patients were followed. The operation was successfully performed in seven patients. The mean operation times for pure laparoscopic surgery and robotic-assistant laparoscopic surgery were 175 (range: 150–220) and 187 (range: 170–205) min, respectively, and the mean operative blood loss volumes were 20 (range: 10–30) and 28.75 (range: 15–20) ml, respectively. There were no intraoperative complications. The postoperative drainage time was 5 (range: 4–6) and 5.75 (range: 5–6) d, respectively, and the indwelling catheter time was 6.33 (range: 4–8) d and 7 (range: 7–7) d, respectively. The postoperative hospitalization time was 7.67 (range: 7–8) d and 8 (range: 7–10) d, respectively. There was no obvious pain, no secondary bleeding and no urine leakage after the operation. Postoperative pathology reports revealed chronic urothelial mucosa inflammation. The follow-up results confirmed that all patients were relieved of their symptoms. Both pure laparoscopic and robot-assisted laparoscopic surgery using different anti-reflux ureter bladder anastomoses are safe and effective approaches in the minimally invasive treatment of congenital megaureter.

Endoscopic placement of ureteral stents for treatment of congenital bilateral ureteral stenosis in a dog

CASE DESCRIPTION

A 5-year-old 8.6-kg (18.9-lb) spayed female Pug was evaluated because of chronic hematuria and recurrent urinary tract infections.

CLINICAL FINDINGS

Excretory urography, ultrasonography, and excretory CT urography were performed. Results indicated that the dog had bilateral hydronephrosis and hydroureter and suspected proximal ureteral stenosis. Retrograde ureteropyelography confirmed the presence of stenosis at the ureteropelvic junction of each ureter, along with a large amount of endoluminal ureteral debris. Clinical findings suggested that the dog had a congenital bilateral anomaly of the upper urinary tract.

TREATMENT AND OUTCOME

The dog was anesthetized, and 2 double-pigtail ureteral stents were placed cystoscopically with fluoroscopic guidance for immediate relief of the ureteropelvic junction obstructions. Each stent extended from the left or right renal pelvis to the urinary bladder. The procedures and the patient's recovery from anesthesia were uncomplicated. Continuing improvements in severity of hydronephrosis, hydroureter, and dysuria were evident during routine follow-up examinations at 2, 4, 12, 16, and 45 weeks after stent placement. Over the subsequent 12 months, all clinical signs remained resolved other than a urinary tract infection that was successfully treated with antimicrobials.

CLINICAL RELEVANCE

Ureteral stenosis should be considered as a differential diagnosis for hydronephrosis in dogs, particularly when urinary tract calculi or neoplasia is not present. Chronic hematuria and recurrent urinary tract infections can be associated with this condition. Placement of ureteral stents may be a successful treatment option for ameliorization of congenital ureteral obstructions.

Nondismembered ureteroplasty for congenital midureteral stenosis: a new application of an old technique

OBJECTIVES

To share our experience with nondismembered ureteroplasty (NDU), a novel application of an old technique in congenital midureteral stenosis (CMS).

METHODS

A 35-year-old man was diagnosed as a case of CMS, a rare benign condition on the basis of extensive evaluation, including ultrasonography, intravenous urography, ethylenedicystine renal scan, antegrade and retrograde contrast study of the left kidney and ureter, and a 64-slice computed tomographic angiography of the abdomen with 3-dimensional reconstruction. He was managed by open NDU, where a longitudinal incision over the narrowed segment was closed transversely using the Heineke-Mikulicz principle, thereby preserving the midureteral blood supply, which is considered tenuous.

RESULTS

The patient had a successful outcome and is asymptomatic at 1-year follow-up, with significant resolution of hydroureteronephrosis on ultrasonography, and a nonobstructed left kidney with 37% differential renal function on renal scan.

CONCLUSIONS

Nondismembered ureteroplasty is a meticulous surgical technique emphasizing blood supply preservation; it can be a useful option in relatively long-segment CMS and adds another method in the surgeon's armamentarium for repairing this rare condition. This technique can be especially useful during laparoscopic or robotic repair of such stenosis.