Total proximal ureter substitution using buccal mucosa

Augmented anastomotic ureteral reconstruction using buccal mucosal graft, initial experience

OBJECTIVE

To assess the augmented anastomotic ureteral reconstruction using buccal mucosal graft based on omental flap for managing ureteral stricture.

SUBJECTS AND METHODS

This prospective cohort study was conducted on 13 patients with ureteric strictures of different lengths secondary to Bilhalziasis, iatrogenic (post endoscopy) and post inflammatory etiology in upper and mid ureteral segments were treated with buccal mucosal patch grafts and The graft is fixed to the undersurface or the posterior surface of the omentum before doing graft anastomosis to the ureteral walls as to ensure the process of graft take sticky to the principles of tissue transfer. All patients were subjected to full history taking, clinical examination for assessment of pain, lower or upper urinary track symptoms and laboratory investigation (complete blood count, CRP, liver function test and kidney function test (serum urea and creatinine).

RESULTS

The mean operative time was 148.85 min and mean hospital stay was 3 days. Mean blood loss was ranged from 20 to 210 ml and Stent was removed after 8-12 weeks. The mean follow up was 13 months, all patients had a non-obstructive RI value <0.7 with a non-obstructed drainage pattern on the diuretic renogram except one patient who had severe postoperative UTI necessitating nephrostomy tube insertion his drainage curve was plateau.

CONCLUSION

BMG ureteroplasty is a valuable option for a carefully selected patient. The fixation of the graft on the back surface of the omentum allows for better anatomical reconstruction without any twisting to the omental pedicle.

Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases

BACKGROUND

Management of a long proximal ureteral stricture is challenging. Lingual mucosal graft ureteroplasty (LMGU) is a novel minimally invasive technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation.

OBJECTIVE

To evaluate the long-term effectiveness of LMGU for managing long, complex proximal ureteral strictures in a multi-institutional cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study involved data for 41 patients treated with LMGU at three centers between June 2015 and January 2021.

SURGICAL PROCEDURE

LMGU was performed using either an onlay ureteroplasty in which the diseased ureter was incised ventrally and repaired with a lingual mucosal graft (LMG) to widen the ureteral lumen, or an augmented anastomotic technique in which the obliterated segment of the ureter was excised and reanastomosed primarily on dorsal side, and an LMG was placed on the ventral side.

MEASUREMENTS

Pre-, intra-, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

Of 41patients, 40 were operated with laparoscopic procedures and one with a robot. Twenty-four (59%) patients underwent an onlay ureteroplasty, and 17 (41%) underwent an augmented anastomotic ureteroplasty. The reconstructed ureter was wrapped with omentum in 90% of cases. The median (range) stricture length was 4.8 cm (2.0-8.0), operative time was 166 min (98-306), and estimated blood loss was 65 ml (15-220). No open conversions and intraoperative complications occurred. At a median follow-up of 35 mo (range 13-80), the overall success rate was 97.6% (40/41).

CONCLUSIONS

LMGU is a safe, feasible, and effective long-term technique for managing long, complex proximal ureteral strictures.

PATIENT SUMMARY

We reported a novel technique for long proximal complex ureteral strictures using an onlay lingual mucosal graft (LMG). Our 6-yr outcomes demonstrate that onlay LMG ureteroplasty is a safe, feasible, and effective long-term procedure for ureteral reconstruction.

Buccal ureteroplasty for recurrent extended strictures and obliterations of distal ureter

At the current stage of development of urology, selection of the surgical method for cases of severe obstructive diseases of the upper urinary system remains a challenge. This study aimed to explore the results of application of a buccal graft (BG) to remedy extended recurrent strictures and obliterations of the distal ureter. Seven patients with the mentioned diseases had undergone surgery: for six of them, the method of choice was complete BG ureteroplasty, one had onlay ureteroplasty. One intervention was laparoscopic, the remaining surgeries were open. The length of the replaced ureteral defect was 5–8 cm. In five cases, the flap was additionally vascularized with the iliac muscle, in one we used omentum tissue, in another — both the iliac muscle and the omentum. There were no fatalities registered, nor severe complications as per the Clavien–Dindo classification. The patients were followed-up for 4–18 months; as of today, no recurrence cases were identified. Control examinations showed complete patency of the neoureter and good vascularization of the BG. Thus, this method can be an option in cases disallowing distal ureter restoration with tissues of the patient's own urinary tract or segments of the gastrointestinal tract.

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.