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

Minimally invasive versus open ileal ureter with ileocystoplasty: comparative outcomes and 5-year experience

PURPOSE

To present the experience of ileal ureter with ileocystoplasty (IUC), and compare the outcomes of IUC in minimally invasive procedures to open procedures.

PATIENTS AND METHODS

From December 2017 to April 2023, twenty patients underwent IUC in open or minimally invasive (including laparoscopic and robotic) procedures. The baseline characteristics, perioperative data and follow-up outcomes were collected. Success was defined as relief of clinical symptoms, stable postoperative serum creatine and absence of radiographic obstruction. The perioperative and follow-up outcomes of open procedures and minimally invasive procedures were compared.

RESULTS

The etiology included pelvic irradiation (14/20), urinary tuberculosis (3/20) and surgical injury (3/20). Bilateral ureter strictures were repaired in 15 cases. The surgeries conducted consisted of open procedures in 9 patients and minimally invasive procedures in 11 patients. Compared to open procedures, minimally invasive surgeries had less median estimated blood loss (EBL) (100 ml vs. 300 min, p = 0.010) and shorter postoperative hospitalization (27 d vs. 13 d, p = 0.004). Two patients in the open group experienced grade 3 complications (sigmoid fistula and acute cholecystitis in one patient, and pulmonary embolism in another patient). Over a median follow-up period of 20.1 months, the median bladder functional capacity was 300 ml, with a 100% success rate of IUC.

CONCLUSION

IUC is feasible in both open and minimally invasive procedures, with acceptable complications and a high success rate. Minimally invasive procedures can have less EBL and shorter postoperative hospitalization than open procedure. However, prospective studies with larger groups and longer follow-up are needed.

Robotic reconstruction of necrosed ileal ureter: Technical challenges, intra-operative difficulty, and learning points

This video explores the challenges faced during a re-do robotic intra-corporeal ileal ureter reconstruction in a previously operated case. A 24-year-old woman presented with a 12-cm long stricture after robotic ileal ureter replacement surgery. A proper preoperative evaluation in the form of ureteroscopy and a nephrostogram is essential and the key steps include adhesiolysis, identification of the necrotic ileal ureter, and meticulous dissection. A 13-cm long segment of the ileum was isolated and was anastomosed to the renal pelvis and the bladder. The surgery lasted for 420 min with 300 ml of blood loss. Post-operatively, the patient recovered well and had a normal drainage with no complications at 1-year of follow-up. The factors such as a broad mesentery, a tension-free anastomosis, and avoiding the twisting of the pedicle are crucial for success of robotic ileal ureter replacement surgery.

Total intracorporeal laparoscopic ileal ureter replacement in a single position for ureteral stricture based on membrane anatomy

PURPOSE

The aim of this study was to present our initial experience and prove the feasibility of total intracorporeal laparoscopic ileal ureter replacement (TILIUR) in a single position for ureteral stricture based on membrane anatomy.

MATERIALS AND METHODS

Between January 2021 and April 2023, six patients underwent TILIUR in a single position for ureteral strictures based on membrane anatomy. All patients with a past medical history underwent radical hysterectomy with bilateral pelvic lymph node dissection as well as extensive ureteral stricture due to radiotherapy. The procedure is performed completely laparoscopically. Dissection of the digestive system as well as ureteral stricture or renal pelvis is based on membrane anatomy. The surgery is performed in a single position.

RESULTS

TILIUR in a single position for ureteral stricture based on membrane anatomy was successfully performed without open conversion in all patients. Among the 6 patients, 3 patients underwent combined ileal ureter replacement (IUR) and abdominal wall ostomy, 2 underwent unilateral IUR, and 1 underwent bilateral IUR. The mean length of the ileal substitution was 22.83 cm (range: 15-28). The average operative time was 458 ± 72.77 min (range 385-575 min), and the average intraoperative blood loss was 158 mL (range 50-400 mL). The median postoperative hospital stay was 15.1 d (range: 8-32). The median duration of postoperative follow-up was 15 months (range: 3-29 months). The success rate was 100%.

CONCLUSIONS

TILIUR in a single position may be a promising option for ureteral stricture based on membrane anatomy in selected patients. Moreover, it has a positive effect on patients with renal insufficiency and urinary incontinence. Although IUR is difficult and risky, proficient surgeons can perform the procedure safely and effectively.

Laparoscopic continent cutaneous urinary diversion using a modified Yang-Monti technique in an adult: A case report including 5-year follow-up

Continuous cutaneous urinary diversion is challenging when the appendix is physically unavailable. The Yang-Monti channel is an alternative to the tunneled appendix for urinary diversion. We present a case involving a 49-year-old man who underwent total urethrectomy and cystostomy 10 months previously. No tumor recurrence was observed; however, the patient experienced severe catheter-related bladder irritation after the procedure. The patient was readmitted to the authors' hospital and underwent laparoscopic continent cutaneous urinary diversion using extracorporeal construction of a modified Yang-Monti channel. The operation lasted 232 minutes, with an estimated blood loss of 10 mL. The patient was discharged from hospital 6 days after surgery and removal of the cystostomy tube. After this, clean intermittent catheterization was performed every 3 hours for 4 weeks. Five years after the procedure, the modified Yang-Monti channel was still used for clean intermittent catheterization without any stomal stenosis being observed. The patient was satisfied with his postoperative quality of life.

Ileal Interposition for Ureteral Reconstruction Following Treatment for Abdominopelvic Malignancy: Complications and Outcomes From a Comprehensive Cancer Center

OBJECTIVE

To characterize the outcomes of ileal interposition for the management of ureteral obstruction from tumor and ureteral stricture following treatment for abdominopelvic malignancy.

MATERIALS AND METHODS

A retrospective database analysis was performed for all cases of ileal interposition performed by 5 surgeons from January 2013 to December 2020. Patients were ≥18 years of age and included if undergoing ileal interposition in either the primary setting of a surgical procedure for tumor extirpation or in the delayed setting.

RESULTS

In total, 23 patients who underwent repair of 27 ureteral units were included. The mean age was 60.2 years. Median follow-up was 21.6 months. The most common primary diagnoses were urothelial (35%), colorectal (31%), and cervical (22%) cancer. The etiologies of ureteral obstruction were malignant in 48% and ureteral stricture in 52%. Types of repairs included unilateral interposition in 13 patients, bilateral interposition in 1 patient, interposition to an ileal conduit in 3 patients, and interposition with cystoplasty in 6 patients. There was a statistically significant difference between the mean preoperative (Creatinine 1.05 mg/dL, Estimated Glomerular Filtration Rate 77 ml/min/1.73 m2) renal function and postoperative (Creatinine 1.26 mg/dL, Estimated Glomerular Filtration Rate 67 mL/min/1.73 m2) renal function at the most recent follow-up (P = .024). Eight minor (grade 1-2) and 6 major (grade ≥3) complications developed for a minor and major complication rate of 35% and 26%, respectively.

CONCLUSION

Ileal interposition is successfully utilized as a reconstructive technique at the time of enbloc resection involving the ureter and to address ureteral stricture in the delayed setting.

Totally Intracorporeal Robot-assisted Unilateral or Bilateral Ileal Ureter Replacement for the Treatment of Ureteral Strictures: Technique and Outcomes from a Single Center

BACKGROUND

Few studies on totally intracorporeal robot-assisted ileal ureter replacement (RA-IUR) have been reported.

OBJECTIVE

To report our technique and the outcomes of totally intracorporeal RA-IUR for unilateral or bilateral ureteral reconstruction, involving performing cystoplasty simultaneously.

DESIGN, SETTING, AND PARTICIPANTS

Fifteen patients underwent totally intracorporeal RA-IUR from April 2021 to July 2022 at a single center. The perioperative variables were prospectively collected, and the outcomes were assessed.

SURGICAL PROCEDURE

The surgical procedure included dissection of the proximal end of the ureteral stricture or renal pelvis, harvesting of the ileal ureter, rebuilding of intestinal continuity, upper anastomosis of the ileum to the renal pelvis or the ureteral end, and lower anastomosis of the ileum to the bladder. All operations were performed intracorporeally.

MEASUREMENTS

Patient demographics and perioperative results were prospectively collected and analyzed for perioperative complications and success rates. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

All patients successfully underwent totally intracorporeal RA-IUR without open conversion. Seven patients received unilateral RA-IUR and eight received bilateral RA-IUR. The mean (range) length of the harvested ileal segment was 28.3 (15-40) cm, the operative duration was 261.8 (183-381) min, the estimated blood loss was 64.7 (30-100) ml, and the duration of postoperative hospitalization was 10.5 (7-17) d. At a median (range) follow-up of 14 (8-22) mo, the subjective and functional success rates were 100% and 86.7%, respectively.

CONCLUSIONS

Our results demonstrate that totally intracorporeal unilateral or bilateral RA-IUR (even with ileocystoplasty) can be performed safely and efficiently with acceptable minor complications and a high success rate.

PATIENT SUMMARY

Our study indicates that totally intracorporeal robotic ileal ureter replacement surgery is safe and feasible for ureteral reconstruction, even with ileocystoplasty. The postoperative complications are acceptable. At a median follow-up of 14 (8-22) mo, the subjective and functional success rates were 100% and 86.7%, respectively.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Robotic-assisted Laparoscopic Bilateral Ileal Ureter Replacement With Extracorporeal Ileal Segment Preparation for Bilateral Extensive Ureteral Strictures: The Initial Experience

OBJECTIVE

To present our initial experience and evaluate perioperative, and follow-up outcomes following the novel technique of robot-assisted laparoscopic bilateral ileal ureter replacement (IUR) with extracorporeal ileal segment preparation for bilateral extensive ureteral strictures (BEUS).

METHODS

We prospectively enrolled 4 consecutive patients with BEUS undergoing robot-assisted laparoscopic bilateral IUR with extracorporeal ileal segment preparation between June 2021 and October 2021. A 4-arm technique was used. The demographic characteristics, perioperative data, and follow-up outcomes as well as the description of surgical technique were reported.

RESULTS

All the patients had BEUS, and the length of strictures was over 10.ßcm in both sides. All procedures were performed effectively with a median operative time of 312.5.ßminutes (range 227-433) and a median estimated blood loss of 75.ßmL (range 50-200). In one patient, additional partial small bowel resection procedure was performed. No case was converted to open surgery. The median length of the ileal graft was 29.ßcm (range 15-32). The median postoperative hospitalization was 10 days (range 6-13). Two patients developed metabolic acidosis, and no major complications during the perioperative and follow-up period were reported. All patients presented symptom-free, with no signs of restenosis and improved/stabilized hydronephrosis, during the median follow-up of 12 months (range 12-15).

CONCLUSION

We present the details and initial experience of robot-assisted laparoscopic bilateral IUR with extracorporeal ileal segment preparation. According to the median follow-up of 12 months, this minimally invasive procedure is a safe, feasible, and effective approach in the management of BEUS.

Robot-assisted laparoscopic ileal ureter replacement with extracorporeal ileal segment preparation for long ureteral strictures: a case series

BACKGROUND

Complete intracorporal robotic ileal ureteric replacement is challenging. We aimed to present the surgical technique of robotic ileal ureter replacement with extracorporeal ileal segment preparation for long ureteral strictures.

METHODS

From March 2019 to March 2021, 18 patients underwent robotic ileal ureter replacement with extracorporeal ileal segment preparation by one experienced surgeon. The demographic, perioperative, and follow-up data were recorded. Success was defined as the resolution of the presenting symptom, a stable estimated glomerular filtration rate and unobstructive drainage on imaging examination.

RESULTS

All 18 surgeries were successfully completed without conversion. The median length of the intestinal tube used was 20 (12-30) cm. The median operative time was 248 (170-450) min, the median estimated blood loss was 50 (10-200) ml, and the median postoperative hospital stay was 7 (5-27) days. At a median follow-up of 16 (13-28) months, all patients were symptom-free. No or mild hydronephrosis was confirmed in 17 patients; 1 patient had moderate hydronephrosis without peristalsis of the ileal ureter. The renal function was stable in all patients. The overall success rate was 100%. Postoperative complications, including 4 cases of urinary infections (Grade I), 1 case of an incision hernia (Grade I), 4 cases of kidney stone formation (Grade I), 6 cases of metabolic acidosis (Grade I), 4 cases of incomplete ileus (Grade II), and 1 case of an incision infection (Grade IIIb).

CONCLUSIONS

Robot-assisted laparoscopic ileal ureter replacement with extracorporeal ileal segment preparation is safe, feasible, and effective for the treatment of long ureteral strictures, especially in high-volume tertiary referral centers with extensive robotic surgery experience capable of managing severe peri-operative complications.

Long-term results of extended Boari flap technique for management of complete ureteral avulsion: A case report

BACKGROUND

Ureteroscopy is well-established as a primary treatment modality for urolithiasis. Ureteral avulsion, particularly complete or full-length avulsion with a resultant long segment of the ureter left attached to the ureteroscope, is a rare but devastating complication of the procedure. Management of this complication is challenging. Moreover, general consensus regarding the optimal management is undetermined. We report our experience of managing a complete ureteral avulsion case via an extended Boari flap technique with long-term results.

CASE SUMMARY

A 41-year-old female patient subjected to complete ureteral avulsion caused by ureteroscopy was referred to our hospital. A modified, extended Boari flap technique was successfully performed to repair the full-length ureteral defect. Maximal mobilization of the bladder and affected kidney followed by psoas hitch and downward nephropexy maximized the probability of a tension-free anastomosis. Meticulous blood supply preservation to the flap also contributed to the success. During the 4-year study period, no complications except for a mild urinary frequency and a slightly lower maximum urinary flow rate were reported. The patient was satisfied with the surgical outcomes.

CONCLUSION

The extended Boari flap procedure is a feasible and preferred technique to manage complete ureteral avulsion, particularly in emergencies.

[Ureteral stenosis following hematopoietic stem cell transplantation: A case report]

Ureteral stenosis is a comparatively rare complication following hematopoietic stem cell transplantation (HSCT). The etiology is still unclear and most believe that this may be due to the reactivation of BK virus in a state of immunodeficiency. In the later stages of ureteral stenosis with scarring, invasive interventions must be taken to relieve the hydronephrosis. Common treatments, such as D-J stent placement and permanent nephrostomy may not only entail the risk of infection, but also seriously affect the quality of life. Few cases of surgical intervention have been reported. In this article, a 25-year-old female was admitted to Peking University First Hospital suffering from recurrent flank pain. Seven years before, she developed hemorrhagic cystitis and bilateral urethritis 40 days after allogeneic HSCT. After continuous bladder irrigation and antiviral therapy, the left-sided hydronephrosis gradually alleviated while the right-sided one did not improve. D-J stents were used for urine drainage for 7 years before percuta-neous nephrostomy. Preoperative antegrade pyelography revealed significant hydronephrosis in the right kidney with long stricture of proximal-middle ureter. After comprehensive decision, she underwent ileal ureter replacement. The operation was successful. The segmental lesion was dissected and the scar tissue was removed. A 25 cm intestinal tube was isolated to connect the pelvis and bladder. An anti-reflux nipple was created at the distal end of ileal ureter to prevent the potential infection. The blood loss was minimal. After surgery, the drainage tube was removed in 2 weeks, the nephrostomy tube and the D-J stent was removed in 3 months. Follow-up mainly included clinical assessment, serologic testing, renal ultrasonography, blood gas analysis and radiological examination. During the follow-up of 6 years, she was symptom-free and no postoperative complications occurred. The serum creatinine level was stable. No hydronephrosis was observed under ultrasonography. Obvious peristaltic waves and ureteral jets of the ileal ureter was confirmed on cine magnetic resonance urography. To sum up, ureteral stenosis after HSCT is relatively rare. Obstruction caused by scarring is usually irreversible and surgical intervention should be designed according to the location and length of the lesion. Ileal ureter replacement can be a safe, feasible and effective method to solve this kind of complex stricture.

Ileal ureteral replacement for the management of ureteral avulsion during ureteroscopic lithotripsy: a case series

INTRODUCTION

To describe our initial experience with ileal ureteral replacement (IUR) for the management of ureteral avulsion (UA) during ureteroscopic lithotripsy.

METHODS

Between September 2010 and April 2021, ten patients received ileal ureteral replacement for ureteral avulsion during ureteroscopic lithotripsy. Anterograde urography and computed tomography urography (CTU) were applied to evaluate the lesion. Follow-up was performed with magnetic resonance urography and renal ultrasound as well as clinical assessment of symptoms. We retrospectively analysed the clinical data of ten patients treated with ileal ureteral replacement for the treatment of ureteral avulsion.

RESULTS

Four patients underwent open ileal ureteral replacement, two underwent laparoscopic ileal ureteral replacement, and four underwent robotic-assisted ileal ureteral replacement. The mean operative time (OT) was 310 min (range 191-530). The mean estimated blood loss (EBL) was 193 mL (range 10-1000). The mean length of the ileal graft was 21 cm (range 12-25). The median postoperative hospital time was 13 days (range 7-19). All surgeries were effectively completed, and no case required open conversion in laparoscopic and robotic-assisted surgeries. There was no obvious hydronephrosis according to contrast-enhanced computed tomography 3-dimensional reconstruction images without serious complications or progressive hydronephrosis during a median follow-up duration of 51 months (range 5-131), and the success rate was 100%.

CONCLUSIONS

Our initial results and experience showed that ileal ureteral replacement for the management of ureteral avulsion during ureteroscopic lithotripsy is safe and feasible.

Cine magnetic resonance urography and Whitaker test: dynamic visualized and quantified tools in ileal ureter replacement

Background

To assess the feasibility and usefulness of cine magnetic resonance urography (MRU) and Whitaker test as postoperative evaluation tools of ileal ureter replacement.

Methods

We retrospectively collected the medical records of 42 patients who underwent ileal ureter replacement between August 2015 and August 2020. The morphology, luminal diameter, amplitude, contraction ratio, peristaltic frequency, ureteral jets and peristalsis efficiency were recorded in cine MRU. Under different perfusion loads, image and pressure changes of the reconstructed upper urinary tract were recorded in the Whitaker test. Patients were categorized into normal pressure and elevated pressure groups.

Results

A total of 42 patients underwent cine MRU, and 20 of them finished the Whitaker test successfully. The mean amplitude was 9.29±3.51 mm, and the contraction ratio was 0.607 (0.247–0.790). The median peristaltic efficiency was 0.75 (0.29–1). Three patients presented an unusual rise in renal pelvis pressure, which was 54, 26, 57 cmH₂O respectively. The amplitude of the ileal graft in the elevated pressure group was larger (13.80±5.73 vs. 8.09±3.38 mm, P=0.024), the contraction ratio was higher [0.68 (0.59–0.79) vs. 0.59 (0.25–0.79), P=0.028], the peristaltic frequency was more active [7 (6–8) vs. 4 (3–8), P=0.025], but the peristaltic efficiency was lower [0.50 (0.29–0.50) vs. 0.75 (0.33–1), P=0.029] compared to the normal pressure group. There were no significant differences in the ureteral jets [3 (2–4) vs. 3 (1–7), P=0.840), creatinine (97.3±7.3 vs. 103.2±30.7 µmol/L, P=0.753), and estimated glomerular filtration rate (eGFR) (76.4±14.1 vs. 68.5±28.7 mL/min·1.73 m², P=0.663).

Conclusions

Cine MRU provides morphological and peristaltic motility of the ileal graft, cine MRU after ileal ureter replacement was recommended as a routine examination. The Whitaker test represents a complementary investigation to evaluate pressure changes to reveal the ability to transport urine, and it can be used as a supplementary examination to clarify equivocal cases.

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.

Ureteral reconstruction for complex strictures: a review of the current literature

PURPOSE

Frequently employed procedures for ureteral reconstruction include balloon dilation, pyeloplasty and ureteral re-implants. However, these procedures do not work for complex ureteral disease. The goal of this literature review is to report on techniques and success rates for the following techniques: buccal graft ureteroplasty, appendiceal interposition, transureteroureterostomy, ileal ureter and autotransplantation.

METHODS

A comprehensive literature search for English-language original and review articles was conducted using PubMed. The following terms were queried: "ureteral reconstruction", "buccal graft", "appendiceal interposition", "ileal ureter", "transureteroureterostomy", "autotransplantation".

RESULTS

Procedures involving the buccal mucosa or appendix offer minimally invasive techniques and low morbidity with good short-term success. Drawbacks to appendiceal interposition include the availability and length of appendix, and 10-20% of patients may have insufficient appendix upon intra-operative assessment. Transureteroureterostomy is typically limited to extensive exonerations due to concerns of injury to the contralateral kidney, even with reported success rates > 90%. Ileal ureter may carry a risk of metabolic acidosis in patients with renal insufficiency along with bowel-related complications. Ileal ureter and autotransplantation are reserved for the most severe cases due to their high morbidity but do offer options for the complex patient.

CONCLUSION

Ureteral stricture disease not amenable to pyeloplasty, ureteroureterostomy or ureteroneocystostomy offers a challenge to urologist. Careful patient selection with pre-operative assessment of renal and bladder is vital to a successful operation with minimal complications.

Ureteral intussusception: a case report and review of literature

Ureterorenoscopy (URS) is a minimal invasive procedure used for diagnosis and management of the upper urinary tract. Due to the vast advancement in URS technologies, the efficacy and safety greatly improved with lower complication rates. Intussusception is a rare complication of URS. We report a case of iatrogenic ureteral intussusception that was managed with ileal interposition.

Totally intracorporeal robotic ileal ureter replacement: focus on surgical technique and outcomes

BACKGROUND

The aim of the present study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations.

METHODS

Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences.

RESULTS

Median operative time was 270 (range 240-300) min. No Clavien-Dindo complication >2 was collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found.

CONCLUSIONS

Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Laparoscopic ileal ureteral replacement to preserve the natural anti-reflux system: An initial case report

INTRODUCTION

Ileal ureteral replacement is one of the treatment options for long ureteral strictures. Most ileal ureteral replacements anastomose the distal side of the ileal segment directly to the bladder. We have reported here an initial case of laparoscopic ileal ureteral replacement for preserving the natural anti-reflux system.

CASE PRESENTATION

A 29-year-old male presented with right flank pain, and his imaging results revealed multiple strictures of the right upper-middle ureter. Hence, we performed a laparoscopic ileal ureteral replacement surgery. The normal distal ureter was preserved, and the distal side of the ileal segment was anastomosed to it. As such, the natural anti-reflux system could be completely preserved. Following this, the renal function was maintained, and no urinary tract infection was recorded.

CONCLUSION

Laparoscopic ileal ureteral replacement, which preserves the natural anti-reflux system, can be considered as a treatment option for refractory upper-middle ureteral strictures.

Etiology and Ureteral Reconstruction Strategy for Iatrogenic Ureteral Injuries: A Retrospective Single-Center Experience

OBJECTIVE

To analyze the etiology, characteristics, and ureteral reconstruction strategies of iatrogenic ureteric injuries in a high-volume center.

METHODS

Between September 2010 and August 2019, we retrospectively collected patients who underwent ureteral reconstruction due to iatrogenic ureteric injuries. Patient profiles, laboratory data, imaging studies, perioperative data, and complications were recorded.

RESULTS

Sixty-eight patients were enrolled in this study. The upper, middle, and lower thirds of the ureter were affected in 30, 2, and 36 cases, respectively. Of the 68 ureteric injuries, 69.1% occurred during urological procedures, followed by gynecological procedures, general surgery, radiotherapy, and orthopedic surgery. The majority of urological injuries (41, 87.2%) occurred due to stone removal. There was a significant difference in the age, sex, and location of ureteric injuries between the urological and nonurological groups. The median follow-up time was 17.9 months. The overall symptom remission rate was 91.2% and ranged from 87.5 to 100% for different reconstructive surgeries.

CONCLUSIONS

Urological procedures were the most common cause of iatrogenic ureteric injury; thus, extra care should be taken. Timely detection and appropriate treatment of the ureteric injuries are necessary. Treatment strategies should be depended on the location and length of injury.

Indocyanine green fluorescence imaging for laparoscopic complex upper urinary tract reconstructions: a comparative study

Background

To describe our technique for using an intraureteral injection of indocyanine green (ICG) and visualization under near-infrared fluorescence (NIRF) to facilitate challenging upper urinary tract reconstructions (UUTRs) and to present the comparative outcomes.

Methods

We collected 36 patients who underwent laparoscopic UUTRs between April 2019 and March 2020, and we divided the patients into two groups based on the use of ICG (ICG group and non-ICG group). Demographic characteristics, perioperative outcomes, and functional outcomes were compared between the two groups.

Results

There were 18 cases in the ICG group and 18 cases in the non-ICG group, respectively. There were no differences in the baseline characteristics between the two groups. The intraoperative time to identification of the ureter (TIU; 20.9±11.7 vs. 30.0±14.6 min, P=0.03) and length of postoperative hospital stay (LPHS; 11.1±3.0 vs. 16.6±10.0 days, P=0.03) were significantly shorter in the ICG group. There was also a trend for lesser time for locating the stricture (43.0±27.9 vs. 55.4±18.6 min, P=0.14) and lower estimated blood loss (EBL) in the ICG group patients (88.3±75.4 vs. 91.7±46.2 mL, P=0.22). During the mean 3.8-month follow-up for the ICG group and the 6.2-month for the non-ICG group, there was a trend for more severe complications in the non-ICG group.

Conclusions

Visualizing intraureteral ICG under NIRF is useful in challenging UUTRs, allows for rapid ureteral identification and accurate real-time delineation of the ureteral stricture margins, and provides encouraging follow-up outcomes compared with those in the non-ICG group.

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.

Reconstruction of full-length ureter defects by laparoscopic bladder flap forming

To evaluate the safety and efficacy of laparoscopic bladder muscle flap reconstruction in the treatment of extensive ureteral avulsion. Patients with full-length (re length > 20 cm) and upper ureteral (avulsion length > 10 cm) defects were eligible. All patients were treated with laparoscopic bladder muscle flap reconstruction. Peri-operative information and post-operative complications were recorded. The kidney function, urinary ultrasound or computed tomography (CT), sun-renal function tests emission computed tomography (ECT) and cystography after operation were recorded. Ten patients were included (7 with full-length and 3 with upper ureteral defects). Median age was 56 years and 70% of them were female. The average operation time and blood loss was 124 min and 92.2 ml. There was no treatment-related adverse effects including urinary leakage, renal colic, fever, etc. The median follow-up was 18.5 months (3–39 months). The surgery did not significantly alter the renal function and separation degree of the renal pelvis during long-term follow-up. Double J stents were removed in nine patients (90%) within six months after operation. Only one case was diagnosed with post-operative anastomotic stricture, and subsequently received laparoscopic ipsilateral nephrectomy one year after the reconstruction operation. All cases had normal voiding and pear-shaped cystography. Laparoscopic bladder flap repair is a safe and effective treatment approach together with several advantages for patients with full-length or upper ureteral avulsion.

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy

PURPOSE

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios.

METHODS

From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures.

RESULTS

A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2-6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P < 0.001). At a mean follow-up of 12.8 months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches.

CONCLUSION

Laparoscopic and robotic onlay flap/graft ureteroplasty can be safe and feasible to repair long proximal/middle ureteral strictures while robotic procedures showed higher efficiency, faster recovery but higher cost. Our algorithmic strategies may provide beneficial references for their standardization and dissemination into clinical care.

[Robot-assisted laparoscopic upper urinary tract reconstruction surgery: A review of 108 cases by a single surgeon]

OBJECTIVE

To summarize the experiences and outcomes of 108 robot-assisted laparoscopic upper urinary tract reconstruction surgeries conducted by a single surgeon.

METHODS

We consecutively and retrospectively reviewed 108 patients who underwent robot-assisted laparoscopic upper urinary tract reconstruction surgeries by a single surgeon from November 2018 to January 2020. The patient demographics, perioperative variables, postoperative complications and follow-up data were recorded. Fifty-three modified dismembered pyeloplasties (MDP), 11 spiral flap pyeloplasties (SFP), 11 ure-teroureterostomies (UUT), 4 lingual mucosal onlay graft ureteroplasties (LMU), 5 appendiceal onlay flap ureteroplasties (AU), 11 ureteral reimplantations (UR), 6 Boari flap-Psoas hitch surgeries (BPS) and 7 ileal ureter replacements (IUR) were enrolled finally. The success was defined as the improvement in subjective pain levels, and the improvement in the degree of hydronephrosis at ultrasound.

RESULTS

All the surgeries were successfully completed without open or laparoscopic conversion. The median operative time was 141 min (range: 74-368 min), median blood loss was 20 mL (range: 10-350 mL) and median hospital stay was 4 d (range: 3-19 d) in MDP group, with the success rate of 94.3%. The median operative time was 159 min (range: 110-222 min), median blood loss was 50 mL (range: 20-150 mL) and median hospital stay was 5 d (range: 3-8 d) in SFP group, with the success rate of 100%. The median operative time was 126 min (range: 76-160 d), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 5 d (range: 4-9 d) in UUT group, with the success rate of 100%. The median operative time was 204 min (range: 154-250 min), median blood loss was 30 mL (range: 10-100 mL) and median hospital stay was 6 d (range: 4-7 d) in LMU group, with the success rate of 100%. The median operative time was 164 min (range: 135-211 min), median blood loss was 75 mL (range: 50-200 mL) and median hospital stay was 8.5 d (range: 6-12 d) in AU group, with the success rate of 100%. The median operative time was 149 min (range: 100-218 min), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 7 d (range: 5-10 d) in UR group, with the success rate of 90.9%. The median operative time was 166 min (range: 137-205 min), median blood loss was 45 mL (range: 20-100 mL) and median hospital stay was 5 d (range: 4-41 d) in BPS group, with the success rate of 83.3%. The median operative time was 270 min (range: 227-335 min), median blood loss was 100 mL (range: 10-100 mL) and median hospital stay was 7 d (range: 5-26 d) in IUR group, with the success rate of 85.7%.

CONCLUSIONS

The surgeon performed and modified numerous complicated upper urinary tract reconstruction surgeries by the robotic platform, which facilitated the development of the standardized upper urinary tract reconstruction surgical technique.

[Robot-assisted laparoscopic upper urinary tract reconstruction surgery: A review of 108 cases by a single surgeon]

OBJECTIVE

To summarize the experiences and outcomes of 108 robot-assisted laparoscopic upper urinary tract reconstruction surgeries conducted by a single surgeon.

METHODS

We consecutively and retrospectively reviewed 108 patients who underwent robot-assisted laparoscopic upper urinary tract reconstruction surgeries by a single surgeon from November 2018 to January 2020. The patient demographics, perioperative variables, postoperative complications and follow-up data were recorded. Fifty-three modified dismembered pyeloplasties (MDP), 11 spiral flap pyeloplasties (SFP), 11 ure-teroureterostomies (UUT), 4 lingual mucosal onlay graft ureteroplasties (LMU), 5 appendiceal onlay flap ureteroplasties (AU), 11 ureteral reimplantations (UR), 6 Boari flap-Psoas hitch surgeries (BPS) and 7 ileal ureter replacements (IUR) were enrolled finally. The success was defined as the improvement in subjective pain levels, and the improvement in the degree of hydronephrosis at ultrasound.

RESULTS

All the surgeries were successfully completed without open or laparoscopic conversion. The median operative time was 141 min (range: 74-368 min), median blood loss was 20 mL (range: 10-350 mL) and median hospital stay was 4 d (range: 3-19 d) in MDP group, with the success rate of 94.3%. The median operative time was 159 min (range: 110-222 min), median blood loss was 50 mL (range: 20-150 mL) and median hospital stay was 5 d (range: 3-8 d) in SFP group, with the success rate of 100%. The median operative time was 126 min (range: 76-160 d), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 5 d (range: 4-9 d) in UUT group, with the success rate of 100%. The median operative time was 204 min (range: 154-250 min), median blood loss was 30 mL (range: 10-100 mL) and median hospital stay was 6 d (range: 4-7 d) in LMU group, with the success rate of 100%. The median operative time was 164 min (range: 135-211 min), median blood loss was 75 mL (range: 50-200 mL) and median hospital stay was 8.5 d (range: 6-12 d) in AU group, with the success rate of 100%. The median operative time was 149 min (range: 100-218 min), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 7 d (range: 5-10 d) in UR group, with the success rate of 90.9%. The median operative time was 166 min (range: 137-205 min), median blood loss was 45 mL (range: 20-100 mL) and median hospital stay was 5 d (range: 4-41 d) in BPS group, with the success rate of 83.3%. The median operative time was 270 min (range: 227-335 min), median blood loss was 100 mL (range: 10-100 mL) and median hospital stay was 7 d (range: 5-26 d) in IUR group, with the success rate of 85.7%.

CONCLUSIONS

The surgeon performed and modified numerous complicated upper urinary tract reconstruction surgeries by the robotic platform, which facilitated the development of the standardized upper urinary tract reconstruction surgical technique.

A Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter

BACKGROUND

Iatrogenic ureteral injuries are devastating complications potentially resulting in irreversible impairment of renal function and/or infectious sequelae. Only few data are available on the management of such injuries to the abdominal ureter.

OBJECTIVE

To report the etiology, perioperative outcomes, and treatment failure rate of different reconstructive surgical interventions for iatrogenic injuries to the abdominal ureter in a contemporary case series.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed consecutive patients who underwent reconstructive surgery for iatrogenic injuries to the abdominal ureter at our academic centers between July 2013 and April 2019. All interventions were performed via either an open or a robot-assisted approach by a single expert surgeon.

SURGICAL PROCEDURE

Different surgical reconstructive procedures, such as Boari bladder flap, ureteroureterostomy, ileal replacement, and pyeloureteroplasty, have been adopted.

MEASUREMENTS

Outcome measures were the etiology of iatrogenic injuries, rate of postoperative complications, and rate of treatment failure, defined as upper urinary tract obstruction requiring permanent urinary drainage.

RESULTS AND LIMITATIONS

Nineteen patients were included. Injuries were consequent to endourological procedures in nine (47.4%), gynecological procedures in two (10.5%), colonic surgery in two (10.5%), vascular surgery in two (10.5%), and other surgeries in four (21.1%) cases. Boari bladder flap was performed in 12 (63.2%), ureteroureterostomy in two (10.5%), ileal substitution in two (10.5%), and pyeloureteroplasty in three (15.8%) cases. Only four (21.1%) procedures were performed robotically. Major postoperative complications were recorded in three (15.8%) patients. After a median follow-up of 16 (interquartile range 12-24) mo, treatment failure was observed in two (15.8%) cases. We accept the limitations of a small retrospective single-surgeon series with preference-based management choice.

CONCLUSIONS

In our series, endourological procedures were the most frequent cause of iatrogenic injuries to the abdominal ureter requiring reconstructive surgery. A Boari bladder flap was the preferred option to bridge extensive ureteral defects. Despite the complexity of such procedures, major postoperative complications were infrequent and treatment failure rate was low.

PATIENT SUMMARY

We report on a contemporary series of patients with disparate iatrogenic injuries to the abdominal ureter requiring complex reconstructive surgery. Despite the difficulty of such procedures, we found that major postoperative complications were infrequent and treatment failure rate was low.

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.