Open ureteroplasty with buccal mucosa graft for long proximal strictures: A good option for a rare problem

[Robot-assisted laparoscopic ureteroplasty with buccal mucosa graft for complex ureteral stricture]

OBJECTIVE

To investigate the feasibility, safety and effectiveness of robot-assisted laparoscopic buccal mucosa graft ureteroplasty in the treatment of complex long proximal ureteral stricture.

METHODS

The clinical data of 20 patients with proximal ureteral stricture undergoing robot-assisted laparoscopic buccal mucosa graft ureteroplasty admitted to the Department of Urology, Peking University First Hospital and Beijing Jiangong Hospital from July 2022 to January 2023 were prospectively collected and analyzed. Intraoperative conditions, postoperative complications and follow-up data were also recorded and analyzed.

RESULTS

The operations under robot-assisted laparoscopy were performed successfully in all the 20 patients without conversion to traditional laparoscopic surgery or open surgery. The study included 14 males and 6 females with a mean age of (41±11) years (range: 19 to 60 years) and a mean body mass index of (24.3±3.6) kg/m2 (range: 18.2 to 31.8 kg/m2). There were 9 cases on the left side and 11 cases on the right side. The strictures of all the patients were located in the proximal segment of the ureter (including the ureteropelvic junction). The mean preoperative serum creatinine was (92.2±23.3) μmol/L (range: 49.2 to 138.9 μmol/L), and the mean length of ureteral stricture was (2.8±0.9) cm (range: 1.0 to 4.0 cm). Ten patients had previously undergone unsuccessful reconstructive surgery. During the operation, 12 patients received posteriorly augmented anastomosis with ventral onlay. The mean length of the buccal mucosa graft harvested during the operation was (3.1±0.6) cm (range: 2.0 to 4.3 cm), and the median width was 1.5 cm (range: 1.0 to 2.0 cm). The omentum flap was used to wrap the reconstructed ureteral segment in all the 20 cases. The median operative time was 154 min (range: 113 to 300 min), and the median estimated blood loss was 45 mL (range: 0 to 100 mL). The median postoperative hospital stay was 4 d (range: 4 to 14 d). The mean postoperative follow-up time was (15.0±1.7) months (range: 12.5 to 17.9 months), and the surgical success rate was 100.0% in this study. After surgery, 11 patients reported mild discomfort at the oral donor site, 2 patients deve-loped urinary tract infection, and no postoperative complications were reported in the other 7 patients. The mean serum creatinine was (90.9±23.9) μmol/L (range: 60.0 to 153.0 μmol/L) six months after surgery.

CONCLUSION

Robot-assisted laparoscopic buccal mucosa graft ureteroplasty for the treatment of complex long proximal ureteral stricture has satisfactory efficacy without severe complications, which has shown good feasibility, safety and effectiveness. However, large sample studies and long-term follow-up are still needed to evaluate its long-term efficacy.

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.

Ureteroplasty with buccal mucosa graft without omental wrap: an effective method to treat ureteral strictures

PURPOSE

Successful treatment options for ureteral strictures are limited. Surgical options such as ileal interposition and kidney autotransplantation are difficult and associated with morbidity and complications. Techniques such as Boari flap and psoas hitch are limited to distal strictures. Only limited case studies on the success of open buccal mucosa graft (BMG) ureteroplasty exist to this date. The purpose of this study was to evaluate the success of open BMG ureteroplasty without omental wrap.

METHODS

In this single-center retrospective study between July 2020 and January 2023, we included 14 consecutive patients with ureteric strictures who were treated with open BMG ureteroplasty without omental wrap. The primary outcome was the success of open BMG ureteroplasty. Further endpoints were complications and hospital readmission. Outcome variables were assessed by clinical examination, kidney sonography, and patient anamnesis.

RESULTS

Out of 14 patients, 13 were stricture and ectasia-free without a double-J stent at a median follow-up of 15 months (success rate 93%). No complications were observed at the donor site, and the complication rate overall was low with 3 out of 14 patients (21%) having mild-to-medium complications.

CONCLUSIONS

Open BMG ureteroplasty without omental wrap is a successful and feasible technique for ureteric stricture repair.

Laparoscopic ventral onlay ureteroplasty with buccal mucosa graft for complex proximal ureteral stricture

INTRODUCTION

There is lack of papers dedicated to the laparoscopic buccal mucosa graft (BMG) ureteroplasty of the complex upper ureteral stricture. The aim of this study is to evaluate the results of laparoscopic BMG ureteroplasty in patients with complex proximal ureteral stricture.

MATERIAL AND METHODS

Twenty-four patients underwent laparoscopic ventral onlay BMG ureteroplasty for long or recurrent proximal ureteral stricture not amenable to uretero-ureteral anastomosis over 2019-2022. Patient demographics, operative time, estimated blood loss, length of stay, follow-up, intra- and postoperative complication rate and percentage of stricture-free at last visit were analyzed.

RESULTS

The mean stricture length was 3.6 cm. The mean operative time was 208.3 min, while mean blood loss was 75.8 mL. The length of hospital stay was 7.3 days. No intraoperative complications were observed. Postoperatively, seven patients developed complications (29.2%). Five patients experienced a Grade II (according to Clavien nomenclature). Two patients developed a Grade IIIa complication, which included leakage of the anastomosis site. The mean follow-up was on the 22 months with stricture free rate 87.5%.

CONCLUSION

Patients with proximal ureteral strictures could be effectively treated by laparoscopic ventral onlay ureteroplasty with a buccal mucosa graft.

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.

Validation of robotic-assisted ureteroplasty with buccal mucosa graft for stricture at the proximal and middle ureters: the first comparative study

Although ureteroplasty with buccal mucosa graft for long-segmental ureteral stenosis has been developed long ago, evidence was still restricted to case series in published literature. This study aims to validate ureteroplasty with buccal mucosa graft (BMG) in long-segment stricture at the proximal and middle ureters under designed comparative methods. From April 2015 to January 2019, we performed robotic-assisted ureteroplasty with BMG with a two-phase design and compared ureteroplasty and BMG (phase 2 surgery) with endoscopic stenting (phase 1 surgery). Paired data of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), hydronephrosis grade, and physical and psychological domains of the World Health Organization Quality of Life (WHOQOL)-BREF were compared. A total of 29 patients were enrolled, and only three (10%) patients had hydronephrosis resolution after treatment with endoscopic stenting (p = 0.250 to baseline). Compared to endoscopic ureteral stent, Hedges' g of ureteroplasty with BMG was 0.56 (95% CI 0.43-0.69), 0.63 (95% CI 0.46-0.80), 0.80 (95% CI 0.56-1.04), and 1.06 (95% CI 0.69-1.43) in EGFR, GFR, physical domain of WHOQOL-BREF, and psychological domain of WHOQOL-BREF, respectively (All significance; p < 0.001). After 12-month follow-ups, no recurrence of stricture was reported. In conclusion, Robotic-assisted ureteroplasty with BMG onlay is efficient in reconstruction of long-segment stricture of the proximal and middle ureters.

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.

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.