Reconstruction of Ureteral Necrosis in Kidney Transplantation Using an Ileum Interposition

Whole ureter replacement with Yang-Monti principle: successful treatment of challenging conditions

BACKGROUND

No clear consensus has been reached on the reconstruction of long-segment or total ureter discontinuation. Here we present our experience using the Yang-Monti technique in total ureter reconstruction.

METHODS

This study was a single-center retrospective study of patients who underwent Yang-Monti ileal whole ureter reconstruction (from the ureteropelvic junction[UPJ] to the ureterovesical junction). Data were collected on patients' baseline characteristics, stricture etiology, the time interval between insult and surgical repair, pre/postoperative serum creatinine, estimated glomerular filtration rate (eGFR), split renal function, complications during admission and follow-ups, and the indwelling durations of JJ tubes and nephrostomy tubes, if presented.

RESULTS

Seven patients underwent Yang-Monti ileal ureter reconstruction in 2010-2020 at our hospital. One of the patients underwent single-session bilateral ureter repair. Radiation therapy-related fibrosis and degloving injury were the most common etiologies for ureter injury. The median interval between ureter insult and operation was 8 months. The median follow-up was 36.7 months. The average operation time was 11.4 h, and the average blood loss was 273 ml. Postoperatively, no significant differences were found in serum creatinine, eGFR, or split renal function. As for postoperative complications, two patients experienced ileus and were treated conservatively. One patient had UPJ stenosis, which resolved after re-anastomosis surgery 11 months later. Metabolic acidosis or electrolyte imbalance was not reported.

CONCLUSION

We found that ileal replacement of total ureteral loss using the Yang-Monti principle is effective and durable. This is the largest cohort study conducted with more than 2 years of follow-up.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents

OBJECTIF

Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US).

MATERIAL

We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion.

RESULTS

22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4μmol/l respectively, P=0.67), nor urinary diversion.

CONCLUSION

KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers.

LEVEL OF EVIDENCE

3.

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.

Preperitoneal Surgical Approach to Treat Vesicoureteral Anastomotic Leakage, Distal Stenosis or Reflux After Kidney Transplantation

BACKGROUND

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment.

METHODS

Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1 year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks.

RESULTS

This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter.

CONCLUSIONS

The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

Successful urinary tract reconstruction following ureteral necrosis in kidney transplant patient

Ureteric complications following renal transplantation are well known to cause significant morbidity and compromised graft survival. The necrosis of a major part of the ureter could be a highly detrimental situation, and hardly solvable complication, that poses great challenges. Herein we are presenting a case report to introduce a possible surgical solution following repeated ineffective radiological interventions, in a patient with ureteric necrosis that appeared 3 months after cadaveric kidney transplantation. We transplanted the right kidney to the right iliac fossa performing end-to-side vascular anastomoses and end-to-side uretero-ureterostomy. His clinical course was uneventful during 3 months, when he presented a mild borderline acute cellular rejection together with dilatation of the pyelon. Percutaneous nephrostomy was performed by interventional radiologist. During further radiologic interventions the stenosis was not permeable. We finally made up our minds for surgical solution. We found a totally necrotized graftureter. During a second operation we performed a right nephrectomy, transsecting the pyelon. After mobilization of the transplanted kidney approaching and identifying the pyelon, a large pyelopyelar anastomosis was performed with stenting. The postoperative follow-up showed excellent urine flow from the kidney to the bladder, then the TRD was removed. Surgery had to be considered only if minimally invasive procedures are infeasible or ineffective. A regimen of reconstructive methods are well-known, but all cases have to be evaluated individually. If the native kidneys can be removed, their pyelons and entire ureters should be used for reconstruction.