Replacement of the ureter by small intestine: clinical application and results of the ileal ureter

Laparoscopic intracorporeal ileal ureter replacement: multi-institutional data from 102 patients

OBJECTIVE

To present long-term results of our laparoscopic intracorporeal ileal ureter replacement (LIUR) cohort, including more complex cases of laparoscopic ileocalycostomy.

MATERIAL AND METHODS

We collected records of patients undergoing LIUR. Follow-up included a chemical profile and urine cultures. Imaging consisted of renal ultrasonography, excretory urography, cystography, and computer tomographic or magnetic resonance urography.

RESULTS

One hundred and two patients were included. Stricture location was left (46.1%), right (39.2%), or bilateral (14.7%). No open conversion was performed. Seventy-four patients (72.5%) underwent a total ureteral unit removal. The mean operative time was 289.4 (120 - 680) minutes. The estimated blood loss was 185.2 (10-400) mL. Three patients had intraoperative complications, and fifteen had early postoperative complications. The mean postoperative hospital stay was 12.2 (7-35) days. The mean follow-up duration period was 37.7 (12-162) months. Most patients' follow-up was uneventful (88%), and seven patients presented with Grade 2 late complications.

CONCLUSIONS

Intracorporeal laparoscopic ileal ureteral replacement in cases of extensive ureteral lesions offers optimal long-term outcomes and a low complication rate. Ileocalycostomy constitutes a viable option in the small group of patients with long proximal ureteral strictures and intrarenal pelvis.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation

OBJECTIVE

To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option.

METHODS

We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed.

RESULTS

One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis.

CONCLUSION

Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

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.

Ileal ureter replacement and ileocystoplasty for the treatment of bilateral ureteral strictures and bladder contracture: technique and outcomes

BACKGROUND

The aim of this study was to explore the feasibility of ileal ureter replacement and ileocystoplasty for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture.

METHODS

A retrospective review of clinical data from seven patients who underwent bilateral Ileal Ureter Replacement and ileocystoplasty from April 2019 to February 2023 was conducted. The surgeries were performed using open, laparoscopic, and robot-assisted laparoscopic approaches. Baseline characteristics, perioperative, and mid-term results of the patients were collected. Follow-up period of 3-28 months. A detailed description of the technique was reported.

RESULTS

The mean age of the patients was 52.86±6.06 years. The average duration of surgery was 365±28.54 minutes, and the estimated intraoperative blood loss was 357.14±184.06 mL. The mean length of harvested ileum was 37.86±8.40 cm. The preoperative serum creatinine level was 88.02±18.05 μmol/L, postoperative day 1 creatinine level was 90.7±12.93μmol/L, postoperative 3-month creatinine level was 93.77±33.34 μmol/L, and the mean creatinine level at the last follow-up was 94.89±27.89μmol/L. The postoperative bladder capacity was 249.43±32.50 mL on average. The average length of hospital stay was 26.57±15.46 days. No complications of Clavien-Dindo grade 3 or higher were observed. During the follow-up period, no patients experienced deterioration of renal function after surgery.

CONCLUSIONS

Bilateral ileal ureter replacement and ileocystoplasty are effective surgical technique for the treatment of bilateral long-segment ureteral strictures combined with bladder contracture caused by radiation therapy.

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.

Ileal Ureter Utilization in Patients With Previous Urinary Diversions

OBJECTIVE

To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions.

METHODS

A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications.

RESULTS

Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy.

CONCLUSION

Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

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 complex urinary tract reconstruction using intestinal segments: redefining the paradigm

Complex urinary tract reconstruction has significantly advanced with the increasing use of robot-assisted procedures. Robotic surgery aims to achieve the same outcomes as open surgery while minimizing morbidity by causing less blood loss, faster postoperative recovery, and reducing complications. This article shares our technique, challenges encountered, and experience of robot-assisted complex urinary tract reconstruction using intestinal segments. Between January 2020 to March 2022, 6 patients who underwent robot-assisted complex urinary tract reconstruction using intestinal segments at our centre were retrospectively reviewed. Demographic, clinical, and operative data were recorded. Patients underwent renal function tests, blood gas analysis, and radiographic imaging in the follow-up. Symptomatic and radiologic relief were the criteria for success. Out of 6 cases, three patients underwent ileal ureter replacement, two combined ileal ureter with augmentation ileo-cystoplasty and one augmentation ileo-cystoplasty alone. The mean age, estimated blood loss, length of hospital stay, and follow-up period were 32.6 years, 110 ± 13.1 mL, 7.0 ± 1.1 days, and 11.3 months, respectively. The indications for surgery were either benign ureteral stricture following lithotripsy or sequelae of genitourinary tuberculosis. No intra-operative complications were found. Clavien-Dindo grade-II and Grade-IIIa were found in three and one patient, respectively. During follow-up, none had compromised renal function or acidosis. Robot-assisted complex urinary tract reconstruction using intestinal segments is safe and offers the advantages of minimally invasive techniques. Techniques demonstrated in this article make these reconstructions feasible with good surgical and clinical outcomes.

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.

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.

Single ileal segment in a cat-tail configuration for bilateral ureteric strictures

Introduction

Management of bilateral long length ureteric strictures is difficult with few options for reconstruction. In this report, we describe our experience with the use of a single, 15- 20 cm ileal segment for reconstruction of bilateral long length (involving more than 2/3^rd ureter) ureteric strictures.

Patients and Methods

A retrospective analysis of 5 cases operated between 2015 and 2020for bilateral long length ureteric strictures, using a single segment ileal interposition in a cat tail configuration was performed. We evaluated renal function, surgical success, incidence of urinary tract infection and complications of the procedure. Surgical success was defined as an asymptomatic patient with no hydronephrosis and/or prompt drainage of the kidney on radiological investigations.

Results

The average age of presentation was 42.8 ± 7.4 years (33-53) years). All the cases were secondary to a gynaecological intervention. The mean creatinine prior to surgery was 0.81 ± 0.36 mg % (range 0.5 -1.4 mg%). Mean duration of follow-up was 28.6 ± 20.6 months (Range 10 - 56 months). Mean hospital stay was 14.4 ± 3.36 days (range 12-20 days). Two patients developed ileus and one patient developed deep venous thrombosis in the post-operative period. One patient developed pyelonephritis within one month of surgery. There was no deterioration of renal function with the mean serum creatinine at last follow-up being 0.9 ± 0.36 mg% (range 0.6 - 1.5 mg%).

Conclusion

The use of an ileal segment in cat-tail configuration for bilateral simultaneous ileal replacement is a feasible and safe option. The medium-term result states that it is effective in the preservation of renal function and provides a good conduit for drainage.

Bilateral ileal ureter substitution for patients with ureteral strictures secondary to gynecological tumors radiotherapy: a multi-center retrospective study

Background

The selection of treatment for bilateral ureteral strictures caused by radiotherapy in patients with gynecological tumors often brings great challenges to urologists. This study was designed to analyze the characteristics of radiation-induced ureteral strictures and summarize the surgical experience of bilateral ileal ureter substitution.

Methods

We retrospectively collected the medical records of 18 patients between June 2010 and June 2019 who had a radiation-induced bilateral ureteral strictures. Time interval from radiotherapy to the discovery of ureteral stricture was categorized into short-term (less than 12 months) and long-term (over 12 months) groups. All patients received reverse “7” bilateral ileal ureteral substitution. Surgical success was defined as no restenosis, relief of symptoms, and improved/stabilized hydronephrosis.

Results

The patients had been suffered from ureteral stricture for a median of 12 [2–106] months. The mean length of the left and right ureteral stricture was 9.6±2.6 and 8.8±3.2 cm, respectively. The mean length of the ileal graft was 29.1±7.4 cm. The mean operative time was 308.4±70.2 min, and the mean estimated blood loss was 254.7±166.2 mL. The postoperative hospital stays in the short-term group was significantly shorter than that in the long-term group (14.0 vs. 20.6 days, P=0.049). During a median follow-up time of 24.1 (4.5–71.9) months, the success rate was 94.4%. Eight minor complications and two major complications occurred in 7 patients.

Conclusions

Bilateral ileal ureter substitution can be an effective strategy for radiation-induced ureteral stricture in patients with gynecological tumors.

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.

Long-term Follow Up of Ileal Ureteral Replacement for Complex Ureteral Strictures: Single Institution Study

OBJECTIVE

To report our 16-year experience with ileal ureter interposition for complex ureteral stricture. Ureteral reconstruction continues to evolve to include less invasive techniques to successfully manage ureteral stricture. However, long, complex, obliterative and especially radiated ureteral strictures are not amenable to less invasive techniques and may require Ileal ureter interposition.

MATERIALS AND METHODS

Retrospective review of a single institution's ureteral reconstruction database was performed. Demographics, operative details, success rate, complication rate, and length of follow-up were noted. Unilateral replacements utilized ileal ureteral interposition. Success rate was defined as no need for further open intervention.

RESULTS

Between 2003 and 2019, 188 ureteral reconstructions were performed, of which 46 required ileal ureter interposition. Of these 46 patients, 10 required bilateral reconstruction. Average age was 53 years, 26 (57%) were female. The average stricture length was 9.1 cm (2-20 cm). Stricture etiology included iatrogenic causes (n = 24, 52%), radiation causes (n = 12; 26%), vascular disease (n = 3; 7%), and idiopathic retroperitoneal fibrosis (n = 3; 7%). Forty-three surgeries were performed by open abdominal approach; 3 were performed robotically. The average length of operation was 412 minutes, blood loss 417 mL and LOS was 10 days. At mean follow up of 4.4 years (1-16 years), overall success rate was 83%, with 17% (n = 8) patients requiring subsequent major surgery (5 successful ureteral revision, 3 nephrectomy) and 11 (24%) patients experiencing a major complication.

CONCLUSION

In our long-term follow up of over 4 years, ileal ureteral interposition remains a successful option for complex ureteral strictures in properly selected patients.

Complex Ureteral Reconstruction in Kidney Transplantation

OBJECTIVES

Despite advances in surgical techniques and organ preservation, transplant ureteric strictures remain a common complication in kidney transplantation. A variety of endourological and surgical techniques have been utilized; however, there is a lack of consensus on the optimal modality in dealing with these complex cases.

MATERIALS AND METHODS

We present challenging ureteral reconstruction cases after failed attempts at ureteral dilatation, failed conventional open repairs, and/or with bladder dysfunction.

RESULTS

All renal allografts were salvaged by successful use of bladder Boari flap and intestinal segment interpositions/diversions.

CONCLUSIONS

Operative repair remains the most durable and successful approach, and minimally invasive options should be reserved for nonsurgical candidates, with consideration of a single attempt in patients with early, distal, short (<2 cm), nonischemic strictures.

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.

Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney

OBJECTIVE

To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney.

PATIENTS AND METHODS

Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome.

RESULTS

Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted.

CONCLUSION

Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m² is considered relative contraindication.

Laparoscopic "reverse 7" ileal ureteral replacement for bilateral extensive ureteral strictures performed completely intracorporeally: the initial experience

PURPOSE

To present our initial experience and evaluate the feasibility of the novel technique of completely intracorporeal laparoscopic "reverse 7" ileal ureteral replacement (IUR).

MATERIALS AND METHODS

Between December 2018 and September 2019, two patients underwent completely intracorporeal laparoscopic "reverse 7" IUR, which were female patients with bilateral extensive ureteral strictures (BEUS) secondary to radical hysterectomy and pelvic lymph node dissection for cervical cancer and postoperative radiotherapy. Antegrade pyelography and retrograde pyelography showed BEUS preoperatively.

RESULTS

The novel technique was performed successfully by the same surgeon without conversion to open surgery. The operating time of each patient was 420 min and 410 min, respectively. Meanwhile, the estimated blood loss of each patient was 120 ml and 100 ml, respectively. There were no major complications during the perioperative period. After ureteral stent was removed, antegrade pyelography postoperatively revealed excellent drainage with the resolution of hydronephrosis in both patients. After removing of ureteral stent and nephrostomy tube, no patients have a complaint about the donor site or the onset of flank pain.

CONCLUSIONS

To our knowledge, we present the initial experience with completely intracorporeal laparoscopic "reverse 7" IUR. With initial follow-up outcomes, this novel minimally invasive technique appears to be feasible and efficacious in treating BEUS in carefully selected patients.

Ileal ureter replacement: Early morbidity and long-term results

INTRODUCTION

Ileal ureter is a technique that consists of replacing the ureter by a segment of ileum to treat a long ureteric lesion or a lesion involving the lumbar ureter. The primary objective of our study was to assess the early perioperative morbidity of ileal ureter according to the Clavien-Dindo classification. The secondary objectives were to assess the morbidity and the medium- and long-term outcome of renal function.

MATERIALS AND METHODS

Single-centre retrospective study, collecting data from patients operated between February 2005 and October 2019. All patients who underwent ileal ureter replacement surgery in our unit were included in this analysis. The ureteric defect was longer than five centimetres and involved the pelvic and/or iliac and/or lumbar ureter. All ileal ureter replacements were performed by open surgery using isoperistaltic ileal grafts.

RESULTS

Twenty-one patients (11 women and 10 men) underwent total or subtotal, unilateral or bilateral ileal ureter replacement, corresponding to 25 kidneys. The grade III early postoperative complication rate was 9.5% (two cases) mainly consisting of bleeding. No grade IV or V complications were observed. With a mean follow-up of 85 months, long-term morbidity essentially consisted of infectious complications. No patients developed anastomotic strictures. Mean serum creatinine was 116.3μmol/L preoperatively, 105.6μmol/L one month postoperatively and 112.2μmol/L at last follow-up. Renal function was generally preserved or even improved, except for patients with preoperative renal failure.

CONCLUSION

Ileal ureter replacement is a surgical alternative associated with low morbidity and satisfactory long-term functional results.

LEVEL OF EVIDENCE

3.

Renal autotransplant for major ureteric loss: Results from median 11 years of follow-up

OBJECTIVE

Renal autotransplant (RA) is an underutilized procedure to treat major ureteric loss. Studies on long-term outcomes and follow-up after RA are scarce. This study aimed to report the long-term outcomes and follow-up after RA.

MATERIAL AND METHODS

We identified 9 patients, from 2007 to 2019, who underwent RA after major ureteric loss (where direct restoration of continuity was not possible). We collected data regarding the etiology of ureteric loss, preoperative differential renal function, method of nephrectomy (laparoscopic or open), method of anastomosing the residual ureter/pelvis to the bladder, postoperative complications, duration of hospital stay, and renal function and drainage postoperatively and until the last follow-up. Changes in renal function and/or any obstruction to urinary drainage of the ipsilateral kidney postoperatively or during follow-up were measured. The Wilcoxon matched-pairs signed-rank test was used to compare the mean creatinine values preoperatively, postoperatively, and at last follow-up (p<0.05 was considered statistically significant).

RESULTS

All the patients had uneventful intraoperative and postoperative periods. The mean hospital stay was 6.4 (5-8) days. The median follow-up was 132 (46-156) months. The mean preoperative serum creatinine level was 1.0 (0.7-1.7) mg/dL. The mean creatinine value postoperatively and at last follow-up had no significant difference with preoperative value (p=0.96 and 0.75, respectively). The postoperative diethylene triamine pentaacetic acid scan demonstrated good perfusion and drainage. There was no deterioration of renal function or drainage during the follow-up.

CONCLUSION

RA is an excellent modality to treat major ureteric loss. It preserves renal function and avoids the problems related to bowel interposition and the need for long-term follow-up.

Subtotal ureteral substitution with ileum for patients with multiple ureteral stenosis

The use of small bowel for ureteral substitution in patients with ureteral stenosis can, nowadays, be safely performed with a laparoscopic or robotic mini-invasive approach. To date, this technique required a complete substitution of the ureter with ileum. In this work we present our robotic intracorporeal sub-total ureteral substitution preserving the distal part of the ureter with the aim to reduce the risk of vescico-ureteral reflux. We report the case of a 65-years old male with a “functional” right single kidney and multiple recurrent stenosis. Our technique seems to be feasible and safe, no intra or postoperative complication were recorded. At 3 months of follow-up the trans-nephrostomic enhanced CT showed a completely opacification of ileal ureter, thus the nephrostomic tube was removed. At 6 and 12 months the patient was asymptomatic and with a level of serum creatinine 1.9 and 1.6 mg/dL, respectively. In conclusion the sub-total ureteral substitution with ileum can be a safety and effective procedure for patients who require a mandatory preservation of homolateral renal function.

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.

Cine magnetic resonance urography for postoperative evaluation of reconstructive urinary tract after ileal ureter substitution: initial experience

AIM

To report the initial experiences with functional cine magnetic resonance urography (cine MRU) and assess its usefulness as a novel postoperative evaluation method of ileal ureter substitution.

MATERIALS AND METHODS

The medical records of 17 patients from who underwent cine MRU during June 2010 to December 2019 during their follow-up after ileal ureter substitution were collected. The cine MRU videos of reconstructive urinary tract were observed, and the luminal diameter, contraction ratio, peristaltic waves, and ureteral jets were measured.

RESULTS

Seventeen patients underwent cine MRU after ileal ureter substitution during their follow-up. Based on their cine MRU videos assessing the morphology and the peristaltic motility of the reconstructive urinary tract, there was resolution of preoperative hydronephrosis, which matched their ameliorative renal function. Clearly, peristaltic motility of the ileal graft was observed in 14 patients with obvious peristaltic waves and ureteral jets.

CONCLUSION

This study is the first to assess the clinical utility of functional cine MRU during the patient follow-up after ileal ureter substitution. Cine MRU is a radiation-free, non-invasive imaging method that can clearly show the morphology and the peristaltic motility of the ileal graft. Therefore, cine MRU, as a novel technique, will be extremely useful in the postoperative evaluation of patients after ileal ureter substitution.

Small Bowel Adenocarcinoma of Ileal Ureter 40 Years After Ureteral Reconstructive Surgery

Malignant neoplasm arising from ileal ureter used for ureteral reconstructive surgery is an exceedingly rare event. Ureteroileoplasty was being performed since the beginning of the last century, but it was described more extensively in literature during the 1950s.^1,2 Recurrent urinary infections, chronic renal failure, urolithiasis, anastomotic stricture, metabolic acidosis, and chronic dilation of the graft had been described as late complications of ureteroileoplasty.^3,4 Herein, we describe history, imaging and pathologic findings of a small bowel adenocarcinoma arising from ileal ureter in a woman of 78-year-old, subjected to ureteroileoplasty about 40 years earlier.

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

BACKGROUND

Ileal ureter replacement is an alternative treatment for various length ureter defects. We present our experience and outcome of ileal ureter replacement in China.

METHODS

We retrospectively collected data of patients who underwent ileal ureter replacement between January 2010 and January 2015. We reviewed the medical history, indications for surgery, operative data, perioperative data, and outcomes. Besides, follow-up data included symptom, urine routine test, serum creatinine, serum electrolyte status, and radiographic test.

RESULTS

There were 23 patients who underwent ileal ureter replacement by the same surgeon. Twenty patients were performed unilateral ileal ureter replacement, two patients underwent a combination of ileal ureter replacement and Boari flap-psoas hitch, and one received bilateral ileal ureter replacement. Among these patients, the main cause leading to surgical treatment was iatrogenic injuries (n = 15), especially urinary surgery procedure (n = 11). The median follow-up time was 45 months. There were 6 early complications and 6 late complications after operation. Only one patient suffered from small bowel-related complication and was cured by conservative treatment. Only the patient who underwent bilateral ileal ureter replacement had metabolic acidosis. And 22 patients (95.7%) had a good renal function.

CONCLUSIONS

Ileal ureter replacement is an efficacious and safe procedure for the therapy of long ureteral defects. With appropriate technical considerations, the complication rate may decrease.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment. Left untreated they are associated with severe short- and long-term complications such as urinoma, septic state, renal failure, and loss of a renal unit. Treatment depends on timing of diagnosis, as well as extent of injury, and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts. While recent advances in ureteral tissue engineering are promising the topic is still underreported. Historically a domain of open surgery, laparoscopic and robotic-assisted approaches have proven their feasibility in small case series, and are increasingly being utilized as means of reconstructive surgery. This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.

Functional Outcome of Completely Intracorporeal Robotic Ileal Ureteric Replacement

OBJECTIVE

To assess perioperative, clinical, and functional outcomes following completely robotic ileal ureter.

METHODS

We retrospectively reviewed 7 consecutive patients undergoing completely intracorporeal ileal ureteric replacement between November 2015 and May 2017. One patient had a solitary kidney. A 4-arm technique was used. In 5 patients, additional psoas hitch procedure was performed. Patients had retrograde filling and removal of the ileal stent and transurethral catheter at an average of 14 days postoperatively. Renal ultrasonography, serum analysis, and diuretic renography were performed at follow-up 3 months postoperatively.

RESULTS

Mean operative time was 328 ± 66.3 minutes and median estimated blood loss was 100 mL (range 50-200); mean length of the ileal substitute was 20.4 cm (range 18-24). No case was converted to open surgery. In 1 patient, there was a prolonged insufficiency of the pyeloileal anastomosis, requiring prolonged stenting. Apart from that, there were no major complications and no open surgical or endoscopic reinterventions. On 3-month follow-up, all patients presented symptom-free, with no signs of obstruction on ultrasound and significantly improved glomerular filtration rate, creatinine levels, and differential renal function (P = .02, 0.03, and 0.046, respectively). Five patients had a diuretic halftime <10 minutes, 2 had a halftime between 10 and 20 minutes.

CONCLUSION

Completely intracorporeal robotic ileal ureteric replacement results in full functional restoration of the upper tract in cases of long defects of the mid and upper ureter.

Use of the Ileum for Ureteral Stricture and Obstruction in Bilateral, Unilateral, and Single-kidney Cases

OBJECTIVE

To investigate the functional outcomes of ileal ureter replacement for complex ureteral loss, including bilateral and single ureter stricture, as a result of various etiologies.

METHODS

In 2013-2016, 31 patients underwent ileal ureter replacement surgery. The data for their assessments included etiology, combined surgical procedures, ureteral replacement type, postoperative complications, and changes in renal function.

RESULTS

The 31 study patients had a median age of 56.0 (range 18-65) years and were followed for a median of 23.6 (range 6.5-43.2) months. There were 14 bilateral, 12 unilateral, and 5 single-kidney cases. The main indication for surgery was ureteral defects after gynecological surgery and radiation in 24 patients (77.4%). The mean operation time was 370.6 minutes and the median hospital stay was 25.2 (range 6-79) days. Various types of ileal arrangement were performed to cover bilateral ureter loss. After 30 days past surgery, 24 patients (77.4%) were in a stable state and 5 (16.1%) had decreased serum levels of creatinine. Short-term complications greater than grade 3 on the Clavien scale occurred in 10 patients (33.3%), and long-term complications occurred in 27 (87.1%). However, all cases were well relieved by conservative care, and surgical intervention was needed in only 1 case. Apart from 2 patients who died because of the progression of cervical cancer, all patients had stent-free status at 22.4 months.

CONCLUSION

Ileal ureter replacement is a useful reconstructive surgery for complex ureteral loss, such as bilateral and single-kidney cases resulting from various etiologies.

Long-term results of ileal ureteric replacement: a 25-year single-centre experience

OBJECTIVE

To report the long-term outcomes of ileal ureteric replacement (IUR) in complex reconstruction of the urinary tract.

PATIENTS AND METHODS

From 1991 to 2016, IUR was performed in 157 patients with structural or functional ureteric loss. In 52 patients, bilateral IUR became necessary. Implantation sites where either the native urinary bladder (n = 79) or intestinal reservoirs (n = 78). In the latter group, the technique was used at the time of primary urinary diversion (n = 34), in a secondary approach (n = 29), and in undiversion or conversion procedures (n = 15). Anti-refluxive implantation was performed in 37 patients. In eight patients the ileal ureter was implanted into the cutis as an ileal conduit. All patients were followed prospectively according to a standardised protocol.

RESULTS

The mean follow-up was 54.1 months. In 114 patients with dilatation of the upper urinary tract before surgery a significant improvement of the dilatation was confirmed in 98 patients. Serum creatinine levels decreased or remained stable in 147 of the 157 patients. Reflux was present in all cases without and in six cases with an anti-reflux mechanism. In six patients, operative revision became necessary because of severe metabolic acidosis, mucus obstruction or stenosis of the ileal ureter.

CONCLUSIONS

To our knowledge, this is the world's largest single-centre series of IUR reported to date. Long-term follow-up confirms that this approach is a safe and reliable solution, even under complex conditions. Anti-refluxive implantation is recommended for intestinal reservoirs, whereas reflux prevention seems to be of minor importance when the native bladder is chosen as the site of implantation.

Ureteral Reconstruction With Ileum: Long-term Follow-up of Renal Function

OBJECTIVE

To assess long-term renal preservation and surgical outcomes in patients undergoing ureteric substitution with ileum. This has been a mainstay of reconstruction options for lengthy ureteral defects.

METHODS

Consecutive patients aged 18 or older undergoing ileal ureters at our institution were retrospectively reviewed (from 1989 to June 2013). Patients with <6 months of follow-up were excluded. Demographic, surgical, and renal functional outcomes were reviewed. Renal function was assessed by the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease Study equations.

RESULTS

Of the 108 patients meeting the inclusion criteria, 86 (79.6%) had single-renal unit reconstruction and 22 had bilateral reconstruction. Eighty-four (77.8%) had radiation-induced stricture and 24 had iatrogenic or trauma-induced strictures. The median follow-up was 51 months (interquartile range: 22-112). Short-term complications included Clavien grade I (16 [14.8%]), Clavien grade II (3 [2.8%]), Clavien grade III (9 [8.3%]), and Clavien grade IV (3 [2.8%]). Long-term complications included fistula in 6 patients (5.6%), renal failure requiring dialysis in 2 patients (1.9%), hyperchloremic metabolic acidosis in 4 patients (3.7%), and incisional hernia in 11 patients (10.2%). Nine patients (8.3%) had small-bowel obstructions; 3 (2.8%) required adhesiolysis. Four patients (3.7%) had an anastamotic stricture. Nineteen patients (17.6%) had worsening renal function. Cox proportional hazards regression found that those with bilateral repair were at 3.7 times increased risk of worsening renal function (P = .02).

CONCLUSION

Ureteral substitution with ileum provides an effective and versatile long-term reconstructive option with minimal renal function compromise in properly selected patients. Bilateral reconstruction may contribute to worse long-term renal function.

[Ureteral stricture as a late complication of radiotherapy : Possible treatment options]

Ureteral strictures are uncommon complications of radiotherapy which are often recognized late. Their consequences range from harmless dilatation of the ureter to loss of renal function and potential life-threatening urosepsis.Therapy of radiogenic ureteral stricture is a challenging task for every urologist. Several surgical strategies including minimally invasive procedures, reconstruction and partial or complete replacement of the ureter are available.This article provides an overview of the various options in the treatment of radiogenic stricture of the ureter, focusing on the use of ileum and colon segments for ureteral substitution.

Renal Autotransplantation: 27-Year Experience at 2 Institutions

PURPOSE

Renal autotransplantation is an infrequently performed procedure. It has been used to manage complex ureteral disease, vascular anomalies and chronic kidney pain. We reviewed our 27-year experience with this procedure.

MATERIALS AND METHODS

This is a retrospective, observational study of 51 consecutive patients who underwent renal autotransplantation, including 29 at Oregon Health and Science University between 1986 and 2013, and 22 at Virginia Mason Medical Center between 2007 and 2012. Demographics, indications, operative details and followup data were collected. Early (30 days or less) and late (greater than 30 days) complications were graded according to the Clavien-Dindo system. Factors associated with complications and pain recurrence were evaluated using a logistic regression model.

RESULTS

The 51 patients underwent a total of 54 renal autotransplants. Median followup was 21.5 months. The most common indications were loin pain hematuria syndrome/chronic kidney pain in 31.5% of cases, ureteral stricture in 20.4% and vascular anomalies in 18.5%. Autotransplantation of a solitary kidney was performed in 5 patients. Laparoscopic nephrectomy was performed in 23.5% of cases. Median operative time was 402 minutes and median length of stay was 6 days. No significant difference was found between preoperative and postoperative plasma creatinine (p = 0.74). Early, high grade complications (grade IIIa or greater) developed in 14.8% of patients and 12.9% experienced late complications of any grade. Two graft losses occurred. Longer cold ischemia time was associated with complications (p = 0.049). Of patients who underwent autotransplantation for chronic kidney pain 35% experienced recurrence and 2 underwent transplant nephrectomy. No predictors of pain recurrence were identified.

CONCLUSIONS

The most common indications for renal autotransplantation were loin pain hematuria syndrome/chronic kidney pain, ureteral stricture and vascular anomalies in descending order. Kidney function was preserved postoperatively and 2 graft losses occurred. At a median followup of 13 months pain resolved in 65% of patients who underwent the procedure. Complication rates compared favorably with those of other major urological operations and cold ischemia time was the only predictor of postoperative complications.

Management of iatrogenic ureteral injury

Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic, colorectal, and vascular pelvic surgery. There is also potential for considerable ureteral injury during endoscopic procedures for ureteric pathology such as tumor or lithiasis. While maneuvers such as perioperative stenting have been touted as a means to avoid ureteral injury, these techniques have not been adopted universally, and the available literature does not make a case for their routine use. Distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesico-psoas hitch. Mid-ureteral and proximal ureteral injuries can potentially be managed with ureteroureterostomy. If the distal segment is unsuitable for anastomosis then a number of techniques are available for repair including a Boari tubularized bladder flap, transureteroureterostomy, or renal autotransplantation. In rare cases renal autotransplantation or ureteral substitution with gastrointestinal segments may be warranted to re-establish urinary tract continuity. Laparoscopic and minimally invasive techniques have been employed to remedy iatrogenic ureteral injuries.

[Avoidance and management of complications in open surgical ureter reconstruction]

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

Tissue engineering and ureter regeneration: is it possible?

Large ureter damages are difficult to reconstruct. Current techniques are complicated, difficult to perform, and often associated with failures. The ureter has never been regenerated thus far. Therefore the use of tissue engineering techniques for ureter reconstruction and regeneration seems to be a promising way to resolve these problems. For proper ureter regeneration the following problems must be considered: the physiological aspects of the tissue, the type and shape of the scaffold, the type of cells, and the specific environment (urine). 
This review presents tissue engineering achievements in the field of ureter regeneration focusing on the scaffold, the cells, and ureter healing.

Long-term functional outcomes after ileal ureter substitution: a single-center experience

OBJECTIVES

To assess the indications and outcomes of ileal ureter replacement for ureteral reconstruction, which remains a technique of choice in certain cases, notably when the ureter has been injured.

METHODS

A retrospective review of the data from patients treated with ureteroileoplasty from 1980 to 2010 was performed. The following data were analyzed: age, etiology of ureter injury, and pre- and postoperative creatinine levels. Follow-up visits occurred at 3 and 6 months postoperatively and at least annually thereafter.

RESULTS

A total of 17 patients with a median age of 43 years were included. The main etiology of the ureteral defect was an iatrogenic ureteral injury after a urologic procedure (n=6). The mean length of hospital stay was 12.4±8 days (range 7-26). Four major complications (grade 3) and 5 minor complications (grade 2) developed. The median follow-up time was 174 months. The mean creatinine level before surgery, at 1 month after surgery, and at the last follow-up visit was 1.3±0.3 mg/dL (range 0.6-3.4), 1.4±0.4 mg/dL (range 0.6-3.6), and 1.8±0.6 mg/dL (range 0.7-4.7), respectively. By the end of the follow-up period, 15 patients still had ileal ureters. Of these, 3 required dialysis.

CONCLUSIONS

The indications for an ileal ureter have evolved in recent years. The ileal ureter appears to remain a reasonable option for ureteral reconstruction to preserve long-term renal function.

[Ureteral reconstruction after ureterorenoscopic injuries]

Ureteral injuries are caused by iatrogenic reasons in about 75% of cases. Among urological procedures ureterorenoscopy (URS) is mainly described as the reason for ureteral injury, although complication rates of URS are generally low. Injuries of the ureter are divided into five grades by the AAST. Grades I-II are referred to as partial and grades III-V as complex ureteral injuries. To avoid higher complication rates there should be no delay in confirmation of diagnosis and initiation of therapy. Correct therapy depends on grade of injury. Partial ureteral injuries are treated by endoscopic inlay of a ureteral stent for approximately 14-21 days. In complex injuries endoscopic ureteroureterostomy could be attempted but leads to rather poor long-term results depending on the length of devascularization of the injured ureter.Procedures with and without use of bowel for ureteral reconstruction and replacement have been described. The type of operative procedure should be selected based on location and degree of ureteral injury. Besides ureteral reconstruction, autotransplantation of the affected kidney can be required in individual cases.

[Complete vesico-ureteral reconstruction with ileum in a case of genitourinary tuberculosis]

INTRODUCTION

Genitourinary tuberculosis represent 3.2% of the possible sites of the disease. The lack of treatment or an inadecuate one may lead to severe complications. We report a case and review thoroughly the literature of genitourinary tuberculosis which needed a complete vesico-ureteral reconstruction.

CLINICAL CASE

A 39 year old female patient with history of pulmonary tuberculosis who had lumbar pain and left ureterohydronephosis. She required a percutaneous urinary derivation and was diagnosed of tuberculosis by means of the urine culture. 18 months afterwards she had a right renal annulation and a left distal ureteral stenosis. A right nephectomy was performed and the left proximal ureter was desinserted accidentally, 1 cm below the pielo-ureteral junction, which required a permanent nephostomy. Then her bladder became gradually retractile. Because she was a young patient and had bad quality of life a complete reconstruction of her left urinary way was performed with an ileum made neobladder and neoureter. DISCUSSION AND CONCLUSSIONS: Bladder and ureter reconstruction with ileum is a good option in difficult cases of lack or irreversible damage of the urinary way. Vesico-ureteral reconstruction letting urethral miction improves quality of life.