Ureteric reconstruction

Bilateral long ureteral strictures were successfully replaced by ileum in inverse seven configuration: A case report

INTRODUCTION AND IMPORTANCE

Ureteral stricture is a potential postoperative complication of pelvic surgery. Repair is performed in the intraoperative or postoperative phase for various reasons. Ileal reconstruction of ureter is considered for extensive and bilateral ureteral injuries.

CASE PRESENTATION

A 44-year-old female presented to the hospital where she had undergone hysterectomy two months prior, with acute renal failure due to bilateral hydronephrosis. Radiological examination revealed bilateral distal ureteral stricture measuring 5 cm in length. After failed balloon-dilation, ileal reconstruction was successfully performed without perioperative complications; and she has remained free from hydronephrosis with normal renal function for four years.

CLINICAL DISCUSSION

Ileal interposition can be used for reconstruction of long lengths or bilateral ureteral injuries. High success rates and low rates of complication have been reported, and the long-term outcome was also acceptable. Apparent ureteral injury was not observed in our case; however, narrowing of ureteral lumen due to submucosal and sub-adventitial edema was observed as a possible cause of strictures. Although, some minor occult injuries during hysterectomy, including thermal effect, ischemia or physical damage due to traction on the ureters were suggested, we were unable to conclusively determine the etiology.

CONCLUSION

Ileal ureter replacement is a useful reconstruction, and the inverse seven configuration is suitable for long bilateral strictures of distal ureter.

Uretero-neocystostomy: a retrospective comparison of open, laparoscopic and robotic techniques

BACKGROUND

Uretero-neocystostomy (UNC) is the gold-standard for distal-ureter repair. Whether the surgery should be conducted minimally invasive (laparoscopic (LAP), robotic RAL)) or open remains unanswered by the literature.

METHODS

Retrospective analysis of surgical outcome of patients treated with UNC for distal ureteral stenosis (January 2012 - October 2021). Patient demographics, estimated blood loss (EBL), surgical technique, operative time, complications and length of hospital stay (LOS) were recorded. During the follow-up period, patient underwent renal ultrasound and kidney function tests. Success was defined as relieve of symptoms or no findings of obstruction needing urine drainage.

RESULTS

60 patients were included (9 RAL, 25 LAP, 26 open). The different cohorts were similar of age, gender, American Society of Anesthesiologists (ASA) score, body-mass index and history of prior treatment of the ureter. No intraoperative complications were detected in all groups. There was no conversion to open surgery in the RAL group, whereas one was found in the LAP arm. Six patients had a recurrent stricture, but with no significant difference between the cohorts. EBL was not different between the groups. LOS was significantly lower in the RAL + LAP group compared to open (7 vs. 13 days, p = 0.005) despite significantly longer operating times (186 vs. 125.5 min, p = 0.005).

CONCLUSION

Minimal invasive UNC, especially RAL, is a feasible and safe surgical method and provides similar results in terms of success rates in comparison to open approach. A shorter LOS could be detected. Further prospective studies need to be done.

[Trends in upper urinary tract reconstruction surgery over a decade based on a multi-center database]

OBJECTIVE

To study the trend of surgical type, surgical procedure and etiological distribution of upper urinary tract repair in recent 10 years.

METHODS

The preoperative and perioperative variables and follow-up data of upper urinary tract reconstruction surgery in RECUTTER (Reconstruction of Urinary Tract: Technology, Epidemiology and Result) database from 2010 to 2021 were searched, collected and analyzed. The surgical type, surgical procedure, duration of hospitalization, time of operation, incidence of short-term complications, and proportion of the patients undergoing reoperations were compared between the two groups of 2010-2017 period and 2018-2021 period.

RESULTS

A total of 1 072 patients were included in the RECUTTER database. Congenital factors and iatrogenic injuries were the main causes of upper urinary tract repair. Among them, 129 (12.0%) patients had open operation, 403 (37.6%) patients had laparoscopic surgery, 322 (30.0%) patients had robot-assisted laparoscopic surgery and 218 (20.3%) patients had endourological procedure. In the last decade, the total number of surgeries showed a noticeable increasing annual trend and the proportion of robot-assisted laparoscopic surgery in 2018-2021 was significantly higher than that in 2010-2017 (P < 0.001). The 1 072 patients included 124 (11.6%) cases of ileal ureter replacements, 440 (41.1%) cases of pyeloplasty, 229 (21.4%) cases of balloon dilation, 109 (10.2%) cases of ureteral reimplantation, 49 (4.6%) cases of boari flap-Psoas hitch surgery, 60 (5.6%) cases of uretero-ureteral anastomosis, 61 (5.7%) cases of lingual mucosal onlay graft ureteroplasty or appendiceal onlay flap ureteroplasty. Pyeloplasty and balloon dilatation had been the main types of surgery, while the proportion of lingual mucosal onlay graft ureteroplasty plus appendiceal onlay flap ureteroplasty had increased significantly in recent years (P < 0.05). In addition, the time of operation was significantly increased (P < 0.05) after 2018, which was considered to be related to the sharp increase in the proportion of robot-assisted laparoscopic surgery. We found that minimally invasive surgery (endourological procedure and robot-assisted laparoscopic surgery) as an independent risk factor (P=0.050, OR=0.472) could reduce the incidence of short-term post-operative complications.

CONCLUSION

We have justified the value of the RECUTTER database, created by the Institute of Urology, Peking University in data support for clinical research work, and provided valuable experience for the construction of other multi-center databases at home and abroad. In recent 10 years, we have observed that, in upper urinary tract reconstruction surgery, the surgery type tends to be minimally invasive and the surgery procedure tends to be complicated, suggesting the superiority of robot-assisted laparoscopic surgery.

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.

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.

Experience managing distal ureteral strictures with Boari flap-psoas hitch and comparison of open and laparoscopic procedures

Background

To summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures.

Methods

This study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference.

Results

All surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients.

Conclusions

With the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

Ureteral Avulsion during Semirigid Ureteroscopy: A Single-Centre Experience

Aims

The aim of the study is to present our experience with the management of ureteral avulsions following semirigid ureteroscopy for ureteral stones. This is one of the largest series reported so far.

Methods and Materials

It is a retrospective and observational study done at Sri Ramachandra Institute of Higher Education and Research over the last 18 years.

Results

There were seven cases of ureteral avulsion following semirigid ureteroscopy. All patients were males with a mean age of 35.7 years. All had impacted stones, with proximal ureteric location in 6 patients and distal ureteric location in 1 patient. Five cases had two-point avulsions with loss of entire ureter. Two cases had one-point avulsion: one distal ureteric and the other mid-ureteric. Of the five cases with whole length ureteral avulsion, four were managed by classical ileal replacement of ureter and the the fifth case was managed by ileal replacement of ureter by the Yang–Monti technique. Of the two cases with one-point avulsion, one was managed by uretero-neocystostomy and the other by uretero-ureterostomy. All the patients had successful outcome.

Conclusions

Even though rare, ureteral avulsion can potentially happen especially when dealing with impacted ureteric stones. Being conscious of the possible occurrence of this serious complication during any difficult ureteroscopy and exercising utmost care during the procedure are important preventive measures. However, this catastrophe can be successfully managed by either immediate definitive repair or in a staged manner.

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.

Beware the band adhesion: an unexpected cause of double obstruction following intraperitoneal kidney transplantation

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.

[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.

Laparoscopic extravesical ureteral reimplantation (LEVUR): a systematic review

BACKGROUND

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review medium term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

METHODS

Medline and Embase databases were searched using relevant key terms to identify reports of paediatric laparoscopic extravesical ureteral reimplantation (LEVUR). Literature reviews, case reports, series of <3 children and adult studies (age >20 years) were excluded.

RESULTS

Five studies were assessed, overall, 69 LEVUR were performed in children. Despite different surgical technique, in all case the technique was respected. Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Median success rate was 96%. Complications were reported in five cases.

CONCLUSIONS

This study is limited by the data given in the individual series: varied criteria used for patient selection and outcome as well as inconsistent pre- and post-operative imaging data precluded a meta-analysis. But it demonstrates that the laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that in well selected patients this procedure will become an established treatment option.

Single-surgeon experience with robot-assisted ureteroneocystostomy for distal ureteral pathologies in adults

PURPOSE

To demonstrate our technical approach for robot-assisted ureteroneocystostomy (R-UNC) for benign and malignant distal ureteral pathologies.

MATERIALS AND METHODS

Between January 2009 and January 2013, a total of 10 patients underwent R-UNC in the distal ureter by a single surgeon. Indications for R-UNC were as follows: idiopathic (3), fistula (2), iatrogenic (2), malignancy (2), and chronic vesicoureteral reflux (1).

RESULTS

Tension-free anastomosis was attained in all 10 R-UNC procedures. A psoas hitch was performed in 6/10 cases (60%). Intravesical and extravesical reimplantations were completed in 5/10 (50%) and 5/10 cases (50%), respectively. A nonrefluxing ureter was constructed in 2/10 cases (20%). The patients' mean age was 52.9±16.6 years, their mean body mass index was 30.8±6.3 kg/m(2), the mean operative time was 211.7±69.3 minutes, mean estimated blood loss was 102.5±110.8 mL, and mean length of stay was 2.8±2.3 days. There were no intraoperative complications. There was one Clavien-Dindo grade I and one Clavien-Dindo grade II postoperative complication. The mean postoperative follow-up duration was 28.5±15.5 months. Two patients had recurrence of ureteral strictures at 3 months postoperatively and were managed successfully with balloon dilation.

CONCLUSIONS

Our technique for R-UNC demonstrates good perioperative outcomes. However, underlying periureteral inflammation and pelvic adhesions may predispose patients for stricture recurrence after R-UNC.

Strategies for open reconstruction of upper ureteral strictures

This article presents a review of the literature regarding surgical techniques and outcomes for reconstruction of strictures involving the upper ureter. The preoperative assessment for proximal ureteral stricture is briefly reviewed, followed by a discussion of ureteroureterostomy, transureteroureterostomy, ureterocalicostomy, bladder flaps, downward nephropexy, bowel interposition grafts, onlay or tubular grafting, renal autotransplantation, and nephrectomy. The future direction for reconstruction of the proximal ureter is proposed.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Laparoscopic ureteroneocystostomy and vesicopsoas hitch for infiltrative ureteral endometriosis

The aim of the study was to assess the safety and efficacy of laparoscopic treatment of distal infiltrative ureteral endometriosis with segmental ureteral resection, ureteroneocystostomy, and vesicopsoas hitch. We performed a retrospective analysis of perioperative data and looked at follow-up outcomes of patients with deep endometriosis with ureteral involvement treated by laparoscopic vesicopsoas hitch. Six patients were treated for left ureteral endometriosis in the study period. Four of those were diagnosed during previous laparoscopies. A ureteroneocystostomy (Lich-Gregoir reimplantation procedure) with vesicopsoas hitch was fashioned laparoscopically in all cases, and a double-J stent was applied intraoperatively. There were no intraoperative or postoperative complications and no cases of extravasation of contrast at cystogram one week after surgery. The median follow-up time was 38 months (range 12-56). All patients had normal renal ultrasound or intravenous pyelogram results at one year follow-up. This study confirmed that laparoscopic ureteroneocystostomy and vesicopsoas hitch is a safe and effective option in the management of distal ureteral endometriosis. In view of the small size of this series, multicenter studies are needed to confirm these conclusions.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Tissue engineered venous matrices for potential applications in the urogenital tract

Tissue engineering is lacking inexpensive, easily applicable techniques for tissue replacement. We investigated the potential use of native veins for tissue-engineering applications in the urological field. Forty-eight porcine veins, half seeded with urothelial cells and half unseeded, were kept in vitro for 7 days. Four seeded and four unseeded scaffolds were analyzed after 3 and 7 days. The remaining 32 veins were implanted subcutaneously into 16 athymic mice. Four athymic mice were sacrificed after 2, 4, 8, and 12 weeks. Histochemistry, immunohistochemistry (anti-pancytokeratin AE1/AE3, anti-desmin), western blot analyses (CD31), and scanning electron microscopy were performed in the retrieved specimens. The histochemistry of the seeded matrices showed the presence of urothelial cells in vitro and in vivo. After 12 weeks, a multilayer of urothelial cells was present in the hemotoxylin and eosin staining, positive for anti-pancytokeratin AE1/AE3. The western blot analyses showed vascularization of the veins in vivo. The results of scanning electron microscopy revealed a cellular layer on the veins. Native venous matrices may be used as tissue-engineered constructs for reconstructing the urinary tract. The clinical relevance of this approach must be proven in a large-animal model.

Urogenital fistulae: changing trends and personal experience of 46 cases

A retrospective study of 46 patients with different types of urogenital fistulae treated by the author during the period from January 1997 to December 2006 is presented. Twenty-two (48%) cases had a vesicovaginal fistula of which 16 (73%) were repaired vaginally and 6 (27%) were repaired abdominally. The remaining fistulae were as follows: 14 (30%) unilateral ureterovaginal fistulae, 6 (13%) ureterovesicovaginal fistulae (one bilateral), and 4 (9%) vesicouterine fistulae. All were repaired abdominally except for one patient with ureterovesicovaginal fistula needing continent urinary diversion using Mainz type II pouch. All fistulae were iatrogenic except one case (2%) which was due to neglected obstructed labor. The iatrogenic causes were gynecologically related in 26 (57%) patients and obstetrically related in 19 (41%) cases. There were two (9%) failed repairs in the vesicovaginal cases, one in each group, and both were salvaged by a secondary surgery. In view of this selected retrospective study and in association with other reports, it seems that with the improvement in the basic health-care services in Egypt, there is a change in the etiology of urogenital fistulae with the vast majority being physician related and no more related to neglected obstructed labor. Such shortcoming should be addressed in the current gynecological surgery training and residency programs.

Laparoscopic ureteral reconstruction for benign stricture disease

OBJECTIVES

To describe our experience with laparoscopic ureteral reconstruction in the adult patient with benign ureteral stricture disease.

METHODS

We retrospectively compared laparoscopic (n = 12) and open (n = 34) ureteroureterostomy, ureteroneocystostomy, and Boari flap procedures conducted from January 1999 to November 2005 for benign stricture disease. The demographic, operative, complication, and outcome data were analyzed and compared.

RESULTS

The patient demographics and ureteral stricture etiology, location, and length were equivalent between the open and laparoscopic groups. The open surgical group had greater operative blood loss (258 versus 86 mL; P = 0.002) and a longer hospital stay (median 5 days versus 3 days; P <0.001) compared with the laparoscopic group. The overall complication rate in the open and laparoscopic groups was 15% and 8%, respectively (P = 0.225). Ureteral patency had been successfully reestablished in all 12 patients (100%) in the laparoscopic group at a mean follow-up of 23 months. In the open group, patency had been achieved in 30 patients (96%) at a mean follow-up of 43 months. No significant difference was found in patency success (P = 0.544) or the duration of follow-up (P = 0.098) between the two groups.

CONCLUSIONS

Laparoscopic ureteral reconstructive surgery is technically feasible and efficacious in treating benign ureteral stricture disease in adults.

Ureteral reimplantation for management of ureteral strictures: a retrospective comparison of laparoscopic and open techniques

OBJECTIVES

To compare the results of laparoscopic ureteral reimplantation with a previous series of open surgery.

MATERIALS AND METHODS

We compared ten patients who underwent laparoscopic vesicopsoas-hitch with (n=4) or without Boari-flap (n=6) technique for ureteral obstructions with ten patients treated by open ureteroneocystostomy for similar pathologies. Patient demographics, preoperative symptoms, radiologic imaging, and postoperative outcomes were analyzed. Postoperative observation time averaged 17 mo (range: 9-23) in the laparoscopic and 65 mo (range: 18-108) in the open group. Success was defined as relief of obstruction in postoperative imaging studies and relief of pain.

RESULTS

Mean length of stricture (28.5 vs. 25 mm) was comparable in both groups. In laparoscopy versus open surgery, mean operative time (228 vs. 187 min) was longer, blood loss (370 vs. 610 ml) and analgesic requirement (4.9 vs. 21.5mg) were significantly lower, and mean time to oral intake (1.5 vs. 2.9 d), hospital stay (9.2 vs. 19.1 d), and convalescence time (2.3 vs. 4.2 wk) were significantly shorter. Success rates yielded 10 of 10 after laparoscopy and 8 of 10 after open surgery. No intra- or postoperative major complications occurred in the laparoscopic series. After open surgery, two patients had major postoperative complications, including urinary extravasation with abdominal haematoma and anastomostic stricture, respectively.

CONCLUSIONS

Laparoscopic ureteroneocystostomy is feasible, providing functional outcomes comparable to open surgery while offering the advantages of a minimal invasive technique (e.g., less postoperative analgesics, and shorter hospitalization and convalescence). Nevertheless, it requires a high level of laparoscopic expertise and should be carried out only in specialist centers.

Handling and prevention of complications in stone basketing

OBJECTIVE

To review the incidence, risk factors, and treatment options of intraoperative and postoperative complications of stone basketing in urology with emphasis on certain principles that must be upheld to prevent those complications.

METHODS

A literature search was performed using the MEDLINE database on stone basketing between 1970 and 2005.

RESULTS

Iatrogenic trauma due to retrieval of a stone is well known but the exact incidence is difficult to ascertain. Rarely, stone basketing can cause major trauma to the ureter, such as avulsion or intussusception, requiring open or laparoscopic intervention for ureteral continuity restoration. Mucosal abrasion, ureteral perforation, and stricture formation have also been described as complications of stone basketing. Occasionally, the engaged or broken basket can provoke anxiety even for experienced urologists. Factors that increase the risk of complications, strategies for repair, and techniques for prevention are discussed extensively.

CONCLUSION

Infrequent, surgical misadventures during stone basketing can occur and must be treated appropriately. Careful attention to instrument selection and surgical techniques and awareness of risk factors and type and site of potential injury are essential to reduce these complications.

[Uretero-transappendix-cystoneostomy as a technique for the reconstruction of the lower part of the ureter]

BACKGROUND

Any large missing part of the ureter may be replaced by transureteroureterostomy, psoas hitch, Boari flap, nephrectomy, renal autotransplanation or by the implementation of an intestinal graft.

CASE REPORT

A patient with a defect of the lumbal-pelvic portion of the right ureter, after the managemenet of a penetrating and perforating gun shot wound was presented. The missing part of the ureter was seccessfully replaced with an appendix. The technique of uretero-transappendix-cystoneostomy complete with a Boari flap and a psoas hitch was used.

CONCLUSION

By the use of an original combination of surgical techniques, a large defect of the ureter and the defect of the bladder, as well as the preservation of the renal function was achieved in a more successful manner.