Lingual mucosal graft ureteroplasty for long (≥5 cm) proximal ureteral stricture: a multi-institutional 8-year experience

Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases

There is lack of papers dedicated to the laparoscopic buccal mucosa graft (BMG) ureteroplasty of the complex upper ureteral stricture. The aim of this study is to evaluate the results of laparoscopic BMG ureteroplasty in patients with complex proximal ureteral stricture. Twenty-four patients underwent laparoscopic ventral onlay BMG ureteroplasty for long or recurrent proximal ureteral stricture not amenable to uretero-ureteral anastomosis over 2019-2022. Patient demographics, operative time, estimated blood loss, length of stay, follow-up, intra- and postoperative complication rate and percentage of stricture-free at last visit were analyzed. The mean stricture length was 3.6 cm. The mean operative time was 208.3 min, while mean blood loss was 75.8 mL. The length of hospital stay was 7.3 days. No intraoperative complications were observed. Postoperatively, seven patients developed complications (29.2%). Five patients experienced a Grade II (according to Clavien nomenclature). Two patients developed a Grade IIIa complication, which included leakage of the anastomosis site. The mean follow-up was on the 22 months with stricture free rate 87.5%. Patients with proximal ureteral strictures could be effectively treated by laparoscopic ventral onlay ureteroplasty with a buccal mucosa graft.

Purpose: To evaluate the onlay technique using the appendix for ureteral reconstruction and describe the initial experience of nine operations performed by one surgeon. Methods: Nine patients with complex ureteral strictures who underwent appendiceal onlay flap ureteroplasty since May 2019 were recruited from our RECUTTER database. There were seven men and two women, with a mean age of 38.9 years; four patients underwent robot-assisted laparoscopic surgery, and five patients underwent traditional laparoscopic surgery. All patients had iatrogenic injuries of the ureter after treatment of stone disease. Seven patients had proximal ureteral strictures, and two had midureteral strictures. The mean stricture length of the nine patients was 3.9 (range 3-4.5) cm. Nephrostomy was performed in seven patients before they presented to our center, and the other two patients had indwelling Double-J ureteral stents. Results: All nine operations were effectively completed without open conversion. The mean operation time was 182 (range 135-220) minutes, the mean estimated blood loss was 71 (range 20-100) mL, and the mean length of postoperative hospital stay was 9 (range 6-12) days. No postoperative complications of high grade (Clavien-Dindo III and IV) occurred within 30 days of surgery. All the patients had their Double-J ureteral stents and nephrostomy tubes removed after complete ureteroscopy and upper urinary tract urodynamic examination or CTU, which showed that the anastomosis healed well and that the urinary tract was unobstructed, respectively. The objective success rate was 100% (all the patients had endoscopic and radiographic resolution of their ureteral strictures). The subjective success rate was 88.9% (one patient developed recurrent back discomfort and a 0.5 cm calculus was found in her renal pelvis). Conclusions: Appendiceal onlay flap ureteroplasty is a viable and effective technique for treating complex proximal and middle ureteral strictures at the right side.

Objective: To share the technique of posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures as well as our initial experience with the technique. Methods: From October 2018 to September 2019, 10 cases of robotic and laparoscopic posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures were recruited from our database of Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER). The perioperative and follow-up data were recorded. Complete success was defined as the absence of clinical symptoms, relieved stenosis on imaging, and a stable estimated glomerular filtration rate without serious complications. Results: All surgeries were completed without serious complications. There were eight laparoscopic surgeries and two robotic surgeries. The median length of defect after posteriorly augmented anastomosis was 3 cm (range, 3-5 cm). The median length of the lingual mucosa graft was 4 cm (range, 3-5 cm). The median operative time was 237 minutes (range, 189-310 minutes). The median estimated blood loss was 40 mL (range, 10-100 mL). The median postoperative length of stay was 7.5 days (range, 5-22 days). The Double-J stent was removed median 3.5 months (range, 2-7 months) after the surgery. At the median follow-up of 11 months (range, 7-20 months), all patients achieved the successful criteria of treatment. Conclusion: The posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures is a feasible and safe technique, which may be an option especially for strictures marginally longer than those that can be safely repaired via end-to-end anastomosis.

Therapeutic Living Donor Nephrectomy for Proximal Ureteral Pathology: A Longitudinal Case Series

Introduction In patients with long ureteral strictures, bowel substitution of the ureter or kidney autotransplantation can be performed, which are technically demanding. For recurrent uretero-pelvic junction obstruction (UPJO) and proximal ureteral strictures, substitution of the ureter using buccal graft may be an alternative. Aim to study the results of laparoscopic ureteral substitution in patients with long proximal ureteral strictures using buccal graft. Material and methods Laparoscopic ureteral substitution of the ureter using buccal graft was performed in 10 patients with long proximal ureteral strictures, 7 of them were men. The average age was 43.5 years. In 6 patients there was a recurrence after previous pyeloplasty, while 3 patients had ureteroscopy due to upper ureteral stone and one patient had ureteral trauma during laparoscopic excision of the kidney cyst. Three patients were admitted to the hospital with nephrostomy tube, seven with a ureteral stent. Using a laparoscopic approach, an affected part of the ureter was dissected along its length, then a stent was placed antegrade and the ureter was substituted with buccal graft using the onlay technique. Results All patients underwent laparoscopic intervention. There were no intraoperative complications. The duration of the procedure ranged from 170 to 340 minutes. There were no cases of anastomotic leakage. Fever was observed in one patient without nephrostomy drainage (Clavien grade I). On intravenous pyelography and computed tomography, the neoureter was wide and patent. In patients with PUJO, a severity of dilation of the collecting system was decreased over time. Clinically, all procedures were successful, as patients were free of nephrostomy tube and symptoms of upper urinary tract obstruction. Conclusion Ureteral substitution using buccal graft may be the method of choice in patients with long proximal ureteral strictures. It is relatively easy, since it does not require extensive dissection of the ureter and provides for the possibility of using buccal graft of the desired length.

Objectives: The aim of the study was to present our modified flap pyeloplasty techniques for recurrent ureteropelvic junction obstruction (UPJO) with a long proximal ureteral stricture and compare outcomes of laparoscopic and robotic procedures. Materials and Methods: Between March 2018 and January 2020, 21 patients underwent modified laparoscopic or robotic flap pyeloplasty for recurrent UPJO with a long proximal ureteral stricture. Our surgical modifications included the “wishbone” anastomosis and “ureteral plate” technique. Demographic, perioperative, and follow-up data were recorded and compared retrospectively between the groups. Success was defined as subjective pain alleviation and hydronephrosis improvement. Results: Thirteen modified laparoscopic flap pyeloplasty (mLFP) and 8 modified robotic flap pyeloplasty (mRFP) were performed successfully without conversion. mRFP tended to have shorter overall operative time (142.4 vs. 179.1 min, p = 0.122) and anastomosis time (43.1 vs. 61.0 min, p = 0.093) than mLFP. No difference was found in estimated blood loss (p = 0.723) and pararenal draining time (p = 0.175) between the groups. The mean postoperative hospital stay of mRFP was significantly shorter than that of mLFP (5.0 vs. 8.2 days, p = 0.015). No major complications occurred. During the mean follow-up of 17.9 months, the overall success rate was 90.5%, and there was no significant difference between 2 groups. Conclusions: The modified flap pyeloplasty could be considered a practical and effective treatment option with a high success rate for recurrent UPJO with a long proximal ureteral stricture, and the robotic procedures showed advantages of higher efficiency and faster recovery.

Introduction and Objective: In this video we present a case of a ureteroscopic and robot-assisted redo ureteroplasty with buccal mucosa graft for a proximal ureteral stricture. Methods: Here, we present a case of 72-year-old female patient with a history of a right-sided proximal ureteral stricture after ureteroscopic stone treatment. For this stricture she underwent robotic end-to-end ureteroplasty. Two years later, she presented with recurrence of the stricture for which she underwent balloon dilatation and tandem stenting. Unfortunately, the stricture recurred rapidly. A redo ureteroplasty with buccal mucosa graft was planned. Results: Surgery and postoperative course were uneventful. Six weeks after surgery, the Double-J stent was removed and 4 months postoperatively, the patient is doing fine without evidence for recurrence of the ureteral stricture. Conclusions: The video illustrates how retrograde ureteroscopy in combination with FireFly fluorescence imaging can be a valuable contribution to identifying the ureter, which in redo cases is often surrounded by a lot of fibrotic tissue. Moreover, localization of the stricture site is facilitated by retrograde ureteroscopy. After onlay of the buccal mucosa graft, patency and watertightness of the ureteroplasty can easily be controlled. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. All authors declare no conflict of interest in connection with this video. Runtime of video: 3 mins 16 secs

PurposeTo report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures.Materials and MethodsWe retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain.ResultsOf 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4–4; maximum, 5), 6 centimeters (IQR, 5–7; maximum, 8), and 5 centimeters (IQR, 4–5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14–51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months.ConclusionsLong-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.

ObjectiveThere is a lack of multi-institutional large-volume and long-term follow-up data on comparisons between robot-assisted surgery and conventional laparoscopic surgery. This study compared the surgical and long-term survival outcomes between patients who underwent robot-assisted or conventional laparoscopic surgery for endometrial cancer.MethodsWe retrospectively reviewed the data of patients from five large academic institutions who underwent either robot-assisted or conventional laparoscopic surgery for the treatment of endometrial cancer between 2012 and 2017, ensuring at least 5 years of potential follow-up. Intra- and postoperative outcomes, long-term disease-free survival, and overall survival were compared.ResultsThe study cohort included 1,003 unselected patients: 551 and 452 patients received conventional laparoscopic and robot-assisted surgery, respectively. The median follow-up duration was 57 months. Postoperative complications were significantly less likely to occur in the robot-assisted surgery group compared to the laparoscopic surgery group (7.74% vs. 13.79%, P = 0.002), primarily limited to minor complications. There were no significant differences in survival: 5-year disease-free survival was 91.2% versus 90.0% (P = 0.628) and overall survival was 97.9% versus 96.8% (P = 0.285) in the robot-assisted and laparoscopic surgery cohorts, respectively. Cox proportional hazard regression models demonstrated that the mode of surgery was not associated with disease-free survival (hazard ratio, 0.897; confidence interval, 0.563–1.429) or overall survival (hazard ratio, 0.791; confidence interval, 0.330–1.895) after adjusting for confounding factors.ConclusionRobot-assisted surgery for endometrial cancer demonstrates comparable long-term survival outcomes and a reduced incidence of postoperative minor complications when compared to conventional laparoscopic surgery.

Objectives: To present our first experience and 12-month outcomes of the novel technique of onlay preputial graft ureteroplasty (PGU) for complex ureteral stricture.Methods: In December 2016, open onlay PGU was made on a male patient who have proximal stricture of the right ureter. The length of upper ureteral stricture was 50 mm. A 60 mm in length and 15 mm in width preputial graft was harvested from the ventral side of the penis and placed in the ureter as a ventral onlay for ureteroplasty. Operative time, intraoperative, and postoperative complications were recorded properly. Follow-up was performed via clinical assessment of symptoms, renal ultrasound, MR urography, and nuclear scan renography.Results: The new technique was effectively performed without any intraoperative and postoperative complications. Residual hydronephrosis in the right side was found through ultrasonography 3, 6, and 12 months and MR urography 6 months postoperatively. But complaint of the patient's pain passed completely.Conclusions: Within our knowledge, we present the first experience with onlay PGU for proximal ureteral stricture. Twelve-month results indicate that the new technique appears to be an excellent option for proximal ureteral stricture. Our experience is encouraging, and it will find wider application in the complex ureteral lesion.

Robotic Management of Benign Mid and Distal Ureteral Strictures and Comparison With Laparoscopic Approaches at a Single Institution

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Objective To explore the therapeutic effect of laparoscopic surgery for complicated ureteral strictures after Holmium laser lithotripsy. Methods There were 67 patients with ureteral stenosis after ureteroscopic lithotripsy or percutaneous nephrolithotomy Holmium laser lithotripsy from January 2009 to September 2017. There were 38 males and 29 females. The average age of patients was 37 years old(rang 21-62 years). 47 cases were hospitalized because of osphyalgia, among whom 8 cases had fever. There were 19 cases of upper ureteral calculi postoperative stenosis, 18 cases of middle ureteral calculi postoperative stenosis and 30 cases of lower ureteral calculi postoperative stenosis, 17 cases of whom had complete atresia. 6 patients had received twice Holmium laser lithotripsy. Two patients had received triple Holmium laser lithotripsy. In 67 cases, 11 cases had received a ureteral stent placement to dilate the affected ureter. 2 cases had received twice ureteral stent placements, two double-J tubes were placed in the two stage surgery. 2 cases had received treatment of incision inside the ureteral stricture by ureteroscope, but symptoms recurred after removal of the double-J tube. There were 15 cases of mild hydronephrosis before surgery, moderate hydronephrosis in 27 cases, severe hydronephrosis in 25 cases.The depth of separation of the renal collecting system was (3.85±0.58)cm, preoperative serum creatinine was 115μmol/L on average(range 46-258 μmol/L). The surgery was done by the abdominal pathway or posterior abdominal pathway. 52 patients had ureteral stenosis resection plus ureter end anastomosis, 15 patients had ureteral bladder replantation. Results All the patients had successful surgery. The operation time was 65-160 min, and the average operation time was 82 min; the intraoperative blood loss was about 20-300 ml, and the average blood loss was about 56 ml; Postoperative fever occurred in two patients and were successfully treated by re-indwelling catheter and antibiotic. The stent was removed after 2-3 months and patients were followed up for 5-24 months after removing the double-J tube, with an average of 12 months. The patients with osphyalgia were significantly relieved. The separation of the renal collecting system was reduced to(3.85±0.58)cm, postoperative serum creatinine was 75.8 μmol/L on average(range 47-165 μmol/L). Renal function stop deterioration in 67 patients. Conclusion The operation of laparoscopic ureteral strictures resection plus ureter end anastomosis or ureteral bladder replantation after ureteral strictures due to the use of Holmium laser lithotripsy is the minimally invasive, safe and effective treatment. Key words: Holmium laser lithotripsy; Ureteral strictures; Laparoscopy

Objective: To investigate the therapeutic outcomes of patients with horseshoe kidney and hydronephrosis under different surgical approaches and with or without isthmus division. Methods: This study is a retrospective case series research. A retrospective analysis was conducted on the clinical data of 23 patients with horseshoe kidney and hydronephrosis who underwent pyeloplasty at the Department of Urology, the First Affiliated Hospital of Zhengzhou University from January 2016 to December 2023. Among them, there were 11 males and 12 females, with an age of (33±15) years (range:7 to 64 years). Patients underwent preoperative examinations, including ultrasonography of the urinary system, intravenous urography, CT urography, or magnetic resonance urography. Retrograde urography or antegrade ureteropyelography was performed when necessary to clarify the degree of hydronephrosis, the location and length of ureteral stricture. For patients with severe hydronephrosis, a ureteral stricture segment >2 cm, a thick renal isthmus in horseshoe kidney, and markedly variant vasculature, open surgery or robotic surgery is preferred. For those with mild to moderate hydronephrosis, a ureteral stricture segment <2 cm, a thin renal isthmus in horseshoe kidney, and no significant vascular variations, laparoscopic surgery is the first choice. The decision to perform isthmectomy should be made based on a comprehensive intraoperative assessment, including the vascular supply to the isthmus, the degree of surrounding adhesions, and the thickness of the isthmus. Perioperative parameters and complications were recorded and analyzed, and regular follow-up was conducted for all patients. Results: All surgeries were successfully completed. Surgical approaches included open surgery in 4 cases, laparoscopic surgery in 14 cases, and robot-assisted laparoscopic surgery in 5 cases. The operative time for open surgery, laparoscopic surgery and robot-assisted laparoscopic surgery was (125±12) minutes (range: 112 to 141 minutes), (122±50) minutes (range: 60 to 233 minutes), and (130±36) minutes (range: 76 to 174 minutes), respectively. The blood loss (M(IQR)) was 100 (25) ml (range: 50 to 100 mL) for open surgery, 35 (30) ml (range: 10 to 100 mL) for laparoscopic surgery, and 20 (10) ml (range: 20 to 50 ml) for robot-assisted laparoscopic surgery. Among 15 patients who underwent isthmus division with pyeloplasty (division group), the operation time was (138±42) minutes (range: 73 to 233 minutes), with blood loss of 50 (80) ml (range: 20 to 100 ml). For 8 patients in the non-division group who only underwent pyeloureteroplasty, the operation time was (98±27) minutes (range: 60 to 135 minutes), with blood loss of 20 (50) ml (range: 10 to 100 ml). The follow-up time of patients after surgery was 16.0 (49.0) months (range: 1.7 to 84.2 months), with a surgical success rate of 100%. Among the 8 patients in the non-division group, all demonstrated significant improvement in hydronephrosis severity compared to preoperative conditions. Notably, 6 patients who previously experienced frequent lower back pain showed no recurrence of symptoms after ureteral stent removal. In the division group of 15 patients, both subjective symptoms and hydronephrosis severity were markedly reduced. Conclusion: For patients with horseshoe kidney and hydronephrosis, the choice of surgical approach and isthmus management strategy should be determined based on a comprehensive consideration of the etiology of hydronephrosis, the degree of ureteral stricture, anatomical abnormalities, and vascular variations.