Appendiceal Flap Research Articles

Robotic-assisted laparoscopic modified ureteroplasty using lingual mucosa grafts or appendiceal flaps for the management of complex ureteral strictures: a retrospective cohort study

ObjectiveTo evaluate the feasibility, safety and efficacy of robot-assisted laparoscopic modified ureteroplasty using a lingual mucosa graft (LMG) or an appendiceal flap (AF) for complex ureteral strictures and summarize our experience.MethodsA total of 16 patients with complex ureteral strictures (range: 1.5–5 cm) who underwent robotic-assisted laparoscopic-modified ureteroplasty and were admitted to our hospital from May 2022-October 2023 were retrospectively analyzed. We used modified presuture methods in patients who needed the posteriorly augmented anastomotic technique to reduce anastomotic tension. Perioperative variables and outcomes were recorded for each patient.ResultsThe operation under robot-assisted laparoscopy was successfully performed in all sixteen patients (12 with LMG ureteroplasty and 4 with AF ureteroplasty) without conversion to open surgery. The mean length of the ureteral structure was 2.90 ± 0.90 cm (range: 1.5–5 cm), the mean operation duration was 209.69 ± 26.74 min (range: 170–255 min), the median estimated blood loss was 75 (62.5) ml (range: 50–200 ml), and the duration of postoperative hospitalization was 10.44 ± 2.10 d (range: 7–14 d). The follow-up time in this group was 6 ~ 21 months. The success rate of the surgery was 100%.ConclusionRobot-assisted laparoscopic modified ureteroplasty using AF or LMG is a safe and feasible operation for complex ureteral strictures and deserves to be popularized.

V09-10 ROBOTIC-ASSISTED AUGMENTED ROOF URETEROPLASTY WITH APPENDICEAL ONLAY FLAP

You have accessJournal of UrologyCME1 Apr 2023V09-10 ROBOTIC-ASSISTED AUGMENTED ROOF URETEROPLASTY WITH APPENDICEAL ONLAY FLAP Andrew Gabrielson, Oscar Li, and Andrew Cohen Andrew GabrielsonAndrew Gabrielson More articles by this author , Oscar LiOscar Li More articles by this author , and Andrew CohenAndrew Cohen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Mid-to-proximal ureteral strictures pose a surgical challenge that historically required ileal ureter substitution, downward nephropexy, or renal autotransplantation. Ureteral reconstruction techniques involving buccal mucosa or appendix have gained traction with success rates approaching 90%. In this video we describe surgical technique for a robotic-assisted augmented roof ureteroplasty using an appendiceal onlay flap. METHODS: Our patient is a 45 year old male with recurrent impacted ureteral stones requiring multiple right-sided interventions including ureteroscopy with laser lithotripsy, ureteral dilation, and laser incision of ureteral stricture. Despite adequate treatment of his stone disease, he had deterioration of his renal split function with worsening right hydroureteronephrosis to the level of the mid-to-proximal ureter consistent with failed endoscopic management of his stricture. We proceeded with simultaneous endoscopic evaluation and robotic repair with plan for either ureteroureterostomy or augmented roof ureteroplasty using buccal mucosa or an appendiceal flap. RESULTS: Ureteroscopy and retrograde pyelogram revealed a 2-3cm near-obliterative stricture in the mid-to-proximal ureter. The ureteroscope was left in situ and the patient was placed in the modified flank position to allow concurrent endoscopic access during reconstruction. The right colon was reflected revealing significant scar tissue overlying the ureter. With the ureteroscope in situ, we utilized firefly imaging to aid in our dissection. The ureter was spatulated and mucosa of the diseased segment of ureter excised in a non-transecting manner. The mucosal edges of the posterior ureter were re-approximated with the ureteral backing left in place. The appendix was harvested on its mesentery, spatulated, and interposed in a pro-peristaltic fashion. A tension-free anastomosis was performed between ureteral mucosa and the open appendix flap. A JJ stent was placed under direct vision and ICG green was used to evaluate blood supply to the margins of the ureter and the appendix flap. The stent was removed 6 weeks postoperatively, and on 3-month follow-up imaging he had resolution of his right hydroureteronephrosis and has had no further episodes of stone formation, infections, or flank pain with 8-month followup. CONCLUSIONS: Augmented roof ureteroplasty with appendiceal onlay is a valuable tool in the urologists arsenal of reconstructive techniques. Use of intraoperative ureteroscopy with firefly imaging can aid in delineating anatomy during difficult ureteral dissections. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e840 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Gabrielson More articles by this author Oscar Li More articles by this author Andrew Cohen More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE

You have accessJournal of UrologyCME1 Apr 2023V01-08 ROBOTIC APPENDICEAL ONLAY FOR THE TREATMENT OF URETEROENTERIC STRICTURE Joseph J. Boyle, Ellen Cahill, Sai Krishnaraya Doppalapudi, and Sammy E. Elsamra Joseph J. BoyleJoseph J. Boyle More articles by this author , Ellen CahillEllen Cahill More articles by this author , Sai Krishnaraya DoppalapudiSai Krishnaraya Doppalapudi More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroenteric anastomotic strictures (UES) are the most common complication requiring repeat surgery following radical cystectomy, occuring in up to 10% of patients. Untreated, they may result in loss of renal function and predispose patients to infection. Open revision of the stricture has been the gold standard, but is technically challenging. Minimally invasive surgical approaches (MIS) in stricture disease can afford greater visibility and maneuverability, while minimizing blood loss. Options for extended strictures or those located in the proximal or midureter have been historically limited to ileal ureter replacement or autologous kidney transplant, both having considerable morbidity. Onlay techniques utilizing buccal mucosa or appendix are options to repair rather than replace longer ureteral strictures. Appendiceal onlay flaps are an encouraging yet relatively under-described alternative for select patients in this group. In this video, we present a case of a 6 cm proximal right UES treated with robotic appendiceal onlay flap repair. METHODS: Procedure performed with Da Vinci Xi system. Patient placed in left lateral decubitus position. Veress needle technique used to insufflate the abdomen. Ports placed in standard position for robotic laparoscopic renal surgery, ensuring placement outside conduit margins. Right ureterolysis performed. 5-French ureteral catheter placed over a wire positioned through previously placed ureteral stent. Ureteroenteric anastomosis identified, with ureteral detubularization from anastomosis to just above stricture with a length of 6 cm. Increased ureteral caliber and vigorous saline efflux marked proximal stricture end. Appendix stapled at cecum and detubularized with preserving mesentery. Appendiceal flap sewn to detubularized segment of ureter. Intraoperative ureteroscopy demonstrated patent repair. JJ stent placed. RESULTS: No intraoperative complications. Case duration was 200 minutes. EBL was 25 mL. He was discharged POD 2 after an uncomplicated post-operative stay. Stent removed at 6 weeks. 3-month ultrasound and renal scan showed no obstruction. He was seen every 6 months with no signs or symptoms of UTI, flank pain, or hydronephrosis on ultrasound. Latest follow-up at 16 months. He reported resolution of chronic malodorous urine. CONCLUSIONS: UES remain a challenge following radical cystectomy. Robotic repair with appendiceal onlay is a safe, durable, and often overlooked treatment option. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e81 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph J. Boyle More articles by this author Ellen Cahill More articles by this author Sai Krishnaraya Doppalapudi More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy.

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. From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6cm) 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. 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 4cm (range 2-6cm). 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 12.8months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches. 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.

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.

A Multi-Institutional Experience With Robotic Appendiceal Ureteroplasty

To report a multi-institutional experience with robotic appendiceal ureteroplasty. This is a retrospective review of 13 patients undergoing right appendiceal flap ureteroplasty at 2 institutions between April 2016 and October 2019. The primary endpoint was surgical success defined by the absence of flank pain and radiographic evidence of ureteral patency. Eight of 13 (62%) underwent appendiceal onlay while 5/13 (38%) underwent appendiceal interposition. Mean length of stricture was 6.5 cm (range 1.5-15 cm) affecting anywhere along the right ureter. Mean operative time was 337 minutes (range 206-583), mean estimated blood loss was 116 mL (range 50-600), and median length of stay was 2.5 days (range 1-9). Balloon dilation was required in 1/12 (8%). One patient died on postoperative day 0 due to a sudden cardiovascular event. Otherwise, there were no complications (Clavien-Dindo > 2) within 30 days from surgery. At a mean follow up of 14.6 months, 11/12 (92%) were successful. Robotic appendiceal ureteroplasty for right ureteral strictures is a versatile technique with high success rates across institutions.

V03-05 ROBOTIC APPENDICEAL ONLAY URETEROPLASTY FOR RECURRENT LOW GRADE UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVE: We report the case of a 63 year-old male smoker with recurrent low grade urothelial carcinoma and papillary urothelial neoplasm of low malignant potential, refractory to multiple rounds of endoscopic management. He underwent successful robotic assisted mid-ureteral segmentectomy followed by augmented ureteroplasty with anterior onlay appendiceal flap. METHODS: After docking, the right ureter was mobilized and direct visual ureteroscopy helped delineate the margins of the tumor using precise suture ligation to sequester the tumorous segment. After specimen removal, the defect was assessed and residual tension due to retraction precluded a suitable primary ureteroureterostomy (UU). After consideration of the various reconstructive options, we decided upon an appendiceal interposition. The appendix had adequate length, and intravenous indocyanine green (ICG) with near-infrared fluoroscopy (NIF) showed good blood supply. Appendix amputation followed by cecopexy to the psoas muscle was performed to reduce pedicle tension. The proximal appendix was unexpectedly found to be obliterated and the plan was revised to perform an augmented ureteroplasty with appendiceal onlay flap. A double-J ureteral stent was placed, followed by the completion of the onlay. RESULTS: Estimated blood loss was minimal (100cc); console time was 219 minutes. There were no complications. The patient was discharged on post-operative day 1. Follow-up retrograde pyelogram showed prompt drainage of contrast and a patent ureter and the stent was removed 10 weeks after the surgery. CONCLUSIONS: The appendix can serve as a suitable ureteral substitution in situations unamenable to UU, given the need for additional length. A skilled reconstructive urologist needs to maintain a high level of intraoperative flexibility in the event that original plans change based on anatomic findings during the case. Additionally, adjuncts such as intraoperative ureteroscopy and the use of ICG/NIF can prove significantly useful during complex reconstructive cases. Source of Funding: None

Ureteral Replacement and Onlay Repair with Reconfigured Intestinal Segments

Ureteral loss represents a surgical challenge to provide low pressure drainage while avoiding urinary stasis and reflux. The ideal replacement should optimize drainage while minimizing absorption, allowing for ureteral repair of varied lengths and locations with maximal preservation of the urinary tract. We reviewed our experience with ureteral repair, focusing on the use of reconfigured intestine. We report what is to our knowledge the novel use of reconfigured intestine as an onlay flap on the preserved ureteral segment and as a circumferential interpositioned segment. A total of 16 ureters were repaired in 4 men and 9 women using reconfigured ileum, colon or appendix. Mean patient age was 45 years (range 26 to 66). The etiology of the ureteral defect was iatrogenic in 8 patients, retroperitoneal fibrosis in 3, trauma in 3 and ureteritis cystica in 1. Mean defect length was 10 cm (range 5 to 20) in the 10 right and 6 left ureters, and the defect was proximal in 3, mid in 4, distal in 7 and panureteral in 2. Ureteral replacement was performed using a segment of ileum in 13 cases or colon in 1. The segment was detubularized and reconfigured according to the Yang-Monti principle and used as a complete retubularized interposed segment in 7 cases or as an onlay flap on the opened ureter without resection in 7. Also, 2 ureters were reconstructed with an incised appendiceal flap onlayed over the preserved ureteral plate. At a mean followup of 44 months (range 12 to 78) all patients underwent antegrade nephrostogram, followed by renal scan and upper tract imaging. All patients tolerated the procedure without initial bowel or urinary tract complications. In 1 patient who had received radiation a ureteral fistula developed to a blind Hartmann pouch at 9 months, requiring repair. Ultimately, cystectomy was done for irradiation cystitis (onlay group). Another patient with bilateral obstruction at presentation lost unilateral renal function during 5 years. Urinary drainage was achieved in all 14 remaining renal units with preservation of function, as shown on renal scan. Patients reported minor mucous production without renal colic or stone formation. Long ureteral defects require tissue replacement when bladder flaps do not suffice. Ureteral replacement can be achieved by reconfigured intestinal segments, which are readily mobilized and secured as interposed segments or as an onlay flap on the preserved ureter. A relatively short segment can be used to repair a lengthy defect along any segment of ureter, also allowing for nonrefluxing reimplantation.

Continent Urinary Diversions in the Exstrophy Complex: Why do they Fail?

Urinary continence is one of the primary goals in the surgical treatment of the patient with exstrophy. Children with inadequate bladder capacity, noncompliant or neuropathic bladder, or failed bladder neck reconstruction may require creation of a continent urinary reservoir to achieve continence. While initial success rates are excellent, some patients suffer persistent urinary incontinence, severely affecting their quality of life. The reasons for such failure and subsequent management were evaluated. A retrospective database review was performed in 748 patients with the exstrophy complex. Patients with a history of failed continent urinary diversion with incontinence from the stoma or urethra were identified. Initial diagnosis, number of previous operations, reason for and time interval after surgery when failure occurred, and management strategies were evaluated. Of 92 patients undergoing continent diversion procedures 19 (21%) had failure initially (15 with classic and 4 with cloacal exstrophy). Four of the 19 patients underwent primary surgery at our institution and 15 were referred. The procedure initially performed was an intussuscepted nipple valve in 8 patients, an intussuscepted ileocecal valve in 1 and an ileal or sigmoid reservoir with appendiceal flap valve (Mitrofanoff) in 10. Main reasons for failure included de-intussusception and bladder neck incompetence. Mean followup after continence was achieved was 2.9 years (range 3 months to 10 years). These patients underwent up to 8 operations to achieve continence (mean 5). Most patients (79%) were successfully treated with either 1 (47%) or 2 revisions (32%), while 1 required 3 reoperations. Overall, 89 of 92 patients (97%) are currently continent, including those requiring medications and further surgical procedures, while 3 are still wet. Most patients with exstrophy with failure of continent urinary diversion have a long complicated surgical history. In this series incontinence from an intussuscepted nipple stoma was mostly due to de-intussusception. In patients with an initial Mitrofanoff stoma all incontinence occurred within the first few months postoperatively. Continence was achieved by either recreation of a Mitrofanoff stoma or bladder neck transection. Patients with a failed continent urinary diversion benefit from careful preoperative evaluation, meticulous surgical execution and persistent attempts to achieve continence.

Appendix Interposition in the Treatment of Severe Posterior Urethral Injuries

The aim of this study was to investigate the applicability of the Mitrofanoff principle in the treatment of severe posterior urethral injuries and determine the feasibility of this technique with its early and late postoperative results. A total of 27 New Zealand rabbits (12 male and 15 female) was used (mean weight 2,272 plus/minus 343 gm.). Using general anesthesia the proximal part of the posterior urethra was transected completely and a 1 cm. segment was excised. A 2 cm. segment of appendix with its intact vascular pedicle was meticulously mobilized and anastomosed to the proximal and distal site of the urethra. Excretory urograms, voiding cystourethrograms, urodynamic investigation and histopathological examination were performed postoperatively. The fertility of the male rabbits was examined in the late postoperative period as well. These results were compared with those of a control group. There was no problem concerning voiding patterns in the pedicled appendiceal flap group. Excretory urograms revealed a properly functioning urinary system. Voiding cystourethrograms showed a normal bladder capacity and voiding pattern, and an intact urethra. Urodynamic analysis was within normal limits except for a decrease in bladder volume. An intact urethral lumen without any strictures or fibrosis was demonstrated histopathologically. No calculus, mucus formation or urinary tract infection was observed in the late postoperative period. Fertility problems were noted in male rabbits. This animal experiment suggested that the pedicled appendiceal flap technique could be used for the treatment of severe forms of posterior urethral injuries.

Appendix Interposition in the Treatment of Severe Posterior Urethral Injuries

The aim of this study was to investigate the applicability of the Mitrofanoff principle in the treatment of severe posterior urethral injuries and determine the feasibility of this technique with its early and late postoperative results. A total of 27 New Zealand rabbits (12 male and 15 female) was used (mean weight 2,272 +/- 343 gm.). Using general anesthesia the proximal part of the posterior urethra was transected completely and a 1 cm. segment was excised. A 2 cm. segment of appendix with its intact vascular pedicle was meticulously mobilized and anastomosed to the proximal and distal site of the urethra. Excretory urograms, voiding cystourethrograms, urodynamic investigation and histopathological examination were performed postoperatively. The fertility of the male rabbits was examined in the late postoperative period as well. These results were compared with those of a control group. There was no problem concerning voiding patterns in the pedicled appendiceal flap group. Excretory urograms revealed a properly functioning urinary system. Voiding cystourethrograms showed a normal bladder capacity and voiding pattern, and an intact urethra. Urodynamic analysis was within normal limits except for a decrease in bladder volume. An intact urethral lumen without any strictures or fibrosis was demonstrated histopathologically. No calculus, mucus formation or urinary tract infection was observed in the late postoperative period. Fertility problems were noted in male rabbits. This animal experiment suggested that the pedicled appendiceal flap technique could be used for the treatment of severe forms of posterior urethral injuries.