Midureteral Stricture Research Articles

A decade's experience of robotic buccal ureteroplasty for post ureteroscopic laser lithotripsy induced strictures—Should this be the new standard?

ObjectiveTo present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes. MethodsThis was a retrospective study conducted at the Department of Urology at Apollo Hospitals, Chennai, India from October 2012 to October 2022. Indications for surgery included worsening hydronephrosis, declining renal function, and recurrent urinary tract infections with obstruction. Apart from liberal exposure of the stricture, we stress upon the use of indocyanine green to assess vascularity and quilting of the graft to bare area of psoas muscle to increase the graft vascularity. ResultsAmong the 15 patients, ureteropelvic junction strictures were observed in eight (53.3 %), while five (33.3 %) had proximal stricture, and two (13.3 %) had mid-ureteral stricture. Notably, eight of the 15 (53.3 %) patients had previous unsuccessful double-J stenting. The median stricture length was 3.5 cm (range: 2–5 cm), with a mean operative time of 167 min (range: 126–214 min) and estimated blood loss of 140 mL (range: 40–200 mL). After a median follow-up of 12 months (range: 4–32 months), 13 out of 15 (86.7 %) patients showed significant improvement in their follow-up functional scans. ConclusionRobotic buccal ureteroplasty is a very effective technique for the management of laser-induced ureteral strictures with good long-term results and minimum morbidity. The results are comparable irrespective of previous failed stenting.

The First Robotic Day Care Procedure in the Management of Testicular Vein Syndrome: A Rare Cause of Hydroureteronephrosis

Clinical History: A 46-year-old gentleman with no comorbidities presented with dull aching pain in the left loin for 6 months. Physical Examination: Examination was unremarkable. Diagnosis: He was evaluated with contrast-enhanced CT scan of the urinary tract that revealed left gross hydroureteronephrosis secondary to midureteral stricture caused by compression of the left testicular vein. Renogram (diethylenetriamine pentaacetate scan) was performed that showed 44% split renal function of the left kidney with a glomerular filtration rate of 86 mL/min. Intervention: He underwent a day-case robotic ureteroureterostomy and intraoperatively the upper ureter was dilated with testicular vein transposing above the midureter that had a stricture, causing dilatation of proximal ureter with hydronephrosis. Upper ureter was transected above the stricture and brought anterior to the testicular vein and the constricted segment was excised. Ureteroureterostomy was performed over 5F/26 cm Double-J stenting using 2-0 Stratafix suture. Outcomes: Follow-up included stent removal at 6 weeks and serial creatinine thereafter has been normal. Follow-up imaging was done in the form of ultrasonography that showed resolution of hydronephrosis at 3 months and 6 months. Patient Consent Statement: Written informed consent was obtained from the patient to publish this research. No competing financial interests exist.This research received no specific grant from any funding agency, commercial or nonprofit sectors. All authors confirm that they have been involved in the conception and design of the study, drafting of the study for intellectual content, and are accountable to the accuracy of all aspects of the content.Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure Runtime of video: 4 mins 17 secs

The role of bowel for minimally invasive treatment of stricture disease

The management of urinary tract stricture disease has evolved over the last several decades, with robotic surgery representing a bourgeoning method for urologic reconstruction. Conventionally, proximal and mid-ureteral strictures, as well as lengthy urethral strictures, have presented a challenge for surgeons to create tension-free repairs. Options for repair include endoscopic dilation, endopyelotomy, ureteroplasty or pyeloplasty, and urethroplasty. Small and large bowel can be incorporated into various urinary tract stricture repairs. Their use has proven successful in reconstructing both upper and lower urinary tract strictures and offers flexibility for complex cases such as lengthy or multifocal strictures. While the use of bowel, most notably the appendix, for stricture repair is not a novel concept, a growing body of evidence supports its use with minimally invasive robotic approaches. In addition, there has been a substantial amount of recent data suggesting low rates of postoperative complications and long progression-free survival after robotic stricture repair using small bowel or rectum. We present a comprehensive review of literature outlining the role of the small bowel, appendix, and rectum in the minimally invasive repair of urinary tract stricture disease, as well as a description of the various techniques employed.

V01-06 OWN FLAP URETEROPLASTY-NEW SOLUTION FOR LONG STRICTURE

You have accessJournal of UrologyCME1 May 2022V01-06 OWN FLAP URETEROPLASTY-NEW SOLUTION FOR LONG STRICTURE Alexander Kheifets, Ben Valery Sionov, Masha Ben Zvi, and Alexander Tsivian Alexander KheifetsAlexander Kheifets More articles by this author , Ben Valery SionovBen Valery Sionov More articles by this author , Masha Ben ZviMasha Ben Zvi More articles by this author , and Alexander TsivianAlexander Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002520.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reconstruction of long stricture in mid ureter is challenging and surgical options are scarce. In this video we present an alternative recourse where reconstruction of narrowed part of ureter is achieved using rotated flap taken from dilated proximal ureter. METHODS: 36 years old healthy woman investigated for recurrent right renal colic, the imaging revealed 3 cm stricture in right mid ureter with significant pre-stenotic dilation. Right kidney appeared obstructed according to DTPA scanning. The video demonstrates all the surgical steps of laparoscopic reconstruction. RESULTS: Operative time was 4.5 hours. Patient went home on second p/o day and the stent was removed 4 weeks following surgery. After more than 4 years of follow up there is no clinical, laboratory or radiographic evidence of recurrence. CONCLUSIONS: This technique may be a valid reconstructive option for mid ureteral long strictures in selected patients. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e53 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Kheifets More articles by this author Ben Valery Sionov More articles by this author Masha Ben Zvi More articles by this author Alexander Tsivian More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP53-02 RECONSTRUCTION OF OBLITERATED URETERAL STRICTURES IS ASSOCIATED WITH INCREASED DIFFICULTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP53)1 Sep 2021MP53-02 RECONSTRUCTION OF OBLITERATED URETERAL STRICTURES IS ASSOCIATED WITH INCREASED DIFFICULTY Randall Lee, Ziho Lee, Aeen Asghar, David Strauss, Robert Harrison, Nathan Cheng, Lee Zhao, Michael Stifelman, and Daniel Eun Randall LeeRandall Lee More articles by this author , Ziho LeeZiho Lee More articles by this author , Aeen AsgharAeen Asghar More articles by this author , David StraussDavid Strauss More articles by this author , Robert HarrisonRobert Harrison More articles by this author , Nathan ChengNathan Cheng More articles by this author , Lee ZhaoLee Zhao More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002083.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is currently a paucity of literature evaluating predictors of increased difficulty for ureteral reconstruction. Herein, we evaluate whether stricture patency (ie. obliterated versus narrowed) affect the difficulty of ureteral reconstruction. METHODS: The multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients who underwent ureteral reconstruction from June 2012 to February 2019. Strictures were identified as obliterated versus narrowed. Patients with obliterated strictures were defined as those unable to be traversed with contrast or an endoscopic guidewire. We utilized operating time (OT), estimated blood loss (EBL), and frequency of utilization of adjunctive mobility procedures (downward nephropexy, psoas hitch) as surrogates for procedure difficulty. Surgical success was defined as the absence of flank pain and the improvement or absence of obstruction on renal scan. RESULTS: A total of 361 patients presented for surgical management. A total of 55 obliterated strictures and 206 narrowed strictures were identified. There was no difference in stricture length between two subsets (P=0.162). Obliterated strictures had significantly longer OT when located in the proximal/mid ureter (239 vs 160 min, P=0.002 and 278 vs 190 min, P=0.05, respectively). The EBL was slightly higher with proximal/mid ureteral reconstruction (100 vs 50 cc, P=0.005). Reconstruction of obliterated strictures at the proximal/mid ureter required significantly more adjunct mobilization procedures, 32% vs 14.7% (P=0.029). Obliterated strictures at the proximal/mid ureter had significantly increased major complications (24% vs 7.9%, P=0.01), but the clinical and radiographic success rates remained similar regardless of location (P=0.3 and P=0.94). CONCLUSIONS: We demonstrate that reconstruction of obliterated proximal and mid ureteral strictures are associated with increased complexity and likelihood to utilize adjunct mobilization procedures. Despite the increased complexity, success rates of obliterated strictures are similar to narrowed strictures. Defining stricture patency aids in preoperative planning and managing intraoperative expectations. No differences were seen when managing distal ureteral strictures. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e939-e939 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Randall Lee More articles by this author Ziho Lee More articles by this author Aeen Asghar More articles by this author David Strauss More articles by this author Robert Harrison More articles by this author Nathan Cheng More articles by this author Lee Zhao More articles by this author Michael Stifelman More articles by this author Daniel Eun More articles by this author Expand All Advertisement Loading ...

Minimally invasive (laparoscopic/robotic) ureteroplasty for long segment proximal and mid ureteral strictures.

Minimally invasive (laparoscopic/robotic) ureteroplasty for long segment proximal and mid ureteral strictures.

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.

Appendiceal Onlay Flap Ureteroplasty for the Treatment of Complex Ureteral Strictures: Initial Experience of Nine Patients.

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.

V05-07 ROBOTIC ASSISTED URETEROPLASTY WITH BUCCAL MUCOSA GRAFT FOR A 3CM MID-URETERAL STRICTURE

INTRODUCTION AND OBJECTIVE:Mid-ureteral strictures greater than 1-2cm in length can prove to be difficult to manage. Mainstay treatment options include chronic indwelling stents, ureteral balloon d...

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.

Robot-assisted laparoscopic midureteral stricture repair and percutaneous stent placement in an infant

Mid-ureteral strictures in infants are a rare cause of hydronephrosis. In this surgical technique video we demonstrate a repair of a mid-ureteral stricture using a robot- assisted laparoscopic approach to mobilize and excise the stricture using the assistance of a hitch stitch as well as placement of a percutaneous stent. This technique was easily performed and successful for this patient.

Congenital mid-ureteral stricture: a case report of two patients

BackgroundCongenital hydronephrosis is a common foetal anomaly. There are numerous causes of hydronephrosis. The diagnosis of ureteral anomalies remains challenging. Congenital mid-ureteral stricture (CMS) is less common than proximal and distal strictures. In most cases involving CMS, this condition is diagnosed intra-operatively. The gold standard treatment is resection of the stenosed segment and ureteroureterostomy.Case presentationWe report two patients with CMS which presented as antenatal hydronephrosis with postnatal workup showed a picture of pelviuretric junction obstruction which required surgical correction. Intraoperative retrograde pyelography (RGP) confirmed the diagnosis of mid ureteral stricture which make us to change the planned surgical intervention from pyeloplasty to excision of the ureteral stricture and ureteroureterostomy as definitive management.ConclusionCMS should be considered whenever proximal mega-ureter is an associated finding. Despite advanced radiological modalities, RGP remains the mainstay approach for diagnosing ureteral anomalies.

Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience

BackgroundMinimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. ObjectiveTo evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. Design, setting, and participantsThis retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. Surgical procedureRBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. Outcome measurements and statistical analysisPreoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitationsThe onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0–8.0), operative time was 200min (range 136–397), estimated blood loss was 95ml (range 25–420), and length of stay was 2 d (range 1–15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. ConclusionsRBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. Patient summaryWe studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

Open and Robotic Techniques for Appendiceal Interposition in Ureteral Stricture Disease

Introduction: Robot-assisted techniques for large ureteral strictures usually involve reconstruction with ureteroneocystostomy, Boari flap, psoas hitch, or with intestinal interposition with an ileal segment. These measures are highly involved, add significant operating room time, and have well-known complications. We present a novel robotic technique for management of right-sided ureteral stricture using an appendiceal interposition. Methods: Using the DaVinci XI Robotic System, we utilized standard right-sided port placement similar to a nephrectomy setup. The appendix was identified, dissected free, and stapled off the cecum, making sure to preserve the mesoappendix. The appendix was then serially dilated using feeding tubes and S-dilators over a guidewire. The ureteral segment to be excised was identified using collecting system administration of indocyanine green (ICG) both in antegrade and retrograde manners. Intravenous ICG was also used to help delineate the strictured ureteral segment as well as the appendiceal segment perfusion. An end-to-end anastomosis between appendix and ureteral ends, in a spatulated manner, was then performed over a Double-J stent. This novel approach was compared with a conventional open laparotomy technique, in which an appendix and cecal flap were utilized for a right-sided ureteral interposition. This patient had a previous ileal interposition for stricture disease that required a long segment replacement. The appendix was mobilized, preserving the blood supply, with the cecum to provide additional length. Dilation of the lumen was not required, and an end-to-end anastomosis was performed over a Double-J stent to bridge the gap between renal pelvis and the bladder. Results: The patient tolerated the procedure well. Operative time was 4 hours, and estimated blood loss was found to be less than 50 mL. The patient developed a postoperative MRSA bacteremia that was treated to resolution with antibiotics. A right antegrade nephrostogram at 6 weeks showed opacification of the entire collecting system with free flow of contrast into the bladder over the stent without evidence of a leak. In the open appendiceal–cecal interposition case, there were no postoperative complications, and antegrade nephrostogram at 6 weeks after stent removal illustrated a patent anastomoses, with excellent passage of contrast as well. Conclusions: Robotic appendiceal interposition for right-sided ureteral stricture is a safe alternative approach to management of right-sided mid ureteral stricture disease. The use of intravenous and intracollecting system-administered ICG significantly aids in identification of the diseased segment as well as vascularity to improve surgeon confidence in the healing capability of the interposed appendix and ureteral ends. This approach is comparable with the more traditional open laparotomy technique of appendix substitution. No competing financial interests exist. Runtime of video: 8 mins 16 secs

Robotic Ureteroplasty with Buccal Mucosa Graft for the Management of Complex Ureteral Strictures.

Surgical management of proximal and mid ureteral strictures that are not amenable to primary excision and anastomosis is challenging. Although a buccal mucosa graft is commonly used during substitution urethroplasty, its use in substitution ureteroplasty is limited. We describe our technique of robotic ureteroplasty with a buccal mucosa graft to manage complex ureteral strictures and we report our outcomes. We retrospectively reviewed the records of 12 patients who underwent robotic ureteroplasty with a buccal mucosa graft between September 2014 and June 2016. The indication for the procedure was a proximal or mid ureteral stricture not amenable to primary excision and anastomosis. The primary outcomes were clinical success, absent symptoms on ureteral pathology and radiological success, defined as absent ureteral obstruction on retrograde pyelography, renal scan and/or computerized tomography. Four of the 12 patients (33.3%) had a ureteropelvic junction stricture, 4 (33.3%) had a proximal stricture and 4 (33.3%) had a mid ureteral stricture. Eight of the 12 patients (66.7%) had previously undergone failed ureteral reconstruction. Median stricture length was 3 cm (range 2 to 5). Median operative time was 217 minutes (range 136 to 344) and mean estimated blood loss was 100 ml (range 50 to 200). Median length of stay was 1 day (range 1 to 6). At a median followup of 13 months (range 4 to 30) 10 of the 12 cases (83.3%) were clinically and radiologically successful. Robotic ureteroplasty with a buccal mucosa graft is associated with low inherent morbidity. It is an effective way to manage complex proximal and mid ureteral strictures.

458 - An alternative technique for treating long mid-ureteral strictures and defects

458 - An alternative technique for treating long mid-ureteral strictures and defects

Laparoscopic Resection and End-to-End Ureteroureterostomy for Midureteral Obstruction in Children.

Midureteral obstruction is an extremely rare condition. This retrospective study assessed the outcomes of laparoscopic ureteroureterostomy (UU) in 13 children with midureteral obstructions. Records of patients with midureteral obstruction who underwent laparoscopic end-to-end UU between July 2011 and August 2015 were reviewed. The medical records comprised patient demographic data, intraoperative details, postoperative outcomes, and related complications. Renal ultrasound, magnetic resonance urography, and radioisotope renography were used for pre- and postoperative assessment. Success was defined as removal of symptomatic obstruction or improvement of hydronephrosis. Thirteen patients from 3.0 months to 12 years old were identified: 6 patients presented with asymptomatic hydronephrosis (according to the renal ultrasonography), 3 with intermittent abdominal pain, and 2 with gross hematuria. The remaining 2 patients presented with urinary extravasation after inguinal hernia repair and the Soave procedure, respectively. All patients underwent laparoscopic end-to-end UU. Procedures were performed using either the laparoscopic transperitoneal approach or laparoscopic retroperitoneal approach. All surgeries were performed successfully except for one case that required open surgery because of difficult anastomosis. There were no intraoperative or immediate postoperative complications. The etiology of the midureteral obstruction included congenital midureteral stricture, ureteral polyp, retrocaval ureter, and iatrogenic injury. The mean surgical time was 148.4 min, and postoperative hospital stay was 4.0-9.0 d. Postoperative outcomes were successful in all 13 patients (100%); median follow-up was 19.1 months. Laparoscopic UU was found to be feasible and safe for the management of midureteral obstruction in children.

V3-08 INGUINAL URETEROURETEROSTOMY FOR MANAGEMENT OF NON-REFLUXING DOUBLE COLLECTING SYSTEM PATHOLOGY AND MID-URETERAL STRICTURES IN CHILDREN

You have accessJournal of UrologyPediatrics1 Apr 2014V3-08 INGUINAL URETEROURETEROSTOMY FOR MANAGEMENT OF NON-REFLUXING DOUBLE COLLECTING SYSTEM PATHOLOGY AND MID-URETERAL STRICTURES IN CHILDREN Jeffrey White, MD, PhD Jessica Goetz, andMD Juan PrietoMD Jeffrey WhiteJeffrey White More articles by this author , Jessica GoetzJessica Goetz More articles by this author , and Juan PrietoJuan Prieto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1309AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteroceles and ectopic ureters in duplicated collecting systems can be managed via upper or lower urinary tract surgical approaches, or a combination of both. Ureteroureterostomy (UU) can be performed via traditional open, laparoscopic or robotic-assisted techniques. A series of ureteroureterostomy via inguinal incision was recently published1; the surgeries were performed in patients with ureteroceles or ectopic ureters without associated lower pole (LP) vesicoureteral reflux (VUR). We have expanded the application of inguinal UU to manage midureteral strictures in small children. METHODS We present a video of the inguinal UU surgical technique in a patient with hydroureteronephrosis secondary to a right ectopic ureter in a double collecting system. Furthermore, the technique was applied to a 3-month old female with a right midureteral stricture causing decreased ipsilateral differential renal function. RESULTS After making a 2.5-cm inguinal incision, the anterior and posterior walls of the inguinal canal were opened to access the retroperitoneum. The duplicated ureters were identified and dissected distally to the common sheath. The dilated upper pole (UP) ureter was transected and the distal stump ligated using 3-0 absorbable sutures. The diameter of the UP ureter was measured, and the LP ureter was incised according to the UP ureter dimension. End to side UU was accomplished using interrupted 6-0 absorbable sutures. The inguinal incision was closed in layers after ensuring the lack of a urinary leak across the anastomosis. Improved hydronephrosis and no complications have been reported so far. CONCLUSIONS Inguinal UU is an excellent alternative for the definitive surgical management of ectopic ureters and ureteroceles without ipsilateral LP VUR. The technique is also feasible to treat mid-ureteral strictures in small children. Inguinal UU has significant advantages over other surgical techniques including shorter surgical times and hospital stay, lower morbidity, and improved cosmetic results. Inguinal UU should be promoted to become part of the surgical armamentarium of pediatric urologists. 1 Prieto et al. Ureteroureterostomy Via Inguinal Incision For Ectopic Ureters and Ureteroceles Without Ipsilateral Lower Pole Reflux. J Urol. 2009; 181:1844-1850. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e423 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jeffrey White More articles by this author Jessica Goetz More articles by this author Juan Prieto More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoendoscopic Management of Midureteral Strictures

The incidence of ureteral strictures has increased worldwide owing to the widespread use of laparoscopic and endourologic procedures. Midureteral strictures can be managed by either an endoscopic approach or surgical reconstruction, including open or minimally invasive (laparoscopic/robotic) techniques. Minimally invasive surgical ureteral reconstruction is gaining in popularity in the management of midureteral strictures. However, only a few studies have been published so far regarding the safety and efficacy of laparoscopic and robotic ureteral reconstruction procedures. Nevertheless, most of the studies have reported at least equivalent outcomes with the open approach. In general, strictures more than 2 cm, injury strictures, and strictures associated either with radiation or with reduced renal function of less than 25% may be managed more appropriately by minimally invasive surgical reconstruction, although the evidence to establish these recommendations is not yet adequate. Defects of 2 to 3 cm in length may be treated with laparoscopic or robot-assisted uretero-ureterostomy, whereas defects of 12 to 15 cm may be managed either via ureteral reimplantation with a Boari flap or via transuretero-ureterostomy in case of low bladder capacity. Cases with more extended defects can be reconstructed with the incorporation of the ileum in ureteral repair.

Clinical characteristics and outcomes of congenital midureteral stricture detected by fetal ultrasonography

Congenital midureteral stricture (CMS), which develops from obstructive lesion between pyeloureteral junction and ureterovesical junction, is relatively rare and its clinical condition and therapeutic strategy have not yet been established. We analyzed the clinical characteristics and surgical outcomes of CMS. From November 2006 to December 2012, out of 137 patients presented with congenital hydrohephrosis, we identified 4 pediatric patients diagnosed with CMS at our institutions. We retrospectively investigated clinical characteristics and surgical outcomes in these 4 patients. Three boys and one girl were identified in this study. All patients were detected hydronephrosis by fetal ultrasonography. The median age at the diagnosis of CMS was 1 year and 11 months. Three patients had obstructive lesion in left side and 1 patient in right. CMSs were located at the level of L4 in 2 patients, and at the level of L5 and S1 in each 1. Split renal function was decreased less than 45% in 3 of 4 patients. Ipsilateral pyeloureteral junction obstruction and ipsilateral hypoplastic kidney were identified in 2 and 1 patient, respectively. One patient developed urosepsis and underwent nephrostomy. Partial ureterectomy and ureteroureterostomy, pyeloplasty were performed in 3 and 1 patient, respectively. Extrinsic obstruction was detected in just 1 patient intraoperatively. In all patients, there were no protruded lesion and atrophied, fibrotic and ischemic muscles were not detected in pathological finding. Neither urinary tract infection nor recurrence of obstructive lesion was detected in all patients at the mean follow-up period of 3 years and 1 month. We analyzed the clinical characteristics of 4 pediatric patients with CMS. In order to prevent critical infection and maintain renal function, it could be considered that surgical intervention is undertaken just after making the diagnosis of CMS.