Nonrefluxing Anastomosis Research Articles

Refluxing Versus Non-Refluxing Uretero-Vesical Anastomosis in Renal Transplant

Background: Urinary tract infection and pyelonephritis are very common in patients with renal transplant. One of mechanism to prevent pyelonephritis is performing a non-refluxing anastomosis of ureter with bladder. Whether this procedure can decrease the rate of urinary tract infection and pyelonephritis is controversial. Objective: To assess the out-come of refluxing versus non-refluxing ureterovesical anastomosis in renal transplant recipients. Study Design: Randomized Control Trial (RCT) Methodology: This RCT was carried out in the Department of Urology and Renal Transplant, Institute of Kidney Diseases Hayatabad Medical Complex Peshawar from January 2015 to January 2020. A total of 52 patients who underwent live donor renal transplant were equally divided into two groups by block randomization, Group A-refluxing and Group B-non-refluxing ureterovesical anastomosis. Informed written consent was obtained from all patients. Each patient was followed for a period of one year and outcome parameters including frequency of anastomotic leakage, anastomotic stenosis, symptomatic UTI, hematuria and mean nadir creatinine level were recorded. The data were analyzed using SPSS version 26 using chi-square test for categorical data and T-test for numerical data keeping p-value < 0.05 as significant. Results: The mean age in group A and group B was 36.6 + 6.1 and 35 + 4.7 years respectively (p-value > 0.05). In group A, no patient developed anastomotic stenosis whereas in group B, 2 (7.7 %) patient developed anastomotic stenosis (p-value > 0.05). 1 (3.8 %) patient in group A developed anastomotic leakage while none of the patients in group B developed any leakage (p-value > 0.05). The mean nadir serum creatinine in group A was 1.3 + 0.4 mg/dl and 1.2 + 0.2 mg/dl in group B (p-value > 0.05). 4 (15.4%) of patients in group A and 3 (11.5%) of the patients in group B developed UTI (p-value > 0.05). Practical Implication: The refluxing ureterovesical anastomosis is relatively easier and less time consuming in comparison to the non-refluxing technique, since there is no statistical difference between their outcomes, the refluxing technique can be utilized in adult kidney transplant recipients. Conclusion: We concluded from this study that there is no statistically significant difference in the out-come between refluxing and non-refluxing ureterovesical anastomosis in renal transplant patients of adult age. Keywords: Lich-Gregoire, Renal Transplantation, Refluxing Ureterovesical anastomosis, Urine Leakage, UTI

Overcoming Obesity and a Short Appendix in the Creation of Continent Catheterizable Stomas. Preliminary Outcomes of the “Casella-Ost Procedure”

To describe a novel method of using a bladder flap to partially span the distance between the bladder and abdominal wall when creating a concealed catheterizable channel. We retrospectively identified 3 patients in whom we performed this reconstruction and report our surgical technique and their outcomes at 23, 27, and 32 months. There were no immediate operative complications and all patients continue to catheterize without difficulty. Two patients reported mild stomal stress incontinence, which resolved with Ditropan in one case, and was not bothersome enough to desire additional treatment in the second. Incorporation of the bladder flap allows for a shorter proximal limb (appendix or tubularized ileum), improving ease of catheterization in addition to providing a surface where a tunneled, nonrefluxing anastomosis between the proximal limb and bladder can be easily performed. Long-term follow-up and greater patient numbers are needed, nonetheless, we have not seen this approach described in the literature and feel that it is an important reconstructive option to be considered when creating a continent catheterizable diversion.

MP79-15 UROLOGICAL COMPLICATIONS IN PEDIATRIC PATIENTS UNDERGOING RENAL TRANSPLANTATION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-15 UROLOGICAL COMPLICATIONS IN PEDIATRIC PATIENTS UNDERGOING RENAL TRANSPLANTATION Irina Stanasel, Cagatay Afsarlar, Hoang Lee, Abhishek Seth, Chester Koh, Patricio Gargollo, Edmond Gonzales, David Roth, and Nicolette Janzen Irina StanaselIrina Stanasel More articles by this author , Cagatay AfsarlarCagatay Afsarlar More articles by this author , Hoang LeeHoang Lee More articles by this author , Abhishek SethAbhishek Seth More articles by this author , Chester KohChester Koh More articles by this author , Patricio GargolloPatricio Gargollo More articles by this author , Edmond GonzalesEdmond Gonzales More articles by this author , David RothDavid Roth More articles by this author , and Nicolette JanzenNicolette Janzen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal transplantation is the management of choice for children with end stage renal disease (ESRD). We performed a retrospective analysis of patients undergoing renal transplantation at a children's hospital in order to evaluate the prevalence and type of urological complications in this patient population. METHODS A retrospective chart review of 100 consecutive children who underwent renal transplantation at a children's hospital between January 2009 and April 2014 was performed. Forty three females and 57 males were identified. The cohort included 37 children who underwent renal transplantation from a living related donor and 63 children who had a renal graft from a deceased donor. The average age at time of transplant was 14.04 years. Twenty six of the 100 children reviewed had a urological etiology for ESRD (posterior or anterior urethral valves, reflux nephropathy, Prune Belly Syndrome, or neurogenic bladder.) All children had a non-refluxing anastomosis performed by either the pediatric transplant surgeon (78) or a consulting pediatric urologist (22.) Four children had a ureteral stent placed at time of reimplantation. RESULTS Children who experienced renal complications were younger at time of renal transplantation, with an average age of 10.5 vs 14.04 years. Postoperatively, all patients underwent follow up with ultrasonography. If hydronephrosis was demonstrated on ultrasound or if the patients developed a urinary tract infection (UTI), patients also underwent a voiding cystourethrogram (VCUG). In cases of suspected obstruction, a MAG-3 renogram was performed. These outcomes are detailed in Figure 1. Twenty six children had a urological reason for ESRD, 11 of whom (42%) developed a urological complication. Of 74 patients without a urological reason for ESRD, 18 (24%) developed urological complications (p=0.13). CONCLUSIONS Children with urological reason for ESRD trend toward having more urological complications. We observed an overall low rate (29%) of urological complications. Although when patients had a UTI a VCUG detected reflux in 15 of 23 patients (65%), our data suggests that performing a VCUG for all transplant patients is unnecessary, and one can be performed if the patient demonstrates hydronephrosis or develops a UTI post-operatively. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1016 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Irina Stanasel More articles by this author Cagatay Afsarlar More articles by this author Hoang Lee More articles by this author Abhishek Seth More articles by this author Chester Koh More articles by this author Patricio Gargollo More articles by this author Edmond Gonzales More articles by this author David Roth More articles by this author Nicolette Janzen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Technical Modifications to Laparoscopic Boari Flap

To describe technical modifications to the laparoscopic Boari flap ureteroneocystostomy procedure. Removal of ureteral stents with conversion to percutaneous nephrostomy drainage before surgery allowed for optimization of tissue quality and visualization during operative repair. Adherence to specific dimensional ratios during flap excision consistently provided for adequate tissue for successful Boari flap construction. A mucosal modification to the Boari flap allowed for an increase in the circumference of the anastomosis and provided an additional means to fortify the suture line and promote healing. Raised mucosal flaps on the Boari flap facilitated construction of a nonrefluxing anastomosis. Finally, a 2-mm needlescopic port placed at the level of the anastomosis facilitated simplified intracorporeal double-J ureteral placement. Laparoscopic Boari flap ureteroneocystostomy is an effective treatment of distal ureteral stricture disease. The technical modifications describe in this report aim to contribute to increased success rates in patients who undergo this procedure.

The Surgical Management of Stones in Patients With Urinary Diversions

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population.Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible.Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

Laparoscopic ureteroneocystostomy for benign lower ureteric stricture: case study and literature review

The surgical treatment of distal ureteric strictures depends on their length and aetiology. Laparoscopic procedures in this setting are uncommon. We describe a laparoscopic non-refluxing ureteroneocystostomy for a symptomatic distal ureteric stricture performed on a 26-year-old man. The operation was carried out successfully without complication. Blood loss was 100 ml with an operating time of 250 min. He was discharged on the fourth day and returned to work after 11 days. Retrograde ureterography and cystography after 1 month showed no evidence of obstruction or reflux. At 3 months, an intravenous urogram showed excellent drainage and at 6 months the patient remained asymptomatic. We advocate the use of laparoscopic ureteroneocystostomy for benign distal ureteric stricture refractory to endoscopic procedures. In symptomatic patients, it is a feasible, safe, minimally invasive procedure with all the added benefits of laparoscopy compared with open repair. A non-refluxing anastomosis is preferable. Reconstructive and intracorporeal suturing skills are needed to carry out this procedure.

The surgical management of stones in patients with urinary diversions.

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population. Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible. Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

Urinary Diversion

After a total cystectomy, urine can be diverted by means of a cutaneous ureterostomy, an intestinal conduit diversion, or a continent diversion. Intestinal conduit diversions use segments of the stomach, jejunum, and, most commonly, the ileum or colon and a refluxing or nonrefluxing anastomosis. Continent diversions include ortho topic voiding pouches and continent catheterization pouches. Complications of urinary diversion may be technical, metabolic, nutritional, or carcinogenic. Surgical techniques for bladder reconstruction continue to improve, as does understanding of the physiologic effects of such surgery.

Biliary appendico-duodenostomy: A nonrefluxing conduit for biliary reconstruction

Biliary conduits constructed during operations for choledochal cysts or biliary atresia are frequently complicated by reflux of gastrointestinal contents, stasis, and obstruction with resulting cholangitis. We have used the appendix as a biliary conduit for cases of biliary atresia and choledochal cyst, adapting the urologic technique of a tunneled, nonrefluxing anastomosis for reconstruction of the biliary tree--biliary appendico-duodenostomy (BAD). From our preliminary experience with this technique, it appears promising.

Experience with Pyeloureterostomy Associated with Simple Ligation of Native Ureter without Ipsilateral Nephrectomy in Renal Transplantation

Ureteroneocystostomy was used as the primary method of urinary tract reconstruction in 282 allograft renal transplants at our center since 1965. A nonrefluxing anastomosis was incorporated whenever possible. Seven patients who suffered major urological complications involving the ureteroneocystostomy required pyeloureterostomy as the method of repair using the patient’s distal native ureter. No ipsilateral nephrectomy was performed and simple ligation of the native ureter with nonabsorbable suture was accomplished. Of the 7 patients 3 suffered hydronephrosis of the native kidney. None of these patients had signs or symptoms secondary to acute and chronic ureteral occlusion. Our experience suggests that intentional ligation of the native ureter during pyeloureterostomy does not result in increased morbidity to the transplant patient, and that the need for ipsilateral nephrectomy with its own added morbidity may not be necessary.