Proximal Strictures 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.

Esophageal Lichen Planus: The Efficacy and Safety of Tacrolimus in Reducing Inflammation and Need for Dilation.

Esophageal Lichen Planus (ELP) is a rare inflammatory disease most seen in middle-aged Caucasian women, manifested by sloughing mucosa, thick exudate, and proximal strictures. Most case reports and small series highlight using steroids and other immunosuppressants. To our knowledge, oral tablet tacrolimus has not been studied. We aimed to assess the change in ELP after oral tacrolimus treatment. The primary outcome was the efficacy of tacrolimus objectively through our scoring system, ELPSS. All consecutive adults with ELP who underwent more than one EGD by two esophagologists and being treated with tacrolimus or other treatment were eligible for inclusion in this retrospective cohort study. Inflammation and fibrostenotic disease were graded using the novel ELP Severity Score (ELPSS). Twenty two patients met the inclusion criteria. Half (11) received tacrolimus (dose 1-2 mg BID) and half (11) received other therapy (i.e. cyclosporine, topical steroids, or none). Mean ELPSS on first EGD, extraesophageal manifestations of disease, presenting symptoms, and baseline characteristics were similar between groups. Among patients on Tac vs No-Tac, there was a statistically significant improvement in ELPSS (mean difference 1.8 pts; 95% CI 0.25-3.38; P=0.02). Response rate was 89% with Tac vs 30% with No-Tac (P=0.025). All 22 patients underwent bougie dilation safely with a mean diameter of 16 mm achieved. Patients on Tac also required less frequent dilation. Oral tablet tacrolimus reduced the inflammatory and fibrostenotic components of ELP. Thus, low-dose oral tacrolimus is safe and should be considered in patients with more severe disease.

Radiosurgical Maintenance of Indeterminate Proximal Biliary Stricture. Clinical Observation

Radiosurgical Maintenance of Indeterminate Proximal Biliary Stricture. Clinical Observation

Upper gastrointestinal endoscopy in the surgically altered patient.

As management of upper gastrointestinal malignancies improves, and with popularization of bariatric surgery, endoscopists are likely to meet patients with altered upper gastrointestinal anatomy. Short-term, the surgery can cause complications like bleeding, leaks, and fistulas, and longer-term problems such as intestinal or biliary anastomotic strictures or biliary stones can arise, all necessitating endoscopy. In addition, the usual upper gastrointestinal pathologies can also still occur. These patients pose unique challenges. To proceed, understanding the new layout of the upper gastrointestinal tract is essential. The endoscopist, armed with a clear plan for navigation, can readily diagnose and manage most commonly occurring conditions, such as marginal ulcers and proximal anastomotic strictures with standard endoscopic instruments. With complex reconstructions involving long segments of small bowel, such as Roux-en-Y gastric bypass, utilization of balloon-assisted enteroscopy may be necessary, mandating modification of procedures such as endoscopic retrograde cholangiopancreatography. Successful endoscopic management of patients with altered anatomy will require prior planning and preparation to ensure the appropriate equipment, setting, and skill set is provided.

Identification of relapse predictors of IgG<sub>4</sub>-related sclerosing cholangitis

Introduction. Relapses occur in 30–50% of patients IgG4-related sclerosing cholangitis. Relapses may act an independent risk factor for malignancy development and the need in maintenance therapy for relapse prevention is still uncertain. Thus, studying relapse predictors and developing reliable preventive approaches is an important area of research for this condition.Aim. To determine relapse predictors of IgG4-related sclerosing cholangitis.Materials and methods. A single- center dynamic bidirectional observational study was conducted in patients aged 18 years and older with verified IgG4-related sclerosing cholangitis (n = 32). We searched for possible factors influencing the relapse of IgG4- related sclerosing cholangitis. The development of a prognostic model for the relapse probability was carried out using logistic regression. ROC analysis was used to assess the diagnostic performance of quantitative variables in predicting of relapse.Results. The median follow-up period was 33 (16–60) months. The majority of patients with IgG4-related sclerosing cholan- gitis were male (71.9%), median age was 59 ± 13 years. In most patients, delayed diagnosis (median 10.5 [4.8; 22.5] months) was associated with overdiagnosis of primary sclerosing cholangitis (41.2%) or bile duct malignancy (43.8%). Surgical interventions were performed in 50% of patients. Median serum IgG4 level was 2.70 g/L [1.92; 6.48], and 21.9% of patients had normal serum IgG4 level. Disease relapse developed in 34.4% (n = 11) of patients. Serum IgG4 level before glucocorticosteroid therapy ≥ 2.24 g/L and a delay in diagnosis by ≥ 17 months were associated with the relapse (p = 0.040 and p = 0.049 respectively). Multi-organ involvement, and extrahepatic localization of biliary strictures in the patients with the history of surgical interventions increased the risk of relapse 85 (p = 0.001) and 12 (p = 0.047) fold, respectively. The presence of biliary strictures below the confluence reduced the risk of relapse 7.5 fold (p = 0.032).Conclusions. Possible predictors of IgG4-related sclerosing cholangitis relapse may include multi- organ involvement, intrahepatic and proximal extrahepatic strictures, prior surgical interventions in patients with extrahepatic strictures, high serum IgG4 level, and delayed diagnosis.

THE IMPACT OF BENIGN PROSTATE HYPERPLASIA TREATMENT MODALITIES ON THE INCIDENCE AND PROGRESSION OF URETHRAL STRICTURE : A COMPREHENSIVE SYSTEMATIC REVIEW

Background: Urinary tract symptoms in elderly men are frequently caused by BPH, which frequently results in urethral stricture. Perioperative morbidity might result from surgical methods such as simple open prostatectomy and transurethral resection. Several techniques, such as HoLEP, have surfaced as novel therapies. Methods: Following PRISMA 2020 guidelines, this systematic review concentrated on full-text English literature published between 2014 and 2024. Editorials and review articles that appeared in the same journal as the submission were not accepted without a DOI. The literature was assembled using a variety of online databases, including ScienceDirect, PubMed, and SagePub. Result: The study utilized reliable sources like Science Direct, SagePub, and PubMed for screening over 500 publications. Six papers were identified as relevant for systematic analysis, followed by further study and examination of the complete document. Conclusion: The treatment of BPH patients using the TURis system and TUEP is effective in preventing postoperative complications like urethral strictures. However, further large-scale multicentre RCTs are needed to confirm these findings. BMA is suitable for short proximal bulbar urethral strictures, and the inverted omega En-bloc HoLEP technique is safe and effective for all prostate sizes.

Is the Bulbar Urethral Stricture a Single and Uniform Disease?

Objectives: Proximal and distal bulbar urethral strictures (BUS) have different disease characteristics and require different treatment strategies despite being regarded as a single condition. To clarify the differences, we analyzed our database by distinguishing the two types of BUS. Methods: We retrospectively reviewed the data of 196 patients with BUS who underwent urethroplasty at the National Defense Medical College (Japan) between August 2004 and March 2022. We divided patients into proximal (group 1) or distal (group 2) groups based on the stricture segment and compared patient background and surgical techniques for each group. We assessed whether the stricture segment was an independent predictive factor for substitution urethroplasty selection using multivariate logistic regression analysis. The recurrence rates were calculated and compared using the Kaplan–Meier method and log-rank test, respectively. Results: Patients in group 1 had a less frequent non-obliterated lumen (73% vs. 94%, p = 0.020) and significantly shorter strictures (10 mm vs. 23 mm, p < 0.001) more frequently caused by external traumas (47% vs. 26%, p = 0.010) than those in group 2. Logistic regression analysis revealed that the stricture segment (distal) (p < 0.001), stricture length (≥20 mm) (p < 0.001), ≥2 prior transurethral procedures (p = 0.030), and a non-obliterated lumen (p = 0.020) were independent predictive factors for substitution urethroplasty. However, the recurrence rate (p = 0.18) did not significantly differ between the two groups. Conclusions: Proximal and distal BUS have substantially different anatomical characteristics and etiologies and require different reconstructive techniques.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation

ObjectivesTo examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, boari flap, buccal ureteroplasty and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. MethodsWe performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for change in renal function. Demographic data was analyzed and cox proportional hazard models performed. Results158 patients were identified with median follow-up time of 40 months. 81% had a unilateral ileal ureter creation. 50% were female, median age was 53.3. 27% of patients had radiation-induced strictures. Pre-operatively, 56.3% of patients were CKD stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex. 77% had no 30-day complications. Clavien complications included grade 1(18), grade 2(4), grade 3(9), grade 4(5). Long-term complications included worsening renal function(3%), incisional hernia(8.2%), and small bowel obstruction(6.9%). 5(3.1%) patients ultimately required dialysis and 5(3.1%) patients developed metabolic acidosis. ConclusionIleal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Surgical management of upper cervical esophagus stricture caused by ingestion of corrosive substances – a single-center experience

Introduction and aim. Corrosive strictures of the upper cervical esophagus and hypopharynx are hard to treat in the operating room because there is a high chance of aspiration during swallowing after a high-up or proximal esophageal anastomosis. In this cases, we aimed to evaluate the role of intraoperative dilatation of the proximal hypopharyngeal and cervical esophageal stumps during surgery. Material and methods. Patients who underwent surgery and had upper cervical esophageal and hypopharyngeal strictures from corrosive substance ingestion were included. Results. Out of total 27 patients, 10 had a cricopharyngeal or proximal cervical esophageal stricture with a long segment tho racic esophageal stricture that was treated with intra-operative dilatation (IOD) of the proximal hypopharyngeal stump. IOD was done in two cases with Hegar’s dilator and in three cases with wire-guided Savary Gillard dilators. In 74% (20/27) of the cases, the colon was frequently used as an esophageal substitute, while the stomach was only used in 10 cases. On follow-up, none of them developed repeated aspirations or required a tracheotomy. Conclusion. IOD of the proximal hypopharyngeal and cervical esophageal stumps during surgery for corrosive upper cervi cal esophageal or cricopharyngeal strictures helps to save the proximal stump and avoid frequent hospital stays and multiple surgeries.

Robot-assisted buccal mucosal graft ureteroplasty for the treatment of proximal ureteral strictures.

The authors describe their initial experience with robot-assisted buccal mucosal graft (BMG) ureteroplasty for the management of proximal ureteral strictures.

Treating Multifocal Ureteral Strictures with Combined Techniques: 14 Cases of Initial Experience.

Purpose: To evaluate the safety and feasibility of lingual mucosal graft ureteroplasty (LMGU) combined with ureteral reimplantation (UR) for repairing managing multifocal ureteral strictures (MUS). Methods: Between December 2020 and December 2022, 14 patients underwent LMGU combined with UR. Their perioperative data were collected retrospectively and analyzed. For the proximal diseased ureter, the narrow segment was incised longitudinally to open the ventral wall of ureter, and a lingual mucosal graft was placed as an onlay graft. Meanwhile, UR was applied to treat distal ureteral strictures. Results: Of 14 patients, three (21.4%) had previously undergone a failed ureteral reconstruction. The mean (standard deviation [SD]) proximal stricture length was 4.0 cm (1.56), and distal ureteral stricture length was 4.3 cm (0.94). The mean (SD) operative time was 236 minutes (57), the estimated blood loss was 78 mL (41.5), and the length of postoperative stay was 6 days. One (7%) patient underwent double LMGU to treat proximal 2 segments of ureteral stricture. No open conversions and intraoperative complications occurred. With a mean follow-up of 15 months (range 6-29), the recurrence-free rate was 14/14 (100%). Conclusions: LMGU combined with UR is a feasible and effective technique for managing MUS and can be an alternative to ileal ureteral replacement or renal autotransplantation in some selected patients with MUS.

Laparoscopic intracorporeal ileal ureter replacement: multi-institutional data from 102 patients

Objective To present long-term results of our laparoscopic intracorporeal ileal ureter replacement (LIUR) cohort, including more complex cases of laparoscopic ileocalycostomy. Material and methods We collected records of patients undergoing LIUR. Follow-up included a chemical profile and urine cultures. Imaging consisted of renal ultrasonography, excretory urography, cystography, and computer tomographic or magnetic resonance urography. Results One hundred and two patients were included. Stricture location was left (46.1%), right (39.2%), or bilateral (14.7%). No open conversion was performed. Seventy-four patients (72.5%) underwent a total ureteral unit removal. The mean operative time was 289.4 (120 – 680) minutes. The estimated blood loss was 185.2 (10–400) mL. Three patients had intraoperative complications, and fifteen had early postoperative complications. The mean postoperative hospital stay was 12.2 (7–35) days. The mean follow-up duration period was 37.7 (12–162) months. Most patients’ follow-up was uneventful (88%), and seven patients presented with Grade 2 late complications. Conclusions Intracorporeal laparoscopic ileal ureteral replacement in cases of extensive ureteral lesions offers optimal long-term outcomes and a low complication rate. Ileocalycostomy constitutes a viable option in the small group of patients with long proximal ureteral strictures and intrarenal pelvis.

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures

OBJECTIVETo investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction, proximal and middle ureteral stricture disease. METHODSWe retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between 04/2012-12/2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of p<0.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p≤0.05 was considered statistically significant). RESULTSOverall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% versus 25.7%, p<0.01) and a higher proportion of patients who underwent ureteral rest (74.3% versus 48.6%, p<0.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times (CI 1.26-7.54, p=0.01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, p=0.01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSIONSurgical success of RUR for management of UPJO, proximal and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation for multifocal ureteral strictures: Case report and technical description.

To describe the surgical technique of robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation to repair unilateral multifocal ureteral strictures in one stage and report 9-month follow-up outcomes. A longitudinal ventral incision of proximal ureter strictures No. 1 and 2 was performed, and the appendix was detubularised along its antimesenteric border. Then, the appendiceal onlay flap was anastomosed with the spatulated ureter in an onlay fashion. To manage the distal ureteral stricture No. 3, ureteral reimplantation was performed in a tension-free manner. Voiding cystourethrography and antegrade urography showed urine regurgitation into the ureter without dilation and no obstruction of the reconstructed ureteral segment 7weeks after surgery. No postoperative complications occurred during the 9-month follow-up. Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation appears to be a safe and effective surgical method for repairing the unilateral multifocal ureteral strictures.

Laparoscopic ureteroplasty using onlay appendix flap: a case series

BackgroundCurrently, strictures of the ureters often develop after endourology of the upper urinary tract, gynecological, and surgical interventions. For long proximal ureteral strictures, ureteroplasty with an on-lay appendix flap may be an option for treatment.Case presentationFive patients had laparoscopic onlay appendicoureteroplastic for long right ureter strictures. The average age of the patients was 42.5 years old. Four patients developed a stricture after transurethral contact ureterolithotripsy; one patient had it after laparoscopic ureterolysis. The average stricture length was 3.5 (2.8–5.2) cm. The length of the stricture was controlled, including using near-infrared fluorescence imaging. With an average observation time of 14.6 (6.2–28.4) months, the operation was effective in all patients. The urodynamics of the upper urinary tract recovered completely in three patients and comparatively improved in two patients. All of the patients stopped feeling any pain. The observed patients were saved from external and internal drainage.ConclusionsLaparoscopic onlay ureteroplasty with an appendix in a selected group of patients may be the method of choice for long strictures of the middle and upper parts of the right ureter.

Laparoscopic ventral onlay ureteroplasty with buccal mucosa graft for complex proximal ureteral stricture.

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.

S1287 Safety and Efficacy of Self-Expandable Metal Stents in Head and Neck Cancer Patients with Radiation-Induced Proximal Esophageal Stricture

S1287 Safety and Efficacy of Self-Expandable Metal Stents in Head and Neck Cancer Patients with Radiation-Induced Proximal Esophageal Stricture

Risk factors for total laryngectomy associated proximal esophageal stricture formation in head and neck cancer patients.

Development of esophageal strictures is common after the total laryngectomy of head and neck cancer patients. While endoscopic techniques like dilatation by balloon or Salvary bougies are well established, risk factors and pathophysiology for development of refractory strictures are less well understood. To evaluate risk factors associated with occurrence and recurrence of total-laryngectomy-associated esophageal strictures in head and neck cancer patients. We analyzed retrospectively a cohort of 170 head and neck squamous cell carcinoma patients, who underwent total laryngectomy between 2007 and 2017. The outcome measure was laryngectomy-associated proximal esophageal stricture needing an endoscopic dilatation by using a balloon or Savary dilators. Of the 170 patients in the cohort, 32 (18.8%) developed strictures. Mean time between surgery and first endoscopic intervention was 24.4 months. Significant predictive factors were age ≥ 65 (p=0.017), nodal status N> 1 (p=0.003), continued alcohol abuse after surgery (p=0.005) and diabetes mellitus (p=0.005). In a subgroup, 17 of 32 patients developed refractory strictures and needed more than three dilatations to relieve dysphagia. Postoperative mean (p=0.016) and maximum (p=0.015) C-reactive protein (CRP) were predictive for refractory strictures. Symptomatic strictures occurred in 18.8% of the cases. Age, nodal status N>1, continued alcohol abuse and diabetes mellitus were predictive factors. For refractory stenosis (>3 dilatations needed) mean and maximum postoperative CRP were predictive. This may indicate that systemic inflammatory response post-surgery is involved in the stricture formation process.

Similar success rate in proximal and distal colonic stent placement: a retrospective multi-center study

Objectives Stenting of malignant colon obstruction is used as a bridge to surgery or as an alternative to surgical colostomy in a palliative setting. Current guidelines recommend stent placement as the first line of treatment in colonic obstruction in both curative and palliative settings. However, it is unclear whether the location of the malignant obstruction influences the outcome of the stenting procedure. The goal of this study was to compare the outcomes of colonic stents between proximal and distal colonic strictures with regard to technical and clinical success and the risk of adverse events. Methods A multi-center retrospective cohort was composed of patients who underwent a colonic stent placement at two tertiary hospitals between 2013 and 2021. The technical and clinical outcome, stent type used, duration of post-procedural hospital stay and complications were noted. Results A total of 148 patients who underwent colonic stenting were identified. 41 patients underwent stent placement in the proximal colon and 107 patients underwent a distal stent placement. There was no difference in technical success (100% vs 96.3%, p = 0.209), clinical success (97.0% vs 89.6%, p = 0.199) or complications (24.4% vs 37.4%, p = 0,135) Conclusion Technical success and clinical success rates are high and do not differ between stent locations. There is no significant difference in complication rates between proximal and distal colonic stents.

Robotic-assisted double lingual mucosal graft ureteroplasty for multifocal ureteral strictures: Case report and technical description.

Ureteroplasty with a single onlay graft for proximal ureter stricture has been widely used in the clinic. However, robotic ureteroplasty with a double lingual mucosal graft (RU-DLMG) has not been reported. The intraoperative measured ureteral stricture lengths of patient 1 were 1.8, 2.5, and 4.6cm, and those of patient 2 were 2.5 and 3.5cm. We performed a RU-DLMG in which the diseased ureter was incised longitudinally from the ventral side and repaired with a double lingual mucosal graft to widen the ureteral lumen. Because of the presence of a distal ureter stricture, RU-DLMG combined with ureteral reimplantation was performed in patient 1. Antegrade urography showed no obstruction of the reconstructed ureteral segment after removing the ureteral stent. The patients had no complaints about the donor site and flank pain during the 12-month follow-up. RU-DLMG appears to be a suitable option for multifocal ureteral strictures.