Ureteral Replacement Research Articles

Umbilical Cord Vein

In the article by Tritschler et al. (1), with its list of therapeutic alternatives to treat long urethral strictures with a free graft, total urethral replacement by using the umbilical cord vein should definitely be mentioned. In several male trauma cases, total or partial replacement of the urethra with human umbilical cord vein, harvested in the peripartum period or cryopreserved, was done successfully, without any graft rejection reaction (lowest antigen presentation) (2). In longer urethral strictures, but also in those that are extremely narrow, partial or total replacement of the urethra by means of transplanting embryonic umbilical cord veins has yielded excellent long-term results, especially in patients with longer strictures, after the umbilical cord vein had already been tried and tested as a ureteric replacement in clinical use.

Long-term outcome of ileal ureter replacement with proximal antirefluxing technique

Objective To investigate the long-term outcome of ileal ureter replacement with proximal antirefluxing technique. Methods Thirty-four cases with a long uteter stricture or defect （ 15-25 cm） and cancer of middle and lower ureter （ resected ureter ranged from bladder to 5- 8 cm above the tumor） （ male 23 and female 11 ; bilateral 19 and unilateral 15） , were treated by ileal ureter replacement with proxi- mal antirefluxing technique, in which the ureter was replaced with a segment of ileum using an end-to-side anastomosis. The distal part of upper ureter （4 cm） was fixed between the psoas muscle and ileal segm6nt （the ileo-psoas tunnel technique）. The distal ileum was connected to the urinary bladder withpan end-to-side anastomosis. Serum electrolyte, creatinine and blood urea nitrogen （BUN） ; ultrasonography and radiograph- ic investigations of urinary system were recorded during follow up. Results The 34 cases were followed for 12-180 months （mean, 67 months）. The intravenous urography showed that the hydronephrosis improved significantly or diseapeared by a~sessed after 6 month in 25 patients, 9 had improvement. Cystography showed no evidence of ileo-ureteral reflux. Three patients needed oral alkalization because of prevention of hyperchloremie acidosis. Among the 3 patients with ureter cancer, 1 patient died after 3 years because of metastasis and the other 2 patients were well without cancer currence after follow up of 11 and 15 years postop- eratively. Conclusion In our experience, ileal ureteral replacement with the ileo-psoas tunnel anti-refluxing technique is a highly effective procedure for the treatment of long segment ureteral strictures and defect. Key words: Ureter; Ileum; Antireflux; Hydronephrosis

Ureteral Replacement Using Segment of Ileum: An Approach Totally Intracorporeal

Abstract Introduction: The ureteral avulsion during ureteroscopic procedures is a rare complication (incidence 0%–2%).1 Surgical options in this situation include ileal ureter replacement, autotran...

Editorial Comment

Patients harboring upper tract urothelial cancer (UTUC) with coexistent medical renal disease are at an increased risk of progression to endstage renal disease after a radical surgery. For this reason, nephron-sparing approaches in the form of either retrograde or percutaneous endoscopic ablation or resection, as well as segmental ureteral resection with anastomosis, reimplantation, or even ureteral replacement have all been used to achieve oncological control as well as maintain acceptable residual renal function. Comparative Analysis of Oncologic Outcomes of Partial Ureterectomy vs Radical Nephroureterectomy in Upper Tract Urothelial CarcinomaUrologyVol. 81Issue 5PreviewTo compare oncologic outcomes in an international cohort of patients who underwent either partial ureterectomy (PU) or radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Full-Text PDF ReplyUrologyVol. 81Issue 5PreviewThe rarity of upper tract urothelial carcinoma (UTUC) makes it a difficult disease process to study and, until a recent large multi-institutional collaboration in 2009,1 our basic understanding of pathological characteristics, risk factors, and clinical outcomes for UTUC were extrapolated from small, single-institution studies. The American Cancer Society reports that approximately 5212 renal pelvic tumors and 2710 new cases of ureteral UTUC will be diagnosed in the United States in 2013.2 Thus, approximately one third of UTUCs are ureteral tumors. Full-Text PDF

Reply

The rarity of upper tract urothelial carcinoma (UTUC) makes it a difficult disease process to study and, until a recent large multi-institutional collaboration in 2009, 1 Margulis V. Shariat S.F. Matin S.F. et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009; 115: 1224-1233 Crossref PubMed Scopus (773) Google Scholar our basic understanding of pathological characteristics, risk factors, and clinical outcomes for UTUC were extrapolated from small, single-institution studies. The American Cancer Society reports that approximately 5212 renal pelvic tumors and 2710 new cases of ureteral UTUC will be diagnosed in the United States in 2013. 2 Siegel R. Naishadham D. Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013; 63: 11-30 Crossref PubMed Scopus (11434) Google Scholar Thus, approximately one third of UTUCs are ureteral tumors. Our study and another population-based investigation indicate that actuarial utilization of partial ureterectomy (PU) is approximately 10%. 3 Lughezzani G. Jeldres C. Isbarn H. et al. Nephroureterectomy and segmental ureterectomy in the treatment of invasive upper tract urothelial carcinoma: a population-based study of 2299 patients. Eur J Cancer. 2009; 45: 3291-3297 Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar Although all ureteral tumors are certainly not amenable to PU, the discrepancy between incidence of ureteral tumors and utilization of PU suggests that PU may be underutilized, and this warrants a closer look. Current evidence-based recommendations for incorporation of PU for UTUC are limited but do indicate that PU may be used for both low and high-risk tumors. 4 Rouprêt M. Zigeuner R. Palou J. et al. European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas: 2011 update. Eur Urol. 2011; 59: 584-594 Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar Our data supports the concept of expanding the indication for PU to maintain glomerular reserve while not compromising oncologic efficacy. Along with the attendant health benefits of better renal function, PU may also allow for administration of effective adjuvant chemotherapy regimens in patients with advanced stage disease that have greater than 50% mortality at 5 years. 1 Margulis V. Shariat S.F. Matin S.F. et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009; 115: 1224-1233 Crossref PubMed Scopus (773) Google Scholar Our data highlights considering alternative management options as opposed to reflexively performing radical nephroureterectomy (RNU). Editorial CommentUrologyVol. 81Issue 5PreviewPatients harboring upper tract urothelial cancer (UTUC) with coexistent medical renal disease are at an increased risk of progression to endstage renal disease after a radical surgery. For this reason, nephron-sparing approaches in the form of either retrograde or percutaneous endoscopic ablation or resection, as well as segmental ureteral resection with anastomosis, reimplantation, or even ureteral replacement have all been used to achieve oncological control as well as maintain acceptable residual renal function. Full-Text PDF

562 Long-term results of 50 ureteral replacements with ileum

562 Long-term results of 50 ureteral replacements with ileum

Application of Yang-Monti Principle in Ileal Ureter Substitution: Is It a beneficial Modification?

Ureteric substitution using the Yang-Monti principle was reported as a modification of simple ileal ureter replacement. In this study, we evaluate its safety, surgical outcome and impact on renal function. Sixteen patients underwent ileal ureter replacement using the Yang-Monti principle to overcome long ureteric defects. Exclusion criteria included patients with elevated serum creatinine > 1.8 mg/dL, inflammatory bowel syndrome or irradiated bowel. Antireflux implantation into the bladder was performed in 12 patients while 4 patients with intact healthy lower ureters underwent distal ileal-ureteral anastomosis. Follow-up protocol was carried out for up to 3 years in 9 patients. No intra-operative or postoperative mortality or significant complications occurred. There were minor complications in the form of urinary leakage that necessitated prolonged ureteric stenting in one patient, superficial wound infection in another one and 3 patients developed treatable urinary tract infection without late harmful effects. During follow-up, no excess mucus production or metabolic abnormalities were encountered. All patients had preserved renal function (improved in 13 patients and stabilized in 3) without any evidence of urinary obstruction. The reconfigured ileal segment for ureteric substitution is a safe technique with an excellent outcome. It uses short ileal segments for reconstruction of an ileal tube of adequate length and optimal caliber that permits easy antireflux implantation into the bladder so it is not associated with excess mucus production or metabolic abnormalities and offers a durable preservation of renal function without urinary obstruction.

Unusual stent after ureteral substitution. A first case

BackgroundTo the best of our knowledge this is the first case where a Silastic drain is used in ureteral surgery instead of a common urological stent. Patients coming from other institutions, especially in peripheral areas, can be treated with non conventional devices and if traditional imaging is inconclusive, computed tomography (CT) can provide valuable information to make the right diagnosis.Case presentationWe present the unusual case of a 32F Silastic drain found inside the urinary tract in a female patient who had previously undergone ileal loop replacement of the left ureter for post-hysterectomy stricture at another Institution, and had subsequently repeated surgery due to persistent hydronephrosis. Radiological findings on plain abdominal X-ray were quite misleading, while CT allowed a correct assessment of the drain features.ConclusionWhile double J stents of different lengths, sizes and materials are used in ureteral surgery, the use of Silastic drains has not been previously reported. In light of the present experience we don’t suggest its routinely use.

Replacement of Transplant Ureter by Ileum - Results of the Largest Published Patient Cohort

Ureteral stricures in transplanted kidneys occur in 3-10%. Therapeutic approaches differ and include intermittent insertion of a DJ stent, dilation, operative re-anastomosis or a ureter-ureterostomy between the native and the transplant ureter. A common approach in urology is to replace the ureter by an ileal segment. In the field of renal transplantation only 2 cases of ureter replacement by ileum interposition have been published. We report on a series of 7 ileal interpositions as ureteral replacement after renal transplantation. In our department 5 femal and 2 male recipients received this operation after multiple prior treatments had failed. Exycept for one necessary re-operation due to leakage no perioperative complication occured. Long term follow up revealed good renal function with no increased number of complications. Overall, this surgical approach renders good results and increases the surgical armentarium for transplant ureter stenosis.

Sustitución ureteral bilateral con asa ileal

Bilateral ileal ureteral replacement Introduction: Ureteral replacement by a loop of defunctionalized ileum was described more than 2 cen- turies ago and continues to be a therapeutic option at present. This series describes the technique of bilateral ureteral replacement with ileum. Aim: To report 4 cases of bilateral ileal ureteral replacement performed at our institution, its indications, the surgical technique, complications, and a review of the literature. Material and Method: We report 4 cases of extensive bilateral ureteral injury of different etiologies, whose treatment with curative intent was to replace the damaged ureter with a isoperistaltic small bowel segment. Results: The surgical technique used was standard in all cases. There were no intraoperative complications and only one patient had hyperchloremic acidosis. No patient has shown loss of renal function in the long-term follow up. Conclusion: Is an effective therapeutic, safe and reproducible technique to replacement of major bilateral ureteral injuries, independent of the original cause.

Ureteral Replacement with Appendix in a Pediatric Group: A Report of Two Cases and Review of the Literature

Ureteral Replacement with Appendix in a Pediatric Group: A Report of Two Cases and Review of the Literature

Tissue engineering of ureteral grafts by seeding urothelial differentiated hADSCs onto biodegradable ureteral scaffolds

The study is aimed to evaluate the differentiation potential of human adipose-derived stem cells (hADSCs) into urothelial lineage, and to assess possibility of constructing ureteral grafts using the differentiated hADSCs and a novel polylactic acid (PLA)/collagen scaffolds. HADSCs were indirectly cocultured with urothelial cells in a transwell coculture system for urothelial differentiation. After 14 days coculturing, differentiation was evaluated by detecting urothelial lineage markers (cytokeratin-18 and uroplakin 2) in mRNA and protein level. Then the differentiated hADSCs were seeded onto PLA/collagen ureteral scaffolds and cultured in vitro for 1 week. The biocompatibility of the scaffolds was tested by scanning electron microscopy (SEM) and MTT analysis. At last, the cell/scafflod grafts were subcutaneously implanted into 4-week-old female athymic mice for 14 days. The results demonstrated that the hADSCs could be efficiently induced into urothelial lineage by indirect coculture. The differentiated cells seeded onto the PLA/collagen ureteral scaffolds survived up to 7 days and maintained proliferation in vitro, which indicated that the scaffolds displayed good biocompatibility. In vivo study showed that the differentiated cells in the grafts survived, formed multiple layers on the scaffolds and expressed urothelial lineage markers. In conclusion, hADSCs may serve as an alternative cell resource in cell-based tissue engineering for ureteral reconstruction. These cells could be employed to construct a model of ureteral engineering grafts and be effectively applied in vivo, which could be a new strategy on ureteral replacement with applicable potential in clinical research.

Reemplazo ureteral con apéndice cecal

Ureteral replacement with cecal appendix We report two cases with ureteral lesions. A 34 years male with a residual retroperitoneal mass caused by a testicular cancer, that persisted after chemotherapy. During the surgical excision of the mass, the involve- ment of the right ureter was discovered. A 43 years old female with a left ureteral lesion secondary to radiation therapy and with a non-functioning contralateral kidney. In both cases a ureteral replacement with the cecal appendix was performed, without surgical complications. After fi ve years of follow up, the urinary tract of the male patient is normal. The female patient required an endoscopic incision of the connection between the appendix and the urinary bladder, eight years after the surgical procedure. Three years after the endoscopic procedure the repaired urinary tract is in good conditions.

A case of extensive genitourinary tuberculosis: combined augmentation ileo-cystoplasty, ureteric ileal replacement and buccal mucosal graft urethroplasty

Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary TB after lymph nodes. Advanced GUTB leading to strictures of ureters and urethra, and bladder contracture frequently need surgical management. These are usually treated by ileal replacement of ureter, substitution urethroplasty using buccal mucosal graft (BMG) and augmentation ileo-cystoplasty, respectively. These procedures have been well demonstrated individually but all these three procedures have never been combined as single procedure in the same patient. We report a case of advanced GUTB with ureteric and urethral strictures, and bladder contracture which was treated by the ileal replacement of ureter, augmentation ileo-cystoplasty combined with BMG substitution urethroplasty in a single sitting.

Editorial comment: Left ureteral replacement with appendix in pediatric renal transplantation

Editorial comment: Left ureteral replacement with appendix in pediatric renal transplantation

Ureteral Substitution With Reconfigured Colon: Long-Term Followup

Long defects in the mid and upper ureter are not amenable to end-to-end reconstruction. Therefore, we present the long-term results of our technique with reconfigured colon segments. Between June 1998 and July 2008, 14 patients underwent ureteral replacement at our institution with reconfigured colon. In 4 patients the substitute was anastomosed to the skin as a modified colon conduit. In 10 patients it was interposed with anastomosis to the ureter in 4, to the bladder in 5 and to the afferent loop of an ileal bladder substitute in 1. At a median followup of 52.4 months (range 7 to 136) excellent renal function was confirmed in 10 of 14 patients. Now at a median followup of 95.8 months (range 38 to 136) 6 patients are alive, all without an indwelling stent and with no sign of obstruction of the ureteral replacement. Metabolic disorders, mucus obstruction and stricture or adhesive ileus were absent during followup. In this series death was unrelated to the procedure. In 7 patients 11 specific reinterventions were necessary including 4 cases of prolonged stenting after surgery, 3 which required secondary drainage, 3 cases of urinary tract infection at 4 weeks and 3 and 112 months, and 1 acute bowel obstruction due to peritoneal carcinosis. Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.

Ureteral replacement with appendix in pediatric renal transplantation

Ureteral necrosis is an uncommon complication following RT which can adversely affect outcome. Even though authors agree that the native ureter ought to be preserved, there are cases in which graft function can only be salvaged by ureteral substitution. The scant references in the literature on the use of the appendix for left ureteral replacement in children prompted us to report the following two cases in whom the technique was employed and to assess the evolution of graft function in these patients.

Long-term Functional Outcomes After Ileal Ureter Substitution: A Single-center Experience

To assess the indications and outcomes of ileal ureter replacement for ureteral reconstruction, which remains a technique of choice in certain cases, notably when the ureter has been injured. A retrospective review of the data from patients treated with ureteroileoplasty from 1980 to 2010 was performed. The following data were analyzed: age, etiology of ureter injury, and pre- and postoperative creatinine levels. Follow-up visits occurred at 3 and 6 months postoperatively and at least annually thereafter. A total of 17 patients with a median age of 43 years were included. The main etiology of the ureteral defect was an iatrogenic ureteral injury after a urologic procedure (n=6). The mean length of hospital stay was 12.4±8 days (range 7-26). Four major complications (grade 3) and 5 minor complications (grade 2) developed. The median follow-up time was 174 months. The mean creatinine level before surgery, at 1 month after surgery, and at the last follow-up visit was 1.3±0.3 mg/dL (range 0.6-3.4), 1.4±0.4 mg/dL (range 0.6-3.6), and 1.8±0.6 mg/dL (range 0.7-4.7), respectively. By the end of the follow-up period, 15 patients still had ileal ureters. Of these, 3 required dialysis. The indications for an ileal ureter have evolved in recent years. The ileal ureter appears to remain a reasonable option for ureteral reconstruction to preserve long-term renal function.

Successful replacement of an obstructed ureter with an ileal graft in a cat

A 10-year-old spayed female domestic shorthair cat with a 1-week history of vomiting, lethargy, and anorexia was examined. Abdominal radiography and ultrasonography revealed that calculi and a nonpatent stricture obstructed the right ureter, which resulted in secondary dilatation of the ureter proximal to the obstruction and severe hydronephrosis. The left kidney was small and suspected to be failing. Concentrations of BUN and creatinine were elevated. Despite administration of fluids, azotemia persisted. Surgery was performed. The obstructed right ureter was replaced with a vascularized segment of ileum. Azotemia resolved, and the cat improved with regard to clinical signs. The cat was clinically normal for > 36 months after the surgery. An ileal graft can successfully be used as a surgical option for ureteral obstruction in cats.

Laparoscopic skill laboratory in urological surgery: tools and methods for resident training

Laparoscopy has certainly brought considerable benefits to patients, but laparoscopic surgery requires a set of skills different from open surgery, and learning in the operating room may increase surgical time, and even may be harmful to patients. Several training programs have been developed to decrease these potential prejudices. to describe the laparoscopic training program for urological residents of the "Hospital das Clinicas" of the Sao Paulo Medical School, to report urological procedures that are feasible in dry and wet labs, and to perform a critical analysis of the cost-benefit relation of advanced laparoscopic skills laboratory. The laparoscopic skill lab has two virtual simulators, three manual simulators, and four laparoscopic sets for study with a porcine model. The urology residents during their first year attend classes in the virtual and manual simulator and helps the senior urological resident in activities carried out with the laparoscopic sets. During the second year, the urological resident has six periods per week, each period lasting four hours, to perform laparoscopic procedures with a porcine model. In a training program of ten weeks, one urological resident performs an average of 120 urological procedures. The most common procedures are total nephrectomy (30%), bladder suture (30%), partial nephrectomy (10%), pyeloplasty (10%), ureteral replacement or transuretero anastomosis (10%), and others like adrenalectomy, prostatectomy, and retroperitoneoscopy. These procedures are much quicker and caused less morbidity. Laparoscopic skills laboratory is a good method for achieving technical ability.