Ureteral Replacement Research Articles

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.

Effectiveness of Colchicine Therapy in 4 Cases of Retroperitoneal Fibrosis Associated with Autoinflammatory Diseases

To the Editor: Retroperitoneal fibrosis (RPF) is a fibroinflammatory process affecting the retroperitoneal structures. There are no guidelines for its diagnosis or therapy. We describe 4 cases of RPF associated with autoinflammatory diseases, in which treatment with colchicine allowed RPF regression. RPF is an uncommon disease, with unclear pathogenesis. Systemic manifestations (fever, anorexia, weight loss), often associated with local symptoms (flank pain, leg edema, abdominal discomfort), are related to the entrapment of retroperitoneal structures by the fibrotic plaques. Initial therapy aims at restoring the function of the affected organs with the application of ureteral stents, followed by immunosuppressive therapy. Sometimes, ureteral replacement or kidney autotransplant may be necessary1. Colchicine, a tricyclic alkaloid, interferes with microtubule formation, altering mitosis and inhibiting many steps in the inflammatory process. It reduces adhesion of neutrophils to endothelium, inhibiting neutrophil migration, and blocks the in vitro release of fibronectin from alveolar macrophages2,3. It is approved by the US Food and … Address correspondence to Dr. R. Manna, Department of Internal Medicine, Catholic University, largo A. Gemelli 8, 00168 Rome, Italy. E-mail: rmanna{at}rm.unicatt.it

A New Technique for Ureteral Defect Lesion Reconstruction Using an Autologous Vein Graft and a Biodegradable Endoluminal Stent

Ureteral defect lesions are severe complications caused by iatrogenic lesions or trauma. For ureteral defect lesions elaborate surgical intervention is needed, such as autotransplantation or ureteral replacement with small bowel. Thus, we developed a new technique for ureteral defect reconstruction in a pig model using an autologous vein graft splinted by an endoluminal biodegradable poly-L-lactic acid stent (Institute of Textile Technology and Process Engineering, Denkendorf, Germany). In 42 pigs we removed the external jugular vein and used it as an autologous vein graft. After median laparotomy a 3 cm segment was resected from the proximal ureter and replaced by the vein with or without an endoluminal biodegradable poly-L-lactic acid stent. As controls, we used 14 pigs. We observed survival, kidney function, and neoureteral and kidney morphological changes for 7 days and for 6 months. After 6 months the stent material was completely broken down and the vein graft was relined with urothelium. It resembled native ureter with cytokeratin-7 positive columnar epithelium and newly formed capillaries in the ureteral wall. All animals had normal kidney function without renal pelvis congestion. This new technique for ureteral defect reconstruction using an autologous vein graft and a biodegradable endoluminal stent is feasible. It is an interesting alternative in the clinic due to the preservation of physiological urine passage and the antireflux mechanism.

The use of seromuscular tapered ileal tube in ureteral replacement: an experimental model

To assess the capability of urothelium to proliferate, creep and line the inner surface of the interposed seromuscular tapered ileal tube. Under general anesthesia, 15 female dogs underwent resection of 5 cm of the mid ureter and replaced with tapered seromuscular ileal tube stented for 6 weeks. The animals were sacrificed, and cross section of the ileal ureters were examined histologically for the lining cells. Multilayer of transitional epithelium was seen covering all the inner surface of the interposed seromuscular tube at the end of 6 weeks. Excessive inflammatory cell infiltration was a prominent finding in the submucosal layer. Transitional epithelium has the capability to proliferate, grow and cover the inner surface of the interposed seromuscular ileal tube. Urothelium lining avoid the metabolic complications of the intestinal mucosa.

Ureteric reconstruction with reconfigured ileal segments according to Yang-Monti

We report on 4 years experience with ileal ureteric replacement using the Yang-Monti procedure.From April 2001 to January 2009 reconfigured ileal segments were used for total (in 16) or partial (in 2) substitution of the ureter in 18 patients (mean age 47.4 years) with functional ureteric loss secondary to radiogenic or iatrogenic conditions. An antireflux implantation into the native bladder was done in 16 patients. All patients were followed prospectively according to a standardized protocol.The mean follow-up was 4.2 years (0.5-8 years). There were no perioperative deaths. Ultrasound controls showed an improvement of the upper tract dilatation in 11, a constant finding in 5 and a worsening in 2 cases. All of the treated renal units had evidence of improved renal function in ten and stabilization in eight patients. Neither a metabolic complication nor mucous obstruction was observed. Minor short-term complications, mainly febrile urinary tract infection and paralytic ileus, occurred in 50% and long-term complications, infections and hernia in 22%.The ileal ureteral substitute with reconfigured segments offers distinct advantages. A short bowel segment is used with the consequent absence of metabolic complications and excessive mucous production. It allows construction of an ileal ureter with a suitable cross-sectional diameter without any need for tailoring and makes it possible to use an antireflux technique. The intermediate results are encouraging.

Our Experience of Ureteral Substitution in Pediatric Age Group

To find appropriate ureteric substitute in the pediatric age group. Retrospective analysis was done from 2003 to 2008 of all patients operated in our hospital who had undergone ureteric replacement. All cases were followed up to find conduit patency, renal function, and any related complication. Ureteric replacement was performed in 5 cases. Age of the patients ranged from 6 months to 9 years. Three cases were of obstructive megaureter; 1 of redo-pyeloplasty and 1 of iatrogenic injury of the ureter. Three patients underwent partial ureteric substitution of the right ureter, and complete replacement of the left ureter with appendix was performed in 1 patient. In 1 case small bowel was used as Monti tube to substitute the ureter. At median follow-up of 23 months (14-66 months) all patients were well except 1 whose kidney function had deteriorated. We believe that our small series supports that either appendix or small bowel should be considered as Monti's tube for ureteric replacement when confronting with short ureter in pediatric age group.

Ureteric reconstruction and replacement

To review the recent advances on ureteric reconstruction and replacement, in particular, ileal ureteric replacement and laparoscopic and robotic-assisted ureteral reconstruction. Recently, the ureteric replacement with bowel has been carefully assessed by several authors, and the results are quite impressive. Also, very recent studies on laparoscopic and robotic-assisted ureteral repair have been published. Outcomes appear very promising, allowing for a faster recovery and shorter hospital stay for the patient. Today, we can conclude that the field of ureteric reconstruction and replacement is still evolving. Old techniques are supported by an increasing degree of evidence, and new, more minimally invasive surgical strategies emerge. Clearly, there are some disadvantages as well as difficulties to overcome with the new techniques; however, recent studies appear to present promising results.

Surgery for ureteral complications of bilharziasis

OBJECTIVE: To review our experience with reconstructions of ureteral complications of Schistosoma haematobium, in a centre situated in an endemic zone. PATIENTS: Fifty one patients operated for bilharzial complications of the ureters. METHODS: A retrospective analysis of patients operated upon, at the Coast Province General Hospital, Mombasa, Kenya between 1996 and 2008. All patients had obstructive ureteral complications. Data abstracted included demographics, level and nature of complication, surgical options utilized and follow-up. RESULTS: Endoscopic visual internal ureterotomy (VIU) was performed in 21 (41%) patients, resection and ureteroneocystostomy in 27 (49% of 55 procedures done), resection and ureteroureterostomy in one, nephrectomy in two and ileal replacements in two. Nephrostomy was performed in two patients who presented with anuria. Two patients restenosed after VIU and were offered resection and ureteroneocystostomy. One patient restenosed after ureteroneocystostomy and underwent a revision with psoas hitch. One patient with nephrostomy had bilateral ureteric replacement with ileum to skin. The two patients with anuria who had nephrostomy done eventually died of progressive renal failure. CONCLUSION: Schistosoma haematobium is associated with severe complications of the upper urinary tracts. Once established these complications are amenable to surgical correction, by both open and endoscopic techniques as long as renal function is not irretrievably impaired.

Laparoscopic Assisted Ileal Ureter: Technique, Outcomes and Comparison to the Open Procedure

Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution. A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented. Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup. Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls.

Does Open Stone Surgery Still Play a Role in the Treatment of Urolithiasis? Data of a Primary Urolithiasis Center

The introduction and continuous development of percutaneous nephrolithotomy, the achievement of extracorporeal shock-wave lithotripsy, and the advancements in ureterorenoscopy have led to a revolution in the interventional management urolithiasis. The indications for open stone surgery have been narrowed significantly making it a second- or third-line treatment option. We report on patients undergoing open stone surgery for nephrolithiasis in our department during the last 10 years to examine our indications at a primary urolithiasis center and to determine the clinical situations in which open surgery is a reasonable alternative. We reviewed all patients undergoing open stone surgery for upper urinary tract stones from 1997 until 2007 at the Department of Urology, University Hospital Mannheim. A retrospective chart analysis was performed on these patients to identify factors and indications for open stone surgery. Indications for stone surgery, type of surgery performed, stone complexity, anatomical abnormities present, and the residual stone burden were reviewed. During a 10-year period 26 open stone operations were performed in our high-volume center. Indications for open stone removal were complex stone mass with complete or partial staghorn stones, concomitant open surgery, nonfunctioning stone-bearing lower poles, the desire to facilitate future stone passages in cystine stone formers, multiple stones in peripheral calyces, and failed minimal invasive procedures. Procedures performed for stone removal included radial nephrotomies, extended pyelolithotomy, lower pole resection, partial nephrectomy, and ileum ureter replacement. Immediate stone-free rate after a single procedure was 69% (18/26 patients). Although today most stone cases can be handled by minimally invasive treatment, open stone surgery maintains a mandatory role in very selected cases. The most common indication in our series though was complex stones with a high stone burden especially in combination with anatomical variations.

Use of Ileum as Ureteral Replacement in Urological Reconstruction

We reviewed indications and outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction. Between December 1989 and September 2007, 105 patients underwent ileal ureter replacement, of whom 14 were excluded from study due to incomplete data. The remaining 91 patients (99 renal units) comprised the study cohort. Mean patient age was 46.8 years and mean followup was 36.0 months. Indications for an ileal ureter were stricture following genitourinary surgery in 29 cases (31.9%), radiation induced stricture in 17 (18.7%), nonurological surgery iatrogenic injury in 16 (17.6%) and retroperitoneal fibrosis in 11 (12.1%). Only 4 patients (4.4%) had primary ureteral cancer. Long-term complications included anastomotic stricture in 3 patients (3.3%) and fistula in 6 (6.6%). Serum creatinine decreased or remained stable in 68 patients (74.7%) and hyperchloremic metabolic acidosis developed in 3. No patient complained of excessive urinary mucous production. In 68.1% of patients indications for an ileal ureter included radiation induced stricture or iatrogenic injury. The ileal ureter is a reasonable option for long-term ureteral reconstruction with preserved renal function in carefully selected patients.

Ileal ureteric replacement with an ileo‐psoas muscle tunnel antirefluxing technique for the treatment of long segment ureteric strictures

To develop and report our initial experience with a novel antirefluxing technique for segmental ileal ureteric replacement for the treatment of long ureteric strictures. Between January 2000 and January 2007, 12 cases of ureteric strictures (nine bilateral and three unilateral) were treated using a novel surgical technique in which the ureter was replaced with a segment of ileum using an end-to-side anastomosis. An antireflux valve was constructed by fixing the distal part of upper ureter (4 cm) between the psoas muscle and ileal segment (the ileo-psoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis. The 12 cases were followed-up for a mean (range) of 39.42 (12-64) months. There were no cases of pyelonephritis or signs of renal failure after surgery. There was dramatic improvement in hydronephrosis, as assessed by intravenous urography, in the 4-9 months after surgery. Cystography showed no evidence of ileo-ureteric reflux. Mild hyperchloraemic acidosis was detected in two patients and was successfully treated with oral alkalization. In our initial experience, ileal ureteric replacement combined with the ileo-psoas tunnel antirefluxing technique is a highly effective procedure for the treatment of ureteric strictures.

Ureteral segment replacement using an ovine fetal urachus duct (new xenogenic graft) in dogs

The ureter is an important part of the urinary system that can be affected by several disorders such as congenital malformations, extensive iatrogenic ureteral obstruction, ureteritis, retroperitoneal fibrosis, trauma, necrosis, calculi, tumors, etc. We wished to determine whether ovine fetal urachus duct will be accepted when used as a ureteral replacement material in other species. The ureters of five adult native dogs were approached through a ventral midline laparotomy incision. A segment of 3-cm midureter was resected unilaterally. The left ureteral segments were replaced with ovine fetal urachus duct using 5-0 PDS interrupted sutures. Internal ureteral catheter was left for 6 weeks. The patency of the ureters was assessed by intravenous pyelography at 2 and 8 weeks after the surgery, while inflammation and regeneration were assessed grossly and histologically. All five urachus transplantations were accepted successfully in radiological, macroscopical, and histological evaluation. The ovine fetal urachus seems to be an embryonic tissue of extremely low antigenicity and therefore suitable for transplantation.

A case of staghorn stones in a kidney with an ileal ureter treated by percutaneous nephrolithotomy

A 59-year-old man was admitted to hospital for investigation of a 1-year history of intermittent hematuria. He had undergone ileal ureteral replacement for left renal stones 36 years earlier. Renal ultrasonography, physical examination, abdominal plain radiography, intravenous urography, CT urography, measurement of serum levels of creatinine, urea and electrolytes, renal scintigraphy, urinalysis and urine culture. Staghorn calculi in the left kidney, with a high-lying anastomosis between the renal pelvis and the proximal ileal segment. The patient underwent percutaneous nephrolithotomy via a middle-calyx access for the large staghorn stones. After surgery, no residual calculi were found and the patient was discharged with an uneventful postoperative course. At 1 month, renal scintigraphy showed normal bilateral kidney function. The patient received potassium citrate supplementation and was followed up with 6-monthly imaging studies. At the last report, he had been stone-free for 7 months.

Ureteric Injury After Iumbosacral Discectomy: A Case Report and Review of the Literature

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.

Successful use of the appendix for ureteral replacement: report of 10 pediatric cases

Successful use of the appendix for ureteral replacement: report of 10 pediatric cases

The appendix as ureteral substitute: A report of 10 cases

Background Ureteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter. Methods A retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix. Results Ten patients were identified, operated in 2002–2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion ( n = 1), congenital ureteric stenosis ( n = 5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction ( n = 3) and ureteric stricture following reimplantation for vesico-ureteric reflux ( n = 1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16 months (1–72 months), all the patients were well except one whose kidney function had deteriorated. Conclusions Total or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.

Singuläres Ileuminterponat mit beidseitiger Harnleiterimplantation nach Wertheim-Meigs-Operation

Ileum or colon interpositions are qualified procedures for functional ureteral replacement in case of extended ureteric lesions. In most cases, a unilateral interposition is sufficient. Rarely, it is necessary to perform bilateral procedures. We report the case of a 41-year-old female patient with bilateral ureter implantation into a singular ileum segment.

Retroperitoneale Fibrose

Retroperitoneal fibrosis (RPF) is characterised by inflammatory fibrotic processes affecting the retroperitoneal structures. Its prevalence of 1 - 2/200,000 makes it a rare disease. To date, there are no guidelines for the diagnosis of or therapy for the disease. If untreated, the disease may be fatal. In 2006, the Department of Urology of the HELIOS Klinikum Wuppertal undertook to establish a nationwide patient registry, which would facilitate prospective therapy trials and the drafting of recommendations for diagnostic procedures. The pathogenesis of the disease is still unclear. Since some RPF-patients present with associated autoimmune diseases, autoimmune processes are suspected to play a role in causing the disease. The presence of autoantibodies and histological similarities with vasculitis support this hypothesis. Following initial general symptoms, patients display localised symptoms (flank pain, leg oedema, abdominal discomfort), caused by the displacing effect of the fibrotic plaques. Laboratory tests show elevated ESR and C-reactive protein and in some cases a moderate anaemia. Histological examinations should be undertaken to rule out the presence of malignant tumours. Radiological diagnostics (excretory urography, CT, MRI) show a retroperitoneal mass which blocks, compresses and displaces, completely or in part, the large vessels and the ureter. Initial therapy aims at restoring the function of the affected hollow organs through the application of (ureteric) stents, followed by immunosuppressive therapy. If drug therapy is unsuccessful, surgical procedures will follow to protect the ureter from compression. In some cases, ureteral replacement or an autotransplant of the kidney may be necessary. Life-long observation of the patients is necessary, as the disease may be chronic and relapsing. Interdisciplinary and nationwide cooperation is of crucial importance to further investigate this disease.

1817: Artificial Ureteral Replacement Following Kidney Transplantation

1817: Artificial Ureteral Replacement Following Kidney Transplantation