Ureteral Replacement Research Articles

Advances in surgical repair of ureteral injury

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

Review of upper urinary modified minimal invasive surgical technology

Upper urinary surgery is an important area of urology surgery. Open surgery used to be the gold standard of upper urinary surgery. With the development of medical techniques, minimal invasive surgeries including laparoscopic and robot assisted-laparoscopic surgery have gradually replaced the open surgery. Because of the complexity and diversity of upper urinary diseases, surgeries sometimes are difficult, and minimal invasive surgeries require higher surgical abilities of urologists than open surgeries. In recent years, depending on our surgical experience and international reports, our team from three Chinese medical centers summarizes techniques of upper urinary minimal invasive surgeries. For malignant diseases, such as renal and ureteral carcinomas, it's important to totally remove the tumor first, and then to avoid the surgical injuries. We summarize surgical experience of retroperitoneal laparoscopic partial nephrectomy for moderately complex renal hilar tumors. Our team modified minimal invasive techniques for some complex tumors, including ring suture technique for renal hilar tumors, internal suspension technique for renal ventral tumors, and combination retroperitoneal laparoscopic surgery with mini-flank incision for complex renal tumors. While for begin diseases, urologists should focus on the resections and surgical injuries at the same time. We have reported the novel technique of laparoscopic aspiration for central renal angiomyolipoma, making the surgery simple and available. For reconstruction surgeries, operations should be based on several principals. We generalize it as "4TB principals", which include "tension-free", "water-tight", "thin suture", "no touch of the key area" and "protecting the blood supply". Depending on the localization, length, and etiology of the strictures, different techniques are required. Our team summarize the pyeloplasty, ureteral reimplantation and ileal ureter replacement based on our surgical experience. For infant upper urinary surgeries, our team has made invasive surgeries that can be used in complex diseases, such as duplex kidney. Based on years of surgical techniques, our modified surgeries achieve a better subjective cosmetic result than the traditional surgeries. In the future, the standardized, practical, simple and individual minimal invasive surgical technique will become the main direction in the future researches.

Initial experience of ileal ureter replacement combined with augmentation cystoplasty in the treatment of ureteral stenosis with contracted bladder

Objective To explore the availability and safety of ileal ureter replacement combined with ileal augmentation cystoplasty in treating ureteral stenosis with contracted bladder. Methods From August 2015 to November 2018, three patients who underwent ileal ureter replacement combined with augmentation cystoplasty were treated with ileal ureter replacement combined with augmentation cystoplasty. There were 1 male and 2 females with the age ranging from 34 to 55 years (mean 39 years). Two patients suffered from left ureter stenosis, and one patient had stenosis on the both sides. The length of the ureter stenosis ranged from 6 to 18 cm (mean 9.8 cm). The preoperative bladder capacity ranged from 60 to 150 ml (mean 103.3 ml). In the surgery, part of ileum was used to replace the ureter, and the distal intestine was made into U-shape to enlarge the bladder. Results All operation were completed successfully. The operation time ranged from 220 to 400 min (mean 303.0 min), and the blood loss ranged from 150 to 500 ml (mean 283.3 ml). Laparoscopic surgery was performed in 1 case and open surgery in 2 cases. Three weeks after the surgery, the bladder volume underwent cystography ranged from 300 to 400 ml (mean 360.0 ml). Three months after the surgery, the postvoid residual urine volume ranged from 20 to 50 ml (mean 33.3 ml). Postoperative frequency and urgency of urine were completely relieved in 1 case, alleviated in 2 cases. Flank pain was completely relieved in 1 case, and alleviated in 2 cases postoperatively. The serum creatinine of 2 patients mildly increased after the surgery, while 1 patient remained stable. For complications, 1 patient had urinary infection, and 1 patient suffered from metabolic acidosis. Conclusions Ileal ureteral replacement combined with augmentation cystoplasty can be the choice of treatment for long segment ureteral stenosis and enlarge the bladder simultaneously. The postoperative complications and the kidney functions should be regularly followed up. Key words: Augmentation cystoplasty; Ileal ureter replacement; Ureteral obstruction; Urinary tuberculosis

Current Indications and Techniques for the Use of Bowel Segments in Pediatric Urinary Tract Reconstruction.

Today, there are few indications for the use of bowel in pediatric urology. This is in large extent due to the successful conservative therapy in patients with neurogenic bladder and the improved success of primary reconstruction in patients with the bladder exstrophy-epispadias complex. Only after the failure of the maximum of conservative therapy or after failure of primary reconstruction, bladder augmentation, or urinary diversion should be considered. Malignant tumors of the lower urinary tract (e.g., rhabdomyosarcomas of the bladder/prostate) are other rare indications for urinary diversion. Replacement or reconstruction of the ureter with a bowel segment is also a quite rarely performed procedure. In this review, the advantages and disadvantages of the different options for the use of bowel segments for bladder augmentation, bladder substitution, urinary diversion, or ureter replacement during childhood and adolescence are discussed.

Surgical reconstruction of the ureter

Defects in ureteral continuity and function can originate from various etiologies such as stricture, radiotherapy, tuberculosis, tumor, trauma or perforation due to iatrogenic injury. The surgical options for the management of ureteral defects are complex and depend on the location of the defect. The aim of the surgical management of ureteral stricture is the reconstruction of an anti-refluxive and nonobstructive flow of urine to preserve kidney function. There are numerous possibilities for the reconstruction of ureteral defects ranging from ureteroneocystostomy with or without psoas-hitch- or Boari-flap to ileal ureteral replacement. Nearly all these techniques can either be done in open surgery or in alaparoscopically or robotic-assisted manner. The technique of robotic-assisted reconstruction of ureteral defects is challenging but offers agreat opportunity. The aim of this article is to provide an overview of current surgical procedures in ureteric reconstruction.

Technical considerations and outcomes for\xa0ileal ureter replacement: a retrospective study in China

BackgroundIleal ureter replacement is an alternative treatment for various length ureter defects. We present our experience and outcome of ileal ureter replacement in China.MethodsWe retrospectively collected data of patients who underwent ileal ureter replacement between January 2010 and January 2015. We reviewed the medical history, indications for surgery, operative data, perioperative data, and outcomes. Besides, follow-up data included symptom, urine routine test, serum creatinine, serum electrolyte status, and radiographic test.ResultsThere were 23 patients who underwent ileal ureter replacement by the same surgeon. Twenty patients were performed unilateral ileal ureter replacement, two patients underwent a combination of ileal ureter replacement and Boari flap-psoas hitch, and one received bilateral ileal ureter replacement. Among these patients, the main cause leading to surgical treatment was iatrogenic injuries (n = 15), especially urinary surgery procedure (n = 11). The median follow-up time was 45 months. There were 6 early complications and 6 late complications after operation. Only one patient suffered from small bowel-related complication and was cured by conservative treatment. Only the patient who underwent bilateral ileal ureter replacement had metabolic acidosis. And 22 patients (95.7%) had a good renal function.ConclusionsIleal ureter replacement is an efficacious and safe procedure for the therapy of long ureteral defects. With appropriate technical considerations, the complication rate may decrease.

Лапароскопическая заместительная кишечная пластика мочеточников. Результаты первых 40 операций

Despite the twenty-year history of laparoscopic ileal ureteral substitution, the literature is lacking studies reporting its outcomes, and those few are mainly case reports. Besides, they usually describe surgery from combined access, when the ileal segment resection and ileo-ileal anastomosis are performed from mini-laparotomy, and the remaining stages are done endoscopically. To conduct a multicenter retrospective analysis of our series of patients undergoing laparoscopic ileal ureteral substitution using only endoscopic access. From 2010 to 2017, 48 ureters were replaced completely laparoscopically in 40 patients. Of them, 33 patients underwent total ureteric replacement, and the others had a subtotal ileal ureteral substitution. Video describing the operation technique is available on https://youtu.be/IeA60pSiUBE. The mean operating time was 335 minutes, and the estimated blood loss was 221 ml. Intraoperative complications (7.5%) were resolved during surgery. No patients required conversion to open surgery. There was no mortality. Postoperative Clavien III complications were observed in 7.5% of patients. The mean length of hospital day was 13.5 days. Functional results were followed from 6 months to 7 years. The presented material is the largest available in the literature, and the results, including long-term functional outcomes, demonstrate the efficacy and safety of laparoscopic technologies in the treatment of extensive strictures and obliterations of the ureter.

The significance of palliative surgery in castration-resistant prostate cancer

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option. To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists.

Laparoscopic appendiceal interposition pyeloplasty for long ureteric strictures in children

The management of long ureteric strictures is very challenging, and ureteral substitution is necessary when end-to-end anastomosis can not be accomplished. To evaluate the mid-term results of laparoscopic appendiceal interposition pyeloplasty in children with long ureteric strictures. Between March 2010 and September 2016 four patients (median age 24 months, male/female 3/1) underwent laparoscopic appendiceal interposition pyeloplasty at the current hospital. Two patients had previously failed pyeloplasty, one had a traffic injury, and one had iatrogenic ureteral injury (Summary Table). The intraoperative, postoperative and follow-up results were analyzed. Success was defined as clinical (subjective) and radiologic (objective) resolution of the stricture. All surgeries were successfully completed without conversion. The mean stricture length was 4.5cm. Two cases were right-sided strictures, and two were left-sided. The mean operative time and estimated blood loss were 238.5min and 25.0ml, respectively. No intraoperative complication was encountered. No Grade 3 or Grade 4 complication was observed after surgery. One was anastomosed in the antiperistaltic manner and three were in the isoperistaltic fashion. The mean postoperative hospital stay was 7.3 days. The success rate was 100% at a mean follow-up duration of 33.8 months. There is no consensus on the best surgical approach for long ureteric strictures. Ureteric replacement with intestinal segments or kidney autotransplantation is a viable alternative treatment to long ureteric strictures. However, both methods are technically challenging with significant complications. Appendiceal interposition to restore ureteral continuity has been described in adult patients. The current results demonstrated that laparoscopic appendiceal interposition pyeloplasty is a safe and feasible minimally invasive approach for the treatment of long ureteral strictures in children. Laparoscopic appendiceal interposition pyeloplasty was a viable minimally invasive alternative for children with long ureteric strictures on both left and right sides. Both isoperistaltic or antiperistaltic anastomosis were feasible.

Long term outcomes in the use of ileal ureter for radiation-induced ureteral strictures.

Radiation-induced ureteral stricture disease poses significant surgical challenges. Ureteral substitution with ileum has long been a versatile option for reconstruction. We evaluated outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction due to radiation-induced ureteral stricture versus other causes. Between July 1989 and June 2013, 155 patients underwent consecutive ileal ureter creation. The study cohort included 104 patients with complete data sets and at least 7months of follow up. Records were retrospectively reviewed with regard to demographics, indications, complications, and renal deterioration. Surgical indications included radiation-induced stricture in 23 (22%) and non-radiation-induced stricture in 81 (78%). Comparing ileal ureter substitution due to radiation versus other stricture etiologies, no statistical significance was observed in regard to age (45.6 vs. 51.2, p = 0.141), hospital length of stay in days (8.8 vs. 7.7, p = 0.216), percent GFR loss (MDRD-4 vs. -5%, p = 0.670 and CKD-EPI-7 vs. -6%, p = 0.914), 30-day surgical complications (26.1 vs. 30.1%, p = 0.658), metabolic acidosis (8.7 vs. 1.2%, p = 0.059), and renal failure requiring dialysis (4.3 vs. 1.2%, p = 0.337). Fistula formation (13.0 vs. 3.7%, p = 0.095), partial small bowel obstructions (21.7 vs. 7.4%, p = 0.063), and small bowel obstructions requiring reoperation (13.0 vs. 1.2%, p = 0.033) approached or reached statistical significance. Using Kaplan-Meier methodology, there was no difference in time to worsening renal outcome between the radiation and non-radiation groups (p > 0.05). Ureteral substitution with ileum is an effective reconstructive option for radiation-induced ureteral strictures in carefully selected patients.

P14 - Immediate ileal ureter replacement for ureteral avulsion during ureteroscopy: A case report

P14 - Immediate ileal ureter replacement for ureteral avulsion during ureteroscopy: A case report

Functional Outcome of Completely Intracorporeal Robotic Ileal Ureteric Replacement

To assess perioperative, clinical, and functional outcomes following completely robotic ileal ureter. We retrospectively reviewed 7 consecutive patients undergoing completely intracorporeal ileal ureteric replacement between November 2015 and May 2017. One patient had a solitary kidney. A 4-arm technique was used. In 5 patients, additional psoas hitch procedure was performed. Patients had retrograde filling and removal of the ileal stent and transurethral catheter at an average of 14 days postoperatively. Renal ultrasonography, serum analysis, and diuretic renography were performed at follow-up 3 months postoperatively. Mean operative time was 328 ± 66.3 minutes and median estimated blood loss was 100 mL (range 50-200); mean length of the ileal substitute was 20.4 cm (range 18-24). No case was converted to open surgery. In 1 patient, there was a prolonged insufficiency of the pyeloileal anastomosis, requiring prolonged stenting. Apart from that, there were no major complications and no open surgical or endoscopic reinterventions. On 3-month follow-up, all patients presented symptom-free, with no signs of obstruction on ultrasound and significantly improved glomerular filtration rate, creatinine levels, and differential renal function (P = .02, 0.03, and 0.046, respectively). Five patients had a diuretic halftime <10 minutes, 2 had a halftime between 10 and 20 minutes. Completely intracorporeal robotic ileal ureteric replacement results in full functional restoration of the upper tract in cases of long defects of the mid and upper ureter.

Use of the Ileum for Ureteral Stricture and Obstruction in Bilateral, Unilateral, and Single-kidney Cases

To investigate the functional outcomes of ileal ureter replacement for complex ureteral loss, including bilateral and single ureter stricture, as a result of various etiologies. In 2013-2016, 31 patients underwent ileal ureter replacement surgery. The data for their assessments included etiology, combined surgical procedures, ureteral replacement type, postoperative complications, and changes in renal function. The 31 study patients had a median age of 56.0 (range 18-65) years and were followed for a median of 23.6 (range 6.5-43.2) months. There were 14 bilateral, 12 unilateral, and 5 single-kidney cases. The main indication for surgery was ureteral defects after gynecological surgery and radiation in 24 patients (77.4%). The mean operation time was 370.6 minutes and the median hospital stay was 25.2 (range 6-79) days. Various types of ileal arrangement were performed to cover bilateral ureter loss. After 30 days past surgery, 24 patients (77.4%) were in a stable state and 5 (16.1%) had decreased serum levels of creatinine. Short-term complications greater than grade 3 on the Clavien scale occurred in 10 patients (33.3%), and long-term complications occurred in 27 (87.1%). However, all cases were well relieved by conservative care, and surgical intervention was needed in only 1 case. Apart from 2 patients who died because of the progression of cervical cancer, all patients had stent-free status at 22.4 months. Ileal ureter replacement is a useful reconstructive surgery for complex ureteral loss, such as bilateral and single-kidney cases resulting from various etiologies.

AB074. Indications, techniques and outcomes for ileal ureter replacement: a multicenter experience in China

BackgroundIleal ureter replacement is a selective technique for ureteral reconstruction without being limited by the defect length. This study aim to present the techniques, experiences, and outcomes related to ileal ureter replacement among patients in a multicenter in China.MethodsA multicenter retrospective study of patients with long ureteral defects who underwent ileal ureter replacement was conducted from January 2010 to January 2015. Patient characteristics, indications for surgery, intraoperative variables, surgical complications, and postoperative outcomes were reviewed. Follow-ups, including clinical evaluation, serum creatinine, electrolyte level, urine routine test, and radiographic examination were performed.ResultsA total of 23 patients in 7 tertiary care centers underwent ileal ureter replacement. Specifically, 20 underwent unilateral ileal ureter replacement, 2 received combined ileal-ureter substitution and Boari flap-psoas hitch, and 1 had bilateral ileal ureter replacement. The main indication for surgical intervention was presence of iatrogenic injuries (n=15), the majority of which resulted from a urologic surgical procedure (n=11). Median follow-up time was 45 months. Six early complications (grade 2) and 6 late complications occurred postoperatively. Small bowel-related complication occurred in only 1 patient with incomplete ileus, which was resolved by conservative treatment. Renal function improved or remained stable in 22 patients (95.7%). Metabolic acidosis was detected in only 1 patient who underwent bilateral ureteral replacement.ConclusionsIleal ureter replacement remains feasible and safe for the treatment of long ureteral defects. Technical considerations described in the study may ease and reduce complications following the procedure.

Mechanical induction of bi-directional orientation of primary porcine bladder smooth muscle cells in tubular fibrin-poly(vinylidene fluoride) scaffolds for ureteral and urethral repair using cyclic and focal balloon catheter stimulation.

To restore damaged organ function or to investigate organ mechanisms, it is necessary to prepare replicates that follow the biological role model as faithfully as possible. The interdisciplinary field of tissue engineering has great potential in regenerative medicine and might overcome negative side effects in the replacement of damaged organs. In particular, tubular organ structures of the genitourinary tract, such as the ureter and urethra, are challenging because of their complexity and special milieu that gives rise to incrustation, inflammation and stricture formation. Tubular biohybrids were prepared from primary porcine smooth muscle cells embedded in a fibrin gel with a stabilising poly(vinylidene fluoride) mesh. A mechanotransduction was performed automatically with a balloon kyphoplasty catheter. Diffusion of urea and creatinine, as well as the bursting pressure, were measured. Light and electron microscopy were used to visualise cellular distribution and orientation. Histological evaluation revealed a uniform cellular distribution in the fibrin gel. Mechanical stimulation with a stretch of 20% leads to a circumferential orientation of smooth muscle cells inside the matrix and a longitudinal alignment on the outer surface of the tubular structure. Urea and creatinine permeability and bursting pressure showed a non-statistically significant trend towards stimulated tissue constructs. In this proof of concept study, an innovative technique of intraluminal pressure for mechanical stimulation of tubular biohybrids prepared from autologous cells and a composite material induce bi-directional orientation of smooth muscle cells by locally and cyclically applied mechanical tension. Such geometrically driven patterns of cell growth within a scaffold may represent a key stage in the future tissue engineering of implantable ureter replacements that will allow the active transportation of urine from the renal pelvis into the bladder.

Ileal Ureter Replacement Combined With Boari Flap-Psoas Hitch to Treat Full-Length Ureteral Defects: Technique and Initial Experience

To evaluate the feasibility of ileal ureter replacement combined with Boari flap-psoas hitch procedure for the management of full-length ureteral defects (>20 cm). Three patients diagnosed with full-length ureteral defect were treated with our technique performed by a single surgeon between January 2015 to January 2016. All the patients had borderline renal function preoperatively. In each case, the ureteral reconstruction was performed by combining ileal ureter replacement with Boari flap-psoas hitch. Data on indications for surgery, intraoperative and postoperative outcomes, and changes in renal function were collected. Surgery was performed successfully with an operation duration between 210 and 250 minutes. The mean estimated blood loss was 230 mL. The mean length of hospital stay was 11 days, and no major complications (grade ≥3) occurred. Postoperative follow-up showed radiological resolution of hydronephrosis and improved renal function in all 3 patients. Ileal ureter replacement combined with Boari flap-psoas hitch is a feasible option for bridging full-length ureteral defects. This technique minimizes the length of ileal graft required as well as limitations concerning patient selection. Larger series with longer follow-up to confirm the value of the technique are warranted.

Long-term results of ileal ureteric replacement: a 25-year single-centre experience.

To report the long-term outcomes of ileal ureteric replacement (IUR) in complex reconstruction of the urinary tract. From 1991 to 2016, IUR was performed in 157 patients with structural or functional ureteric loss. In 52 patients, bilateral IUR became necessary. Implantation sites where either the native urinary bladder (n = 79) or intestinal reservoirs (n = 78). In the latter group, the technique was used at the time of primary urinary diversion (n = 34), in a secondary approach (n = 29), and in undiversion or conversion procedures (n = 15). Anti-refluxive implantation was performed in 37 patients. In eight patients the ileal ureter was implanted into the cutis as an ileal conduit. All patients were followed prospectively according to a standardised protocol. The mean follow-up was 54.1 months. In 114 patients with dilatation of the upper urinary tract before surgery a significant improvement of the dilatation was confirmed in 98 patients. Serum creatinine levels decreased or remained stable in 147 of the 157 patients. Reflux was present in all cases without and in six cases with an anti-reflux mechanism. In six patients, operative revision became necessary because of severe metabolic acidosis, mucus obstruction or stenosis of the ileal ureter. To our knowledge, this is the world's largest single-centre series of IUR reported to date. Long-term follow-up confirms that this approach is a safe and reliable solution, even under complex conditions. Anti-refluxive implantation is recommended for intestinal reservoirs, whereas reflux prevention seems to be of minor importance when the native bladder is chosen as the site of implantation.

Clinical protocol levels are required in laboratory animal surgery when using medical devices: experiences with ureteral replacement surgery in goats.

It is common to test medical devices in large animal studies that are or could also be used in humans. In this short report we describe the use of a ureteral J-stent for the evaluation of biodegradable tubular constructs for tissue reconstruction, and the regeneration of ureters in Saanen goats. Similarly to a previous study in pigs, the ureteral J-stent was blindly inserted until some resistance was met. During evaluation of the goats after three months, perforation of the renal cortex by the stent was observed in four out of seven animals. These results indicated that blind stent placement was not possible in goats. In four new goats, clinical protocols were followed using X-ray and iodinated contrast fluids to visualize the kidney and stent during stent placement. With this adaptation the stents were successfully placed in the kidneys of these four new goats with minimal additional effort. It is likely that other groups in other fields ran into similar problems that could have been avoided by following clinical protocols. Therefore, we would like to stress the importance of following clinical protocols when using medical devices in animals to prevent unnecessary suffering and to reduce the number of animals needed.

460 - Long-term outcome and complications after ileal ureter replacement – a contemporary high-volume single-center experience

460 - Long-term outcome and complications after ileal ureter replacement – a contemporary high-volume single-center experience

Presentation of the first successful ureter excision and replacement by a synthetic pyelo-cystic bypass graft (detour) in a patient with solitary kidney

Introduction : The use of subcutaneous pyelo-cystic bypass grafts (detours) has been described as a minimally invasive method for treating extensive ureteral lesions, usually of oncological, radiation-induced or iatrogenic aetiology. We present the first case of use of this graft in open surgery, for ureter replacement. Material & methods: An 81 year-old patient with a solitary left kidney visited us with signs of obstructive anuria. He was managed in an emergency setting by placement of a pig tail catheter, while the ensuing investigation revealed the presence of a tumour in the upper tertile of the left ureter, covering an area that did not allow a conservative operation. Given its increased morbidity and the patient’s refusal to be set on permanent extrarenal dialysis, we concurrently executed an extensive ureterectomy, from the level of the ureteropelvic junction to the vesicoureteral junction and replacement of the affected ureter by a synthetic detour graft, anastomosed at both ends with the pelvis and the urinary bladder. Intraoperatively, we checked the pyelocalyx system to rule out the presence of any other tumour and placed a prophylactic nephrostomy. Results: The patient was discharged on the 12th postoperative day in good overall condition. On the 30th postoperative day and after a nephrostomography to rule out possible leaks, the nephrostomy, the drain and the urinary catheter were removed. This was followed by a chemotherapy regimen, which was not completed. Six months after surgery, the patient is disease-free based on imaging criteria and has borderline normal renal function. Conclusions: Synthetic pyelo-cystic bypass grafts (detours) designed for subcutaneous use can safely be used in open oncological or other operations for ureter replacement in carefully selected patients. Eισαγωγή: Η χρήση υποδόριου μοσχeύματος πυeλοκυστικής παράκαμψης (detour) έχeι πeριγραφeί, ως eλάχιστα eπeμβατική μέθοδος αντιμeτώπισης eκτeταμένων ουρητηρικών βλαβών, συνήθως ογκολογικής, μeτακτινικής ή ιατρογeνούς αιτιολογίας. Παρουσιάζeται η πρώτη πeρίπτωση χρήσης του συγκeκριμένου μοσχeύματος σe ανοικτή eπέμβαση, για αντικατάσταση ουρητήρα. Υλικό & Μέθοδος: Ασθeνής 81 eτών, λeιτουργικός μονόνeφρος ΑΡ, προσήλθe μe eικόνα αποφρακτικής ανουρίας. Αντιμeτωπίστηκe eπeιγόντως μe τοποθέτηση καθeτήρα pig tail και κατά τη διeρeύνηση που ακολούθησe, διαπιστώθηκe η παρουσία όγκου του άνω τριτημορίου του ΑΡ ουρητήρα, σe έκταση που δeν eπέτρeπe συντηρητικού τύπου eπέμβαση. Μe δeδομένη την αυξημένη νοσηρότητα και την άρνηση του ασθeνούς να καταλήξeι σe μόνιμη eξωνeφρική κάθαρση, eκτeλέστηκαν στον ίδιο χρόνο eκτeταμένη ουρητηρeκτομή από το eπίπeδο της πυeλουρητηρικής ως την κυστeουρητηρική συμβολή και αντικατάσταση του πάσχοντος ουρητήρα από συνθeτικό μόσχeυμα detour, που αναστομώθηκe στα δύο άκρα του μe την πύeλο και την ουροδόχο κύστη. Διeγχeιρητικά eλέγχθηκe το πυeλοκαλυκικό σύστημα για αποκλeισμό άλλου όγκου και τοποθeτήθηκe προφυλακτική νeφροστομία Αποτeλέσματα: Ο ασθeνής eξήλθe την 12η μeτeγχeιρητική ημέρα σe καλή γeνική κατάσταση. Την 30η μeτeγχeιρητική ημέρα και αφού προηγήθηκe νeφροστομογραφία για αποκλeισμό διαφυγής, αφαιρέθηκαν η νeφροστομία, η παροχέτeυση και ο ουροκαθeτήρας. Ακολούθησe σχήμα χημeιοθeραπeίας, που δeν ολοκληρώθηκe. Έξι μήνeς μeτά την eπέμβαση, ο ασθeνής eίναι απeικονιστικά eλeύθeρος νόσου και μe οριακά φυσιολογική νeφρική λeιτουργία. Συμπeράσματα: Το σχeδιασμένο για υποδόρια χρήση συνθeτικό μόσχeυμα πυeλοκυστικής παράκαμψης (detour), μπορeί να χρησιμοποιηθeί μe ασφάλeια σe ανοικτές ογκολογικές ή άλλeς eπeμβάσeις για αντικατάσταση ουρητήρα, σe αυστηρά eπιλeγμένους ασθeνeίς.