An alternative technique for treating complex ureteral strictures and defects

Salvatore Palermo1, Emanuela Trenti1, Carolina D'Elia1, Evi Comploj1, Christian Ladurner1, Dorian Huqi1, tamara Tischler1, Helmuth Schuster1, Christine Mian1, Armin Pycha1
  • 1 Ospedale Civile di Bolzano (Bolzano)

Objective

Mid-ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists. We describe a new technique of ureteral reconstruction using a peritoneal graft in 8 highly selected cases.

Materials and Methods

Between January 2006 and December 2015, 8 patients with mid-ureteral narrowing and obstruction were treated using a peritoneal graft. Stricture/defect length ranged from 4 to 12 cm. Due to their length, all cases would have otherwise required an ileal ureter, nephrectomy or autotransplantation. Two cases were secondary to long strictures from retroperitoneal fibrosis after vascular surgical procedures, three cases followed an extensive resection, required for large intraureteral masses (2 papillomas and 1 pTaG1) resulting in insufficient ureteral width for closure, 2 cases were secondary to repeated endoscopic procedures for urinary stones and 1 case followed repeated pyeloplastics.
After ureteral incision a free peritoneal graft was harvested from nearby healthy peritoneum. An onlay patch was fixed with running suture to the remaining ureteral plate after placement of an indwelling ureteral catheter. Finally, the ureter was complete wrapped with greater omentum.

Results

Patient follow-up has ranged from 6 to 76 months (average 34.5 months). All postoperative courses were uneventful. The urethral catheter was removed after intravenous pyelography on the 10thpostoperative day. The ureteral stent was removed six weeks post-operatively in 3 patients and after 3 months in the other 5 patients. Five patients were free from stricture recurrence after 6, 30, 36, 54 and 60 months, showing no obstruction and good passage of the contrast without dilatation of the upper urinary tract on the uro-CT or urography. In one patient occurred a stricture recurrence below the reconstructed ureter after 60 months without symptoms and with mild hydronephrosis: the patient died 16 months later with stable disease at 92 years. One patient became symptomatic after removal of the stent; after temporary stenting, also this patient became asymptomatic with narrowing of the ureter below the reconstructed patent ureteric segment and mild hydronephrosis. In the last patient, who had an ureter fissus, the intravenous urography showed obstruction of the reconstructed segment of ureter with hydronephrosis of the upper pole system 6 months after the surgical procedure; the patient was asymptomatic and didn’t required surgery.

Discussions

Mid-ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists and might require more complex treatment like bowel replacement or autotransplantation. These procedure are of considerable magnitude and associated with high rates of complications and long term morbidity [1-2]. As alternative to these complex procedures, Naude and other Authors [3-4] have reported the successfull use of buccal mucosal patch graft for the reconstruction of a variety of ureteric lesions without major complications. Based on this findings we have treated these patients with long mid-ureteral strictures using a peritoneal patch graft, wrapped with greater omentum. The advantage of this technique is the unlimited availability of the material, which can be simply harvested from nearby healthy peritoneum without related complications. Furthermore this technique of reconstruction is simple and devoid of complications; it allows a good drainage of the upper tract and patency of the ureter, preserving as much as possible the vascular supply and reducing the risk of ischemic necrosis. The limitations of this study are the small sample series and its retrospective nature. This approach should be considered in all patients, who would need ureteric replacement for long mid-ureteral strictures, and specially in those with renal impairment, to avoid metabolic problems or increasing morbidity.

Conclusion

We describe a novel technique for treating long mid-ureteral strictures or defects using a peritoneal graft. The technique allows for preservation of any remaining vascular supply of the ureter and can be a feasible and usefull alternative to nephrectomy, ileal ureter and autotransplantation in highly selected cases.

Reference

1. Schoeneich G, Winter P, Albers P, Frohlich G, Muller S. Management of complete ureteral replacement. Experiences and review of the literature. Scand J Urol Nephrol 1997; 31 (4): 383-388
2. Bonfig R, Gerharz EW, Riedmiller H. Ileal ureteric replacement in complex reconstruction of the urinary tract. BJU Int 2004; 93: 575-580.
3. Naude JH. Buccal mucosal grafts in the treatment of ureteric lesions. BJU International 1999; 83:751-4
4. Kroepfl D, Loewen H, Klevecka V, Musch M. Treatment of long ureteric strictures with buccal mucosal grafts. BJU Int 2009; 105: 1452-1455

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