An alternative technique for treating long mid-ureteral strictures and defects

Salvatore Mario Palermo1, Emanuela Trenti1, Evi Comploj1, David D'Andrea1, Christian Ladurner1, Michele Lodde1, Christine Mian1, Armin Pycha1
  • 1 Ospedale 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 6 highly selected cases.

Materials and Methods

Between January 2006 and December 2014, 6 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 and one case was secondary to repeated endoscopic procedure for urinary stones. The other 3 cases followed an extensive resection required for large intraureteral masses (2 papillomas and 1 pTaG1) resulting in insufficient ureteral width for closure.
Following ureteral incision and/or partial resection, 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 then complete wrapped with greater omentum.

Results

Patient follow-up has ranged from 3 months to 5 years (average 32.5 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 3 patients. After 3 months was performed an intravenous urography, which showed the patency and the drainage of the ureters. After 9 months the uro-CT showed no obstruction and a good passage of the contrast without dilatation of the upper urinary tract. The follow-up were performed then annually by IVP, CT-urograms and/or abdominal ultrasounds and showed until now the patency of the ureteral reconstruction.

Discussions

The ureteric strictures can be caused by several factors like stones, infections, fibrosis, malignancy, radiotherapy or iatrogenic surgical trauma after hysterectomy, colorectal and vascular surgery or after endourological surgery. If the stricture is too long or not suitable for treatment with end to end anastomosis, Boari flap or Psoas hitch technique, may require an ileal ureter, autotransplantation or nephrectomy. These procedures are complex and associated with high risk of complications specially in unprepared patients in emergency situations. Furthermore, if the stricture involves the middle ureter, the risk of ischemic necrosis, due to the reduced vascular supply at this level, can be high even for shorter lesions and an end to end anastomosis is not recommended even if feasible, As alternative to these complex procedures, Naude (1) other Authors (2-3-4) 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 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 allows a good drainage of the upper tract and patency of the ureter, praserving as much as possible the vascular supply and reducing the risk of ischemic necrosis.

Conclusion

Mid-ureteral strictures and defects represent one of the most serious reconstructive challenges for urologists. We describe a novel technique for treating long mid-ureteral strictures or defects using a peritoneal graft wrapped with greater omentum. In a small group of patients with long mid-ureteral strictures this technique showed good results in terms of maintaining patency and good urinary drainage. It is technically simple and devoid of complications, feasible even in emergency situation and allows for preservation of any remaining vascular supply of the ureter. In conclusion it can be an usefull alternative in highly selected cases to nephrectomy, ileal ureter and autotransplantation and even to buccal mucosal graft repair.

References

1. Naude JH. Buccal mucosal grafts in the treatment of ureteric lesions. BJU International 1999; 83:751-4
2. Sadhu S, Pandit K, Roy MK, Bajoria SK. Buccal mucosa uretroplasty for the treatment of complex ureteric injury. Indian J Surg 2011; 73 (1): 71-72
3. Agrawal V, Dassi V, Andankar MG. Buccal mucosal graft onlay repair for a ureteric ischemic injury following a pyeloplasty. Indian J Urol 2010; 26: 120-2
4. Kroepfl D, Loewen H, Klevecka V, Musch M. Treatment of long ureteric strictures with buccal mucosal graft. BJU 2009; 105: 1452-5

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