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17 Reconstructive Techniques for Ureteral Injuries: Using Extra-Urinary Autologous…
suturing it to the upper ureter or renal pelvis proximally and to the bladder distally or rarely to the distal ureteric segment if viable [8].
(a) Indications: Recurrent calculi, ureteral stricture, stula, congenital obstruc-
tion of the ureter, extensive ureteral injury, retroperitoneal brosis, tuberculosis, ureteral carcinoma in a solitary kidney [3, 7, 9–11].
(b) Contraindications: inammatory bowel disease, post-radiation, inconti-
nence, bladder neck obstruction, neurogenic bladder, metastatic cancer,
renal failure, and hepatic dysfunction [3, 7, 9, 10].
(c) Technical aspects of the ileal ureter reconstruction: The lumen of the
selected ileal segment must rst be reduced before reconstruction using staplers (GIA) or 4/0 resorbable sutures. Practically, it can be tailored over a
12-Fr Foley’s. The peristalsis direction must be maintained and the proximal
end of the fashioned tube is anastomosed to the proximal ureter or the renal
pelvis, using a 4/0 resorbable suture, in an end-to-end manner and the distal
end will be anastomosed either to the bladder using one of the techniques
described in the ureteroneocystoplasty (Lich-Gregoir extravesical nonreuxing, for example) or to the spatulated cephalic end of the lower ureter
segment if healthy, using the uretero-ureterostomy technique.
If there is bilateral ureteric damage, both sides can be reimplanted into a
common isoperistaltic ileal segment end-to-endwise using the Wallace technique uniting the two ureteric ends, or separately end-to-sidewise after closing the proximal end of the ileal segment, and the distal end of the ileum
segment will be anastomosed to the dome of the bladder in an anti-reux
manner (e.g. Lich-Gregoir technique) (Figs. 17.1, 17.2, and 17.3). The
reconstructions are stented for 3–6weeks, a drain is left in situ for a few
days, and a urethral catheter is kept indwelling for 10–14days [7, 8, 10, 12].
The combination of an ileal ureter and a Boari ap allows the use of a
shorter ileal segment [8] (Fig.17.4).
(d) Complications of an ileal ureter: Paralytic ileus, recurrent UTI with pyelone-
phritis, renal deterioration, ileovesical stricture, mucus obstruction, stula,
stone formation, pancreatitis, metabolic acidosis, diarrhea, and transient hepatic
encephalopathy [3, 7, 9, 10, 12]. The rate of anastomotic stricture and stula
(ileal uretero-enteric or enterovaginal stula) is estimated to be 3.3% and 6.6%,
respectively, after a mean follow-up of 36months [12]. Metabolic acidosis is an
expected complication but a recent series of 23 patients showed that metabolic
acidosis occurred only in the unique patient who underwent bilateral ileal ureter
replacement and not in the 22 others [8].
(e) Results. The results of an ileal ureter in maintaining or improving the renal
function depends on the published series, varying from 75–76% for some [11,
12] to 83–95% of patients for others after various mean follow-ups of
36–65months [7–9]. Kocot etal. observed a signicant improvement in upper
urinary tract dilatation in 86% of their 157 patients [7]. In a series of 14 patients,
the most common site of ureteric injury was the lower and mid-ureteric segments
17 Reconstructive Techniques for Ureteral Injuries: Using Extra-Urinary Autologous…
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147
Fig. 17.1 Seven and reverse seven congurations of bilateral ureteral reimplantation into a common ileal segment. (From Armatys SA etal. [12], with permission from Wolters Kluwer Health)
and the mean length of the mobilized ileum was 11.2cm [11]. The average
nadir serum creatinine levels were 1.57mg/dL and 1.37mg/dL pre-operatively
and at 12months postoperatively, respectively [10].
2. Buccal mucosa grafting.
This technique is very popular for urethral stricture, but only scanty publica-
tions exist for ureteric replacement. The use of buccal mucosa for the ureter was
rst described by Naude in Cape Town, South Africa, in 1999, and can be performed as an onlay or a tubularized graft wrapped with omentum [13]. There
have been a few small series published since then [14, 15]. There is even a small
reported series of 4 patients who underwent robotic-assisted ureteral buccal
reconstructions with buccal mucosa with 100% success after a median follow-up
of 15.5months [16].
3. Replacement by the gonadal vein: An initial cadaveric model with partial ure-
teric replacement using a gonadal vein was published in 2019 with promising
results. The obvious advantage is the course of the gonadal vein parallel to the
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17 Reconstructive Techniques for Ureteral Injuries: Using Extra-Urinary Autologous…
Fig. 17.2 The anti-reux
nipple valve for ileal ureter
substitution. (From Zhong
W etal. [8]. Creative
Commons Attribution 4.0
International License)
ab c
Fig. 17.3 Different types of ureteral replacement. (a) Unilateral ileal ureter replacement, (b)
bilateral ileal ureter replacement, (c) combined ileal–ureter substitution and Boari ap–psoas
hitch. (From Zhong W etal. [8]. Creative Commons Attribution 4.0 International License)
References
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Fig. 17.4 The
combination of ileal ureter
replacement and Boari
ap–psoas hitch technique.
(From Zhong W etal. [8].
Creative Commons
Attribution 4.0
International License)
149
ureter. An animal (porcine) model is expected to conrm the validity of this
autologous graft [17].
References
1. Chaput. Bulletins et Mémoires de la Société de Chirurgie de Paris, Tome XIX, 1893;309.
2. Fenger CI. Surgery of the ureter. Ann Surg. 1894;20(3):257–96. https://doi.
org/10.1097/00000658- 189407000- 00042.
3. Mattos RM, Smith JJ 3rd. Ileal ureter. Urol Clin N Am. 1997;24(4):813–25. https://doi.
org/10.1016/s0094- 0143(05)70422- 5.
4. Shoemaker J. Discussie op voordracht van JM van Damn over interaabdominale plastiken.
Ned Tijdschr Geneesk. 1911:836. PubMed | Google Scholar; Yang WH
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17 Reconstructive Techniques for Ureteral Injuries: Using Extra-Urinary Autologous…
5. Wells CA. The use of the intestine in urology, omitting ureterocolic anastomosis. Br J
Urol. 1956;28(4):335–50.; discussion, 406–16. https://doi.org/10.1111/j.1464- 410x.1956.
tb04783.x.
6. Goodwin WE, Winter CC, Turner RD.Replacement of the ureter by small intestine: clinical
application and results of the ileal ureter. J Urol. 1959;81:406–18.
7. Kocot A, Kalogirou C, Vergho D, Riedmiller H.Long-term results of ileal ureteric replacement:
a 25-year single-centre experience. BJU Int. 2017;120(2):273–9. https://doi.org/10.1111/
bju.13825. Epub 2017 Mar 21
8. Zhong W, Hong P, Ding G, et al. Technical considerations and outcomes for ileal ureter
replacement: a retrospective study in China. BMC Surg. 2019;19:9. https://doi.org/10.1186/
s12893- 019- 0472- 1.
9. Verduyckt FJ, Heesakkers JP, Debruyne FM.Long-term results of ileum interposition for ureteral
obstruction. Eur Urol. 2002;42(2):181–7. https://doi.org/10.1016/s0302- 2838(02)00266- x.
10. Pamecha Y, Shelke U, Patil B, Patwardhan S, Kini S.Use of ileum for complex ureteric reconstruction: assessment of long-term outcome, complications, and impact on renal function. Urol
Ann. 2018;10(4):369–74. https://doi.org/10.4103/UA.UA_5_18.
11. Boxer RJ, Fritzsche P, Skinner DG, Kaufman JJ, Belt E, Smith RB, Goodwin WE.Replacement
of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients.
J Urol. 1979;121(6):728–31. https://doi.org/10.1016/s0022- 5347(17)56972- 4.
12. Armatys S, Mellon M, Beck S, Koch M, Foster R, Bihrle R.Use of ileum as ureteral replacement in urological reconstruction. J Urol. 2009;181:177–81.
13. Naude JH.Buccal mucosal grafts in the treatment of ureteric lesions. BJU Int. 1999;83(7):751–4.
https://doi.org/10.1046/j.1464- 410x.1999.00019.x.
14. Kroep D, Loewen H, Klevecka V, Musch M. Treatment of long ureteric strictures
with buccal mucosal grafts. BJU Int. 2010;105(10):1452–5. https://doi.org/10.1111/
j.1464- 410X.2009.08994.x. Epub 2009 Oct 28
15. Badawy AA, Abolyosr A, Saleem MD, Abuzeid AM.Buccal mucosa graft for ureteral stricture substitution: initial experience. Urology. 2010;76(4):971–5.; discussion 975. https://doi.
org/10.1016/j.urology.2010.03.095.
16. Zhao LC, Yamaguchi Y, Bryk DJ, Adelstein SA, Stifelman MD.Robot-assisted ureteral reconstruction using buccal mucosa. Urology. 2015;86(3):634–8. https://doi.org/10.1016/j.urol-
ogy.2015.06.006. Epub 2015 Jun 26
17. Dal Moro F, Macchi V, Porzionato A, Mandato FG, De Caro R.RUG technique: replacement
of the ureter with gonadal vein. A cadaveric study. Minerva Urol Nefrol. 2019;71(1):85–91.
https://doi.org/10.23736/S0393- 2249.18.03261- 7. Epub 2018 Nov 7. PMID: 30421594
Renal Autotransplantation, Evolving
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Techniques, andTissue Engineering
18.1 Renal Autotransplantation
The rst renal autotransplantation was performed by Hardy in 1963 on a 64-year
man whose right ureter was severed during aortic aneurysm surgery. The patient had
rst a nephrostomy performed, and the ipsilateral kidney could not be sacriced
since the left kidney was hydronephrotic [1].
(a) Indications: These are not limited to ureteric damages. A large series of 108
patients showed that most of the patients (62%) underwent this procedure to
allow extracorporeal (back table) repair of complex renal artery lesions. Ureteric
indications were present in 25% of patients only, while malignancy (extracorporeal partial nephrectomy for bilateral renal cell carcinoma (RCC) or RCC in
solitary kidneys) was the third group of indications with 13% of patients [2]. The
ureteric indications can be summarized by damages or conditions not amenable
to the previously described techniques in solitary anatomic or functioning kidneys: trauma, iatrogenic injuries, atonic ureter, and urinary undiversion [2, 3].
(b) Technical aspects: Renal autotransplantation is performed according to the
same principles of donor nephrectomy and living donor allograft kidney transplantation. An open approach can be chosen through the traditional lombotomy,
or through a transperitoneal route. A transperitoneal laparoscopic technique can
also be utilized [4]. The kidney is harvested with a good length of vessels and
is immediately perfused and cooled in a back table, where further vascular
preparation is completed. The ureter is evaluated and the decision for the subsequent technique is made depending on the available ureteral length. A Gibson
incision is then made to create the kidney bed and skeletonize the recipient’s
vessels. The vascular anastomosis is made to the external iliac vessels using 6/0
Prolene and the continuity of the urinary tract is generally restored by ureteroneocystostomy, ureteroureterostomy, or pyeloureterostomy, if there is a persistent viable ureter proximally or distally [2, 3, 5]. However, when there is no
18
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_18
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18 Renal Autotransplantation, Evolving Techniques, andTissue Engineering
viable ureter at all (panureteral stricture of complete avulsion), the continuity
can be re-established through a pyelovesicostomy preferably through a Boari
ap [6, 7] (Figs.18.1, 18.2 and 18.3).
(c) Complications: With the exception of rejection, all classical complications of
renal transplantation can be excepted here: delayed graft function, vascular
thrombosis, urinary tract infection and sepsis, fever of unknown origin, surgical
site infection and abscess, urinoma, lymphocele, segmental infarction, pneumonia, artery stenosis, incisional hernia, pseudoaneurysm, anastomotic stricture,
graft infection, and chronic wound pain [4].
(d) Results: Excellent long-term outcome is observed with 87–92% having good
renal function after 1.5–14years [2, 3].
Fig. 18.1 A 50-year-old woman with a history of ureteral avulsion during ureteroscopy for
removal of proximal right ureteral stone. Consequently, she underwent a laparoscopic right ureteral re-implantation and stone removal. An antegrade nephrostogram performed 3months later
demonstrated hydronephrosis with retained contrast in the collecting system of the right kidney.
There is no contrast visualized within the right ureter. Two clips can be identied along the anatomical path of the right ureter. (From Pham NH etal. [7], Research and Reports in Urology 2021,
13, 733–737. Originally published by and used with permission from Dove Medical Press Ltd.)
18.1 Renal Autotransplantation
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Fig. 18.2 Abdomen and pelvis CT scan with intravenous contrast demonstrates two main renal
arteries. There is contralateral renal hypertrophy with preserved renal parenchyma on the ipsilateral side. (From Pham NH et al. [7], Research and Reports in Urology 2021, 13, 733–737.
Originally published by and used with permission from Dove Medical Press Ltd.)
153
Fig. 18.3 Abdomen and pelvis CT scan 6months after surgery (the kidney seems to be smaller
because the slices are not via the main axis of the kidney). (From Pham NH etal. [7], Research and
Reports in Urology 2021, 13, 733–737. Originally published by and used with permission from
Dove Medical Press Ltd.)
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18 Renal Autotransplantation, Evolving Techniques, andTissue Engineering
18.2 Evolving Techniques andTissue Engineering
1. Articial ureters: The concept of subcutaneous nephron-vesical bypass (SNVB)
was introduced more than two decades ago with promising results. The initial
results using a silicone-PTFE prosthesis in this minimally invasive procedure
showed encouraging results as a better alternative to permanent nephrostomy
drainage, rendering the patient bagless [8]. Newer prostheses are made of an
outer sheath of polyester over an inner silicone tube (Detour™, Mentor-Porgès)
with equally satisfactory results [9, 10].
The procedure starts with percutaneous insertion of the prosthesis under general anesthesia through an Amplatz sheath. A large-bore plastic hollow tube is
used to create a subcutaneous tunnel from the loin to the suprapubic region
(Fig.18.4a–c). After the passage of the prosthesis, the large bore tube is removed.
A Pfannenstiel incision is then performed to connect the prosthesis to the bladder
through a small cystotomy: the inner silicone tube is inserted into the bladder,
and the outer polytetrauoroethylene tube is xed onto the bladder wall with 4–0
Vicryl sutures.
2. Tissue engineering for ureteral substitutes: The progress of tissue engineering
for ureteral substitutes has faced many challenges related to the nature of the
ideal scaffold. Initially, acellular scaffolds such as small intestinal submucosa
(SIS), collagen, or Gore-Tex, were tried in animal models to regenerate smooth
muscle and urothelial cells, but the experience led to high rates of brosis.
Further trials incorporated cell seeding of acellular scaffolds, including various
candidates: primary smooth muscle or urothelial cells, mesenchymal or adiposederived stem cells. There is still a long way to success, but ongoing research
raises some hope [11].
References
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a
b
c
Fig. 18.4 (a) A large-bore plastic hollow tube is used to create a subcutaneous tunnel from the
loin to the suprapubic region. (b) The bladder is accessed through a Pfannenstiel rectus splitting
incision, and a small open cystotomy is performed following retrograde bladder distension. The
inner silicone tube, with a few small perforations, is inserted into the bladder, and the outer polytetrauoroethylene tube is secured onto the bladder wall with 4–0 Vicryl sutures. (c) Cystogram
conrming the patency of the stent with free reux of contrast from the bladder into the collecting
system with no leaks. (From Lloyd SN etal. [10], with permission from Elsevier)
References
1. Hardy JD. High ureteral injuries. Management by autotransplantation of the kidney.
JAMA. 1963;184:97–101. https://doi.org/10.1001/jama.1963.03700150051008.
2. Novick AC, Jackson CL, Straffon RA. The role of renal autotransplantation in complex urological reconstruction. J Urol. 1990;143(3):452–7. https://doi.org/10.1016/
s0022- 5347(17)39988- 3.
3. Bodie B, Novick AC, Rose M, Straffon RA. Long-term results with renal autotransplantation for ureteral replacement. J Urol. 1986;136(6):1187–9. https://doi.org/10.1016/
s0022- 5347(17)45278- 5.
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