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Application of the “Yang-Monti principle” in children with iatrogenic ureteral injuries
Abstract
BACKGROUND
Iatrogenic ureteral injuries in children are rare, due to its retroperitoneal position. The Yang -Monti ileal substitution serves as a good surgical option in such injuries associated with long segment defects of the ureter.
OBJECTIVES
To review our experience using the Yang Monti principle of ileal ureter substitution in children with long segment ureteric defects and analyse its intermediate term outcomes.
STUDY DESIGN
This was a prospective study, conducted from 2014-2019. All children with iatrogenic ureteral injuries with delayed presentations, undergoing the Yang Monti principle of ileal ureter substitution, were included. These injuries were divided into upper, mid, and distal ureteral injuries and were diagnosed based on a standardized protocol. At follow up, findings of the CT urogram, functional isotope renogram, and renal functions were the key points monitored. The demographic, clinical profile, operative, post-operative complications and follow up data were collated and analyzed.
RESULTS
22 children were diagnosed with iatrogenic ureteral injuries. Of these, 14 children with delayed presentations underwent the Yang Monti principle of ileal ureter substitution. The primary pathology was gangrenous appendicitis (9 cases), calculus cholecystitis (3 cases) and torsion ovary (2 cases). Laparoscopic procedures were the commonest approach for the injury (10). The average age was 11.5 years, with a male predominance. The right ureter was affected in 12 cases. The average time to detection was 7 days. All children underwent an ultrasound guided nephrostomy tube insertion at presentation and the mid ureter (9) was most affected. The mean length of ureteric injury was 3.75 cm. Intra operatively, one ileal segment (2), two ileal segments (11) and three ileal segments (1) were used according to the length of the ureteric defect. Complications were urinary tract infections (2), adhesions (3) and leak (2) which were conservatively managed with no redo surgeries. The median follow up period was 4 years. At follow up CT urogram and isotope diuretic renogram were normal, with preserved renal functions and no metabolic complications in all.
DISCUSSION & CONCLUSION
In children associated with iatrogenic ureteral injuries of long lengths, the “Yang Monti ileal substitution” serves as a good and simple option with lesser complications permitting the preservation of the renal function at follow up.
... Nonetheless, ileal substitutes have some inherent drawbacks, such as large lumen, mucus secretion and metabolite absorption, which usually lead to related complications, such as metabolic acidosis, electrolyte disorders and calculi or mucus obstruction (17). To address these complications of ileal-ureteral replacement surgery, improved techniques have been proposed, including tapered bowel grafts, Yang-Monti technique, and ileal serotype myotubes, but only part of the issues are solved (18,19). To comprehensively resolve these issues, we have innovated a technique that involves remodeling the ileum segment by reducing its diameter and stripping the mucosa to minimize mucosal secretion and absorption. ...
... Nevertheless, conventional ileal-ureteral replacement surgery may lead to postoperative complications such as vesicoureteral reflux, metabolic acidosis, electrolyte imbalances, and calculi or mucus obstruction, attributable to mucosal secretion, waste absorption, and the large luminal diameter of the ileum (17). In order to overcome the problems caused by the large size of the ileal lumen, methods such as tapered intestinal grafts, Yang-Monti surgery have been proposed to reduce the area of the ileal lumen by cutting out the intestinal lumen and reconfiguring the bowel segments, which reduce mucus secretion but do not eliminate mucus secretion (18,19). Attempts to mitigate the complications caused by the intrinsic absorption and secretion function of the ileal mucosa, it has been proposed to use the ileal serotype myotubes for ureteral replacement, and although the secretion and absorption of the ileum are greatly reduced, severe atrophy of the ileum occurs (24). ...
Radical nephroureterectomy (RNU) with bladder sleeve resection is currently the gold standard for the treatment of high-risk ureteral cancer. However, in certain special cases, such as bilateral upper tract urothelial carcinoma(UTUC), isolated and chronic kidney disease, and low-risk UTUC, kidney sparing surgery(KSS) may represent a viable alternative, though it remains highly challenging. The current KSS options for ureteral cancer include endoscopic treatment, segmental ureterectomy, total ureterectomy combined with kidney autotransplantation and nephrostomy. These methods are associated with significant disadvantages, such as a high risk of recurrence and vascular-related complications. On the basis of previous studies, we creatively proposed a surgical method of long segment ureterectomy with tapered demucosalized ileum(TDI) replacement of the ureter for ureteral cancer, and successfully performed this operation on a patient with ureteral cancer. The follow-up results showed that this surgical method provides good tumor control while preserving the patient’s renal function and improves the inherent defect of the ileal replacement of the ureter, which is a feasible choice for patients with ureteral cancer and kidney preservation.
... Ureteral iatrogenic thermal injury is one of the most common causes of ureteral strictures and renal fibrosis (7). At present, the conventional treatments of ureteral stricture usually involve dilatation of the lumen (14-16), reconstructive anastomosis (16), or the placement of grafts, such as ileal ureter, appendix ureter, lingual mucosal graft and buccal mucosa (17)(18)(19)(20). Many patients continue to have poor treatment results and may need additional surgery to relieve recurrent strictures, urine leakage and inflammatory response (21,22). ...
Background
Ureteral thermal injury (UTI) occurs when the ureter is exposed to high temperatures during surgical procedures, leading to tissue damage and ureteral stricture. Dexamethasone (DEX) has been widely used to treat a variety of diseases for its anti-inflammatory and immunosuppressant effects. However, its role in treating UTI remains unclear. The aim of this study was to determine the efficacy of treatment in mice with UTI.
Methods
Thirty C57BL/6J mice were randomly divided into three groups (n=10 per group): (I) control group, (II) UTI group, (III) UTI + DEX group. UTI mouse models were constructed using a fast-pack pro-obturation pack handpiece instrument, and the therapeutic effect of DEX (2.5 mg/kg) on UTI was investigated via intraperitoneal injection for two weeks. Pathological changes in the ureter, renal function, extracellular matrix protein deposition, and inflammatory markers in the kidneys were evaluated in mouse models.
Results
Ureteral histopathological changes were more severe in the UTI group than in the control group; however, DEX treatment alleviated these changes to a certain extent. Mice in the UTI group exhibited elevated renal function. Although DEX alleviated renal function deterioration, the difference was not statistically significant. Moreover, in comparison to the control group, kidney samples from the mice in the UTI group revealed increased messenger RNA (mRNA) levels of inflammation markers, indicating a progressive inflammation response, while DEX significantly reversed interleukin-1β (IL-1β) expression at the protein level. Additionally, fibrosis-related markers were markedly increased in the kidneys of UTI mice. These findings were significantly reversed by DEX treatment, revealing its anti-inflammatory and anti-fibrotic activities.
Conclusions
DEX reduces the severity of renal fibrosis and inflammation after UTI and exerts a significant renal protective effect.
... However, there are some intrinsic drawbacks of ileal substitutes, such as large tract lumen, mucous secretion, and metabolite absorption, which usually lead to pertinent complications like uroschesis, metabolic acidosis, electrolyte imbalance, and mucus obstruction [5]. Several modified techniques are proposed, including tapering the bowel graft, intestinal Onlay flap, and the Yong-Monti procedure, but only part of the issues is solved [6,7]. ...
Purpose
Repair of long-segment ureteral defect (LSUD) is challenging. Currently available procedures carry some potential complications. We modified the ileal graft by tapering the wall and stripping the mucosa to combat associated pitfalls and first reported the medium-term outcomes of 4 patients.
Material and methods
From September 2019 to October 2020, tapered demucosalized ileum (TDI) was used for LSUD reconstruction in 4 patients on the right (2 males and 2 females). Two patients were with panureteral avulsion and 2 with high-risk urothelial carcinoma in the distal ureter. TDI was made by tapering 1/2–2/3 of the antimesenteric ileal wall and stripping the mucosa with a blunt/blunt operating scissor. Follow-up modalities included serum creatinine, electrolytes, ultrasonography, CT urogram, renal scintigraphy, and ureteroscopy.
Results
Mean operation time was 443 min (range 360–550) and blood loss was negligible. The mean follow-up period was 29 months (range 23–36). Vesicoureteral reflux and related pyelonephritis occurred in 1 patient, necessitating a repair operation (Clavien-Dindo grade IIIb). No strictures, obstructions, metabolic disorders, or electrolyte imbalances were observed in the remaining patients. In carcinoma patients, ureteroscopy in month 18 post-operation revealed ileal mucosal regrowth in the form of dwarf isolated islands. All renal units maintained adequate drainage and function during the follow-up.
Conclusions
Ileal wall tapering and mucosa stripping confined to the muscularis mucosae level will not result in shrinkage, fibrosis, or stricture formation of the ileal ureter. The present work provides evidence for further application of TDI in the replacement of LSUD in patients.
... Benign distal ureteral strictures (DUS) in pediatrics are usually caused by urolithiasis, iatrogenic injury, infection, or simply because of congenital developmental abnormalities [1][2][3]. Ureteral obstruction due to stricture formation can lead to significant morbidity, such as chronic pain, infection, hydronephrosis and eventual irreversible renal injury, while posing a challenging disease entity for urologists due to the wide spectrum of treatment modalities required [4]. ...
Objective:
Robot-assisted laparoscopic ureteral reimplantation (RALUR) and trans-umbilical multiport laparoscopic ureteral reimplantation (TMLUR) are both minimally invasive procedures for benign distal ureteral stricture (DUS). However, TMLUR has rarely been reported in published research, thus the difference in mid-term outcome of these two procedures warrants investigation.
Methods:
Patients who underwent RALUR or TMLUR for pediatric DUS from April 2017 to November 2020 at our institution were retrospectively analyzed and 56 patients were included in this retrospective comparison. Demographic characteristics, perioperative data and follow-up results were collected and analyzed in RALUR and TALUR groups.
Results:
RALUR and TMLUR were successfully performed in children aged from 12.0 to 142.0 months, without conversion to open ureteral reimplantation. RALUR took shorter operative time than TMLUR (p = 0.005) with less blood loss (p = 0.001). Meanwhile, patients receiving RALUR encountered a greater financial burden (p < 0.001) with less cosmetic satisfaction than TMLUR. The mean mid-term follow-up time for RALUR and TMLUR was 18.29 months and 24.64 months, respectively. Mid-term follow-up data showed that DUS was relieved with improved renal function after surgery in both groups, with no significant difference.
Conclusions:
RALUR and TMLUR are both safe and efficient for DUS treatment and achieve comparable mid-term outcomes in children. RALUR can reduce operative time and operative blood loss benefiting from its prominent technical superiority, but may currently bring about greater financial burden, with cosmetic satisfaction remaining to be improved.
BACKGROUND: Currently autologic reconstructive surgery in the most significant approach in surgical therapy for enteral insufficiency due to short bowel syndrome. Possible application for short bowel surgery of widespread urologic Yang–Monti–Casale technique is an issue of interest. The technique includes cutting of small bowel segment antimesenteric border with a figured incision and second tubularization at an angle to the mesenterium fixation line which results in elongation and narrowing of the bowel segment. AIM: To determine geometric requirements of small bowel segment for Yang–Monti–Casale procedure to treat short bowel syndrome. MATERIALS AND METHODS: A mathematical model for resulting bowel segment after Yang–Monti–Casale procedure geometry dependency on original bowel length and width was observed. An object of the analysis was a cylindrical surface. Modeling assumptions were that the suface had no thickness and was unstretchable. Only surfaces with length more than width were taken into account. For establishing the dependency of bowel segment after procedure on original parameters a net of cutted with figured incise according the Yang–Monti–Casale technique cylindrical surface was considered. Bowel segment resulting width was computed as a half of the distance between the points that matched during the enteroplasty. Resulting length was computed as the ratio of the surface area and the resulting width. RESULTS: Yang–Monti–Casale procedure provides significant bowel segment elongation and narrowing if original bowel length to width ratio is not more than 2,5:1. The target bowel width 20 ± 2 mm is achieveable if original length is 60–80 mm and original width is 30–65 mm. CONCLUSIONS: Yang–Monti–Casale procedure may be considered as auxiliary technique for short bowel syndrome requiring bowel segment length 60–80 mm, width 30–65 mm, and length to width ratio not more than 2,5:1.
Ureteric injury is rare in gynecological practice. The introduction of laparoscopy to gynecologic surgery has allowed for newer innovations, advancements, and also new challenges in the field. As the complexity of laparoscopically approached gynecologic cases continues to increase, it is imperative for surgeons to be aware of the risk of ureteral injury. Although rare, ureteral complications of laparoscopic gynecologic surgery are quite morbid and may have serious implications in relation to litigations. The incidence of ureteric injury varies between 0.1% and 30%, depending on the type of surgery. Prevention can be attempted by preoperative and intraoperative precautions, although the effectiveness of these measures has not been fully evaluated. Diagnosis of ureteric injury may be made intraoperatively, but 70% are diagnosed postoperatively. Management depends on the timing of diagnosis, the etiology, the length and location of the injury, the extent of the causative operation, and the condition of the woman. In this article, we have reviewed the incidence, etiology, preventive strategies, diagnosis, and management of ureteric injury. Knowledge about their prevention, diagnosis, and management is of utmost importance.
Purpose
Ureteric substitution using the Yang-Monti principle was reported as a modification of simple ileal ureter replacement. In this study, we evaluate its safety, surgical outcome and impact on renal function.
Materials and Methods
Sixteen patients underwent ileal ureter replacement using the Yang-Monti principle to overcome long ureteric defects. Exclusion criteria included patients with elevated serum creatinine > 1.8 mg/dL, inflammatory bowel syndrome or irradiated bowel. Antireflux implantation into the bladder was performed in 12 patients while 4 patients with intact healthy lower ureters underwent distal ileal-ureteral anastomosis. Follow-up protocol was carried out for up to 3 years in 9 patients.
Results
No intra-operative or postoperative mortality or significant complications occurred. There were minor complications in the form of urinary leakage that necessitated prolonged ureteric stenting in one patient, superficial wound infection in another one and 3 patients developed treatable urinary tract infection without late harmful effects. During follow up, no excess mucus production or metabolic abnormalities were encountered. All patients had preserved renal function (improved in 13 patients and stabilized in 3) without any evidence of urinary obstruction.
Conclusions
The reconfigured ileal segment for ureteric substitution is a safe technique with an excellent outcome. It uses short ileal segments for reconstruction of an ileal tube of adequate length and optimal caliber that permits easy antireflux implantation into the bladder so it is not associated with excess mucus production or metabolic abnormalities and offers a durable preservation of renal function without urinary obstruction.
As cesarean sections become a more common mode of delivery, they have become the most likely cause of vesicouterine fistula formation. Vesicouterine fistulas (VUF) are a pathological and uncommon connection between the uterus and the bladder. Patients with VUF may have various clinical presentations. The main symptoms are urinary incontinence, which may be associated with hematuria. Vesicouterine fistulas are usually associated with psychological distress and have a negative effect on quality of life. The accurate and early diagnosis of VUF can be difficult. There are multiple ways to investigate VUF and several examinations may be required to confirm the diagnosis; these examinations may include a cystoscopy, a retrograde cystography, methylene blue test, and a computed tomography scan. We report a case of vesicouterine fistula.
Purpose:
Ureteric substitution using the Yang-Monti principle was reported as a modification of simple ileal ureter replacement. In this study, we evaluate its safety, surgical outcome and impact on renal function.
Materials and methods:
Sixteen patients underwent ileal ureter replacement using the Yang-Monti principle to overcome long ureteric defects. Exclusion criteria included patients with elevated serum creatinine > 1.8 mg/dL, inflammatory bowel syndrome or irradiated bowel. Antireflux implantation into the bladder was performed in 12 patients while 4 patients with intact healthy lower ureters underwent distal ileal-ureteral anastomosis. Follow-up protocol was carried out for up to 3 years in 9 patients.
Results:
No intra-operative or postoperative mortality or significant complications occurred. There were minor complications in the form of urinary leakage that necessitated prolonged ureteric stenting in one patient, superficial wound infection in another one and 3 patients developed treatable urinary tract infection without late harmful effects. During follow-up, no excess mucus production or metabolic abnormalities were encountered. All patients had preserved renal function (improved in 13 patients and stabilized in 3) without any evidence of urinary obstruction.
Conclusions:
The reconfigured ileal segment for ureteric substitution is a safe technique with an excellent outcome. It uses short ileal segments for reconstruction of an ileal tube of adequate length and optimal caliber that permits easy antireflux implantation into the bladder so it is not associated with excess mucus production or metabolic abnormalities and offers a durable preservation of renal function without urinary obstruction.
Background:
Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation.
Objective:
To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers.
Design, setting, and participants:
This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016.
Surgical procedure:
RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side.
Outcome measurements and statistical analysis:
Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.
Results and limitations:
The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%.
Conclusions:
RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures.
Patient summary:
We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.
Motility of the gastrointestinal tract has two major effects: to facilitate the absorption of nutrients and to maintain the aboral propagation of chyme and indigestible material. Both retrograde and normograde flow are required to optimize the absorption of nutrients. Retrograde flow most likely occurs intermittently over short distances to aid in mixing of ingesta and exposing nutrients to the mucosa for absorption. Although little work has been done in the horse to investigate the control of these mixing patterns, most likely there is feedback from both absorption of nutrients and afferent input by mucosal sensory receptors that control these mixing motor patterns in a similar fashion to other species. Since alteration of the normal aboral movement of ingesta causes immediate clinical consequences, the majority of motility investigation in the horse has centered around the control of aboral propagation of ingesta throughout the gastrointestinal tract and the pathophysiology associated with delayed aboral propagation. This chapter reviews the basic mechanisms controlling normal motility patterns, reviews current thoughts as to the mechanisms underlying the pathophysiology of motility disturbances, in particular postoperative ileus, and reviews prokinetics that are available to the equine practitioner.
Ureteric substitution using the Yang-Monti principle was reported as a modification of simple ileal ureter replacement. During April 2013 to June in 2015, 2 patients underwent ileal ureteral substitution using a reconfigured ileal segment of Yang Monti principle in our clinical center. Some slight modifications were made and then follow-up were carried out up to 12 months. For these 2 cases, no significant intra/post-operative complications occurred. In 1 year follow up, serum creatinine (Scr) and blood urea nitrogen (BUN) of both patients decreased to normal. Glomerular filtration rate (GFR), renogram and pyelogram showed a stable split renal function. To better understand the Yang-Monti principle and potential risks and complications, we conduct an systemic review by searching PubMed, Google Scholar and the Cochrane Library database from January 1996 through June 2016. 10 out of 644 publications were identified, which included 269 patients from cohort studies. The most usual indications for Yang-monti therapy were iatrogenic stricture and retroperitoneal fibrosis. Infection and ileus were indicated as the main short time postoperative complications while the fistula and re-strictures happened in long-term. In general, we believe Yang-Monti Principle is a safer and efficient technique for clinical partial and complete ureteral defects if patients and potential risks could be well prepared.
Partial Substitution Of The Ureter Using A Short Segment Of The Ileum Following The Monti ProcedureThe partial substitution of the ureter using a pediculated segment of the ileum is a technique used to re-establish ureteral transit and preserve the renal unit, following the resection of extensive ureteral lesions. Standard surgical procedure for an ileoureteroplasty consists of isolating an ileal duct of equal or greater length than the ureteral defect and interposing it in the urinary tract in an isoperistaltic direction.Monti described a surgical technique that allows for the creation of catheterizable stomas in continent urinary diversions, using the Mitrofanoff principle. These passageways were created from one or several 2.5 cm long ileal sections by means of their detubulization and transverse retubulization.The clinical case study presented here corresponds to a 57 year-old male with a history of ureteral lithiasis, with a 9 cm stenosis of the sacroiliac ureter. He was treated surgically by means of a resection of the stenotic ureter and the interposition of a duct made up of 2.5 ileal sections, treated in accordance with the Monti procedure. Since this operation, the patient’s metabolic state has been completely normal. Morphological and functional results have also proved totally satisfactory, as the use of image techniques have shown.
We present a report of a delayed ureteral injury after a laparoscopic cholecystectomy. The patient presented with one episode of gross hematuria after surgery. He was treated with ureteral stent drainage and did well with no long-term sequelae.
A case of right ureteric damage in a 7-year-old boy who underwent appendicectomy is described. Ultrasound, magnetic resonance urography, nephrostogram, and retrograde ureterogram were helpful in defining the nature and extent of the lesion. He underwent staged procedures of percutaneous nephrostomy, elective resection and reconstruction of midureteral segment, and subsequent removal of double J stent and made a smooth recovery. Ureteric injuries, although rare, have serious consequences. A high index of suspicion is essential for diagnosis. Management is influenced by site, type, extent, and mechanism of injury, as well as the timing of detection.
Iatrogenic ureteral injury in children is a rare occurrence, with sparse literature available regarding optimal repair techniques. We reviewed our experience in the management of iatrogenic pediatric ureteral injuries, particularly with respect to initial versus delayed diagnoses.
All pediatric iatrogenic ureteral injuries repaired by a single surgeon during 1986-2007 were reviewed.
Ten injuries were repaired over 20 years. Median patient age was 12 years. Injuries occurred during five open tumor resections, three laparoscopic procedures and two ureteroscopies. Diagnosis was immediate in four patients. Median ureteral defect length was 4 cm (range 2-5). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. Diagnosis was delayed in six patients by a median of 21 days. Five children (83%) were managed by temporary percutaneous nephrostomy tube and one (17%) by ureteral stent. Delayed repair was performed 1-3 months later. In the patients with laparoscopic or ureteroscopic injuries the median ureteral defect length was 4 cm (range 3-6). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. One child had a proximal ureteral defect 8 cm long; delayed ileal ureter was performed with good results 4 years postoperatively.
Pediatric iatrogenic ureteral injuries are rare and may be repaired by both immediate and delayed techniques as circumstances demand. Standard techniques used in the adult population may be employed in children with the expectation of good long-term results.
During the last 25 years 100 patients have been subjected to transureteroureterostomy. In 2 cases postoperative death was attributable to other pathologic processes. We treated 94 donor units successfully in this manner. An additional 2 units, normal for several years after transureteroureterostomy, had periureteral fibrosis and stricture owing to the inferior mesenteric artery syndrome and required another definitive surgical procedure. Ninety-seven recipient kidneys remained normal after the procedure.
A total of 7 patients underwent cystectomy due to bladder malignancy and the ileum was used for lower urinary tract reconstruction (5 underwent bladder substitutions, 1 an internal ileal reservoir and 1 ileal conduit diversion). Antireflux mechanisms were created by submucosally tunneled ureters and in 1 case the continent mechanism was created by a submucosally tunneled ileal tube. In all cases the Yang needle was used, which consists of a needle portion and a forceps portion. The selected position of the ileum for ureteral and ileal tube implantation is injected with normal saline submucosally to form a wheal. The Yang needle is introduced submucosally, guided under the wheal for a certain distance and then directed through the ileal wall. Smooth dilation of the tunnel is achieved with the dilated portion of the needle without laceration of the mucosa. The needle portion is then removed. The ureter or ileal tube is grasped by the forceps portion of the needle and brought through the tunnel to the mucosal side of the ileal plate, followed by mucosa-to-mucosa anastomosis. For all 14 ureteral implantations only 1 ureter had reflux on postoperative radiographic studies and only 1 of 4 hydroureters remained. No additional obstructive lesions or pyelonephritis was noted postoperatively. The patient whose continent mechanism is formed by the submucosal tunneled ileal tube method is continent and free of an appliance. The Yang needle tunneling technique may be a choice in the creation of antireflux and continent mechanisms.
Presently, urinary diversion with continence mechanisms based on the Mitrofanoff principle is frequently used. For its construction, the critical issue is related to the choice of efferent conduit; the most widely used are the appendix and the tapered ileum. Here, we present two alternative techniques for construction of tubes applicable to the same function. Ten dogs underwent operations with two different types of tubes constructed through transversal tubularization of small segments of ileum. These tubes were implanted in the bladder. The dogs were followed up for 30 days, during which all were continent. Their tubes were easily catheterized. The techniques described met the criteria defined for an efferent tube to be used according to the Mitrofanoff principle.
Pelvic surgery is the most common cause of iatrogenic ureteral injury. The majority of patients with ureteral injuries have no identifiable predisposing risk factors. A simple maneuver that has been taught successfully at our institution that facilitates the identification of the ureter is described. When injury is discovered during surgery, correction of the injury can be repaired with minimal risk of long-term sequelae. Postoperatively, patients with ureteral injury typically present with costovertebral angle tenderness, ileus, fever, and flank pain with a minimal rise in serum creatinine. To prevent ureteral injuries, the surgeon must have a thorough knowledge of the location of the ureter during various pelvic procedures and the specific regions where it is most susceptible to injury.
We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting.
From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data.
In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent.
Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.
Ileal and intestinal ureteral replacement remains a useful procedure for complex ureteral reconstruction. We examined the long-term safety and efficacy of this procedure, especially in regard to maintaining preoperative renal function and the avoidance of major complications.
A total of 56 patients underwent intestinal ureteral substitution at our institution between 1979 and 2003, including 52 with an ileal ureteral replacement, 2 with colonic replacement alone and 2 with bilateral ureteral replacement, necessitating ileum and colon for 1 ureter each. The factors reviewed were indications for surgery, type of ureteral replacement, and the presence and type of complications. Followup data included excretory urogram or equivalent imaging results, and measurement of serum chloride, bicarbonate and creatinine before and after the procedure.
Overall the complication rate remained low. Mean followup was 6.04 years (median 3.2). Most postoperative complications, which occurred in 10 patients (17.9%), were minor in nature, including pyelonephritis, fever of unknown origin, neuroma, hernia, recurrent urolithiasis and deep venous thrombosis. Major complications occurred in 6 patients (10.5%), including anastomotic stricture, ileal graft obstruction, wound dehiscence and chronic renal failure. Overall patients did not experience worsening renal function after the procedure with equivalent median creatinine before and after the procedure (1.0 mg/dl).
During long-term followup major complications are rare and renal function remains preserved. Ileal and intestinal ureteral substitution remains a safe and efficacious procedure in patients with complex and difficult ureteral issues not amenable to more conservative measures.
Both iatrogenic and traumatic ureteral injuries are rare. However, a high index of suspicion is warranted for ureteral injuries because ureteral injuries are associated with increased morbidity. The urologist should be familiar with several methods for identifying ureteral injuries and should make evaluations tailored to the clinical situation. Most ureteral injuries are short transections and can be repaired with debridement and ureteroureterostomy in the proximal and mid-ureter or ureteroneocystostomy in the distal ureter.
Sustitución parcial del uréter por un segmento de íleon tratado según el procedimiento de Monti
- Rodríguez Alonso