ABSTRACT
For a long time, urological surgeons have been troubled by the treatment of long proximal and mid ureteral stricture, and the commonly used ileal ureteral substitution and autotransplantation have certain shortcomings. In recent years, the development of autologous graft technique has brought a new hope for these patients. The commonly used autologous grafts or flaps include oral mucosa, intestinal tissue, urogenital tissue, etc. The feasibility and safety of autologous graft technique have been preliminarily verified, but each kind of graft or flap has different advantages and disadvantages. The research progress of autologous grafts or flaps ureteroplasty in this article was reviewed and the related problems of this technique were discussed.
ABSTRACT
Ureteral calculi after lingual mucosal ureteral reconstruction are rare. In this paper, we reported a case of a male patient who had undergone robotic-assisted laparoscopic lingual mucosal right ureteroplasty. Calculi were found in the right reconstructed ureteral segment 4 months after surgery. Then the patient underwent transurethral ureteroscopic holmium laser lithotripsy combined with a stone retrieval basket, and postoperative urological CT showed no residual calculi in the right ureter. No recurrence of right ureteral calculi or complications were observed during 20 months of follow-up.
ABSTRACT
Objective:To summarize and analyze the current application status of oral mucosal graft (OMG) technique in the repair of ureteral strictures in China, and clarify the feasibility, safety and effectiveness of this technique.Methods:The 175 patients who underwent repair of ureteral stricture using oral mucosal patches from June 2015 to February 2022 were etrospectively analyzed in 14 medical centers in China, including 49 cases in Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 32 cases in Affiliated Seventh Medical Center of PLA General Hospital, 3 cases in The Second Hospital of Anhui Medical University, 6 cases in The First Affiliated Hospital of Zhengzhou University, 56 cases in Peking University First Hospital, 3 cases in Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 cases in Shanghai Sixth People' s Hospital, 4 cases in General Hospital of Estern Theater Command, 4 cases in Lanzhou University Second Hospital, 2 cases in Guizhou Province People 's Hospital, 2 cases in Peking University People' s Hospital, 5 cases in Jinzhou First People's Hospital, 5 cases in The First Affiliated Hospital of Wannan Medical College, 1 case in Shandong Provincial Hospital. In this study, 127 patients (72.6%) used lingual mucosal patches, 32(18.3%) labial mucosa, and 16(9.1%) buccal mucosa. The surgical approach for OMG ureteral reconstruction was mainly minimally invasive, with robot-assisted laparoscopy in 84 patients (48.0%), traditional laparoscopic surgery in 87 patients (49.7%), and open surgery in only 4 patients (2.3%). There were 133 males and 42 females with an average age of (35.0±17.2) years. The mean body mass index (BMI) and stenosis length were (23.1±4.1) kg/m 2 and (4.7±1.8) cm, respectively. The stricture was located in the left ureter in 116 patients, right ureter in 58 case and bilateral ureter in 1 case. The most common causes of ureteral stricture were endoscopic surgery in 88(50.3%)patients, congenital stricture in 55(31.4%)patients, failed ureteroplasty in 29(16.6%)patients, history of extracorporeal shock wave lithotripsy in 13(7.4%)patients, radiotherapy history in 3(1.7%)patients and other causes in 6(3.4%)patients. Strictures were mainly located in the upper ureter, accounting for 61.7% (108/175 cases), followed by 36.0% (63/175) at the ureteropelvic junction and 2.3%(4/175)in the middle ureter. According to the surgical methods, the patients were divided into robot-assisted laparoscopic surgery group ( n=84), traditional laparoscopic surgery group ( n=87)and open surgery group ( n=4). Subgroup analysis of patients in robot-assisted laparoscopic and traditional laparoscopic surgery groups was performed. There were no significant difference in preoperative data between the two groups except for age (32.0±18.3) years vs.(37.0±15.9)years, P=0.040], BMI[(22.5±4.3)kg/m 2 vs. (23.7±3.6)kg/m 2, P=0.028], and etiology of stenosis [endoscopic injury, 34(40.5%) vs. 53(60.9%), P=0.012]. Preoperative hydronephrosis and stricture length were assessed by CTU and ureterography. Ureterography 7-9 weeks after surgery showed patency of the reconstructed segment, or no recurrence of hydronephrosis was judged as success. Evaluate the operation method, operation time, success rate, length of OMG in repairing ureteral stricture between laparoscopic and robot-assisted groups. Results:The overall success rate of oral mucosal graft repair surgery reached 97.7%(171/175). The success rate of ureteral reconstruction in the two groups were 96.4%(81/84)and 98.9%(86/87), respectively ( P=0.351), and the difference was not statistically significant. There was no significant difference for operation time, intraoperative blood loss, and mean oral mucosal length between the robotic and laparoscopic groups[(244.7±85.8) min and (222.7±83.5)min ( P=0.116), (58.9±38.6) ml and (68.4±45.5) ml ( P=0.217), (5.0±2.0) cm and (4.6±1.5) cm ( P=0.350)], respectively.Postoperative complications were reported in 23 (13.1%) patients, such as fever, urinary leakage, lymphatic leakage, infection, but only 2 (1.4%) cases patients had complications of Clavien-Dindo score ≥ Ⅲ. The two patients developed urinary stricture after surgery with failed conservative treatment, and no urinary stricture occurred following endoscopic treatment.The short-term (three months after surgery)incidence of complications in the site where the oral mucosa was taken, such as difficulty in opening mouth, pain, and swelling, was 12.0% (21/175), and there was no significant difference for oral complications between patients harvesting different length of mucosal graft. Conclusions:Ureteroplasty with oral mucosal graft is a safe, feasible and reliable technique for ureteral reconstruction. At present, minimally invasive technology is the main surgical approach for ureteroplasty, and there is no significant difference in operation time and success rate between robotic surgery and laparoscopic surgery.
ABSTRACT
Objective:To explore optimum surgical treatment of ureteral strictures after ureteroscopic holmium laser lithotripsy.Methods:The clinical data of 113 patients with ureteral stricture after ureteroscopic holmium laser lithotripsy from December 2014 to December 2019 were analyzed retrospectively. Of all the patients, there were 73 males and 40 females(aged from 31 to 68) with the mean age of 49 years. The mean length of ureteral stricture was 15mm (from 5mm to 25mm). The mean time since the last holmium laser lithotripsy was 6 months (from 3months to 10 months). According to the different treatment of stenosis, 113 patients were divided into endourological treatment group (34 patients) and reconstruction group(79 patients). According to the different surgical methods, endourological treatment group was divided into ureteral balloon dilatation (18 patients) and ureterotomy (16 patients). Reconstruction group was divided into laparoscopic surgery and open surgery, whose were ureteral stenosis resection and anastomosis. Patients were followed up closely postoperatively. Therapeutic success was defined as disappeared hydronephrosis, and unobstructed anastomosis. Success rate, operation time, postoperative changes of hemoglobin, hospital stay and the incidence of postoperative complications were measured.Results:The follow-up time ranged from 5 months to 53 months, with a median time of 18 months. There was no significant difference in age, sex, BMI, location of ureteral stricture, side of stricture and degree of hydronephrosis between endourological treatment group and reconstruction group( P>0.05). The length of ureteral stricture in reconstruction group was significantly longer than that in endourological treatment group (10.3±4.2 mm vs. 17.2±7.8mm, P<0.001). Although the operation time, postoperative changes of hemoglobin, hospital stay and the incidence of postoperative complications were lower in the endourological treatment group compared to reconstruction group ( P<0.001), the overall success rate of the reconstruction operation was significantly higher than that in endourological treatment group (96.2% vs. 61.8%, P<0.001). Furthermore, there was no significant difference in the success rate between laparoscopic surgery group and open surgery group (95.3% vs.97.2%, P<0.05), and there was no significant difference between the balloon dilatation group and the stenosis internal ureterotomy group (66.7% vs.56.3%, P<0.05).113 cases were followed up for an average of 18 (5-53) months. Conclusions:For the treatment of ureteral stricture after ureteroscopic holmium laser lithotripsy, the success rate of reconstruction group (laparoscopic surgery and open surgery)was significantly higher than that of endourological surgery (balloon dilatation and internal ureterotomy). Reconstruction surgery is the optimum surgical treatment to treat ureteral stricture after ureteroscopic holmium laser lithotripsy.