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1.
Urology ; 188: 138-143, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38657870

RESUMO

OBJECTIVE: To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. METHODS: We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed. RESULTS: One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis. CONCLUSION: Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.


Assuntos
Íleo , Complicações Pós-Operatórias , Ureter , Obstrução Ureteral , Humanos , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Íleo/transplante , Íleo/cirurgia , Ureter/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Obstrução Ureteral/cirurgia , Obstrução Ureteral/etiologia , Adulto , Rim/cirurgia , Fatores de Tempo , Idoso , Seguimentos , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/efeitos adversos
2.
Urology ; 177: 184-188, 2023 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-37076019

RESUMO

OBJECTIVE: To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions. METHODS: A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications. RESULTS: Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy. CONCLUSION: Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.


Assuntos
Ureter , Neoplasias da Bexiga Urinária , Derivação Urinária , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Ureter/cirurgia , Constrição Patológica/etiologia , Creatinina , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos , Íleo/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Estudos Retrospectivos
3.
J Endourol ; 37(2): 151-156, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-36254381

RESUMO

Objective: Management of symptomatic ureteropelvic junction (UPJ) obstruction with hydronephrosis and discordant Tc-99 mercaptoacetyltriglycine (MAG-3) renal scintigraphy is challenging. In this study we describe long-term outcomes of patients who underwent robot-assisted laparoscopic pyeloplasty for the correction of symptomatic UPJ obstruction with discordant preoperative Tc-99m MAG-3 renal scintigraphy. Methods: Patients undergoing robot-assisted laparoscopic pyeloplasty for symptomatic UPJ obstruction at a single academic center from 2009 to 2021 were retrospectively reviewed. Patients were categorized into three groups with varying degrees of obstruction based on preoperative MAG-3 imaging: Group 1: no obstruction (Lasix T1/2 clearance <10 minutes), Group 2: equivocal obstruction (Lasix T1/2 clearance 10-20 minutes), and Group 3: obstruction (Lasix T1/2 clearance >20 minutes. Pyeloplasty success was defined as resolution of symptoms and improvement/stable computed tomography (CT) imaging or MAG-3 scintigraphy. Failure was defined as persistence of symptoms with either obstruction on functional imaging, worsening hydronephrosis, or subsequent intervention. Results: A total of 125 cases were identified, with a median patient age of 35 years. Dismembered pyeloplasty technique was performed in 98.4% of cases. Median preoperative split renal function on MAG-3 scintigraphy was the only statistically significant (p = 0.003) difference in preoperative characteristics between the three groups. There were 15 postoperative complications, with a rate of Clavien-Dindo grade 3 or higher complications of 4.8%. Overall pyeloplasty success was 92.8%, with success rates of 100% (15/15) and 97% (32/33) in the no obstruction and equivocal obstruction groups, respectively. Median time to pyeloplasty failure was 20.4 months. Conclusion: Robot-assisted laparoscopic pyeloplasty is a safe and effective surgical intervention for correcting UPJ obstruction. Patients with symptoms of UPJ obstruction and discordant functional imaging studies demonstrate similar or improved success rates after pyeloplasty compared with patients with documented high-grade obstruction. Based on these findings preoperative renal scan may not be reliable in appropriate selection of candidacy for pyeloplasty.


Assuntos
Hidronefrose , Laparoscopia , Robótica , Obstrução Ureteral , Humanos , Adulto , Pelve Renal/diagnóstico por imagem , Pelve Renal/cirurgia , Estudos Retrospectivos , Furosemida , Laparoscopia/métodos , Obstrução Ureteral/diagnóstico por imagem , Obstrução Ureteral/cirurgia , Hidronefrose/diagnóstico por imagem , Hidronefrose/cirurgia , Cintilografia , Rim/diagnóstico por imagem , Rim/cirurgia , Rim/fisiologia , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/métodos
4.
J Endourol ; 35(S2): S75-S82, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34499549

RESUMO

Minimally invasive approaches for laparoscopic donor nephrectomy are necessary to limit surgical morbidity, and technical challenges differ from those encountered during other laparoscopic renal surgeries. Presented here is a step-by-step guide for laparoscopic donor nephrectomy-focusing on pure laparoscopic and hand-assisted techniques. Both straight laparoscopic and hand-assisted nephrectomies were performed in healthy donors who met transplantation criteria in terms of global health and psychologic well-being. Patient positioning, trocar placement, surgical steps, incision closure, and postoperative care are reviewed. Standard equipment used to complete this procedure is itemized. This guide outlines indications, preoperative preparation, and procedural steps for laparoscopic donor nephrectomy. The techniques and the evolution thereof represent our experience since 2002 for 510 cases. The attached videos demonstrate a high-volume surgeon's typical approach while factoring in anatomical variation. In both cases, the donor nephrectomies were without incident and the patient's postoperative courses were without complication. A basic framework for donor nephrectomy is presented highlighting surgical steps we believe to be essential for graft preservation and ultimately effective transplantation. Although no two cases are the same, systematic approaches will allow for timely case completion, fewer complications, and better donor/recipient outcomes.


Assuntos
Transplante de Rim , Laparoscopia , Humanos , Doadores Vivos , Nefrectomia , Coleta de Tecidos e Órgãos
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