Replacement of ureter by ileum

PURPOSE OF REVIEW: The challenge of bridging long defects of ureter has been reviewed with particular emphasis on the utilization of ileum. RECENT FINDINGS: The application of the Yang-Monti principle can provide an ileal tube of adequate length and suitable cross-sectional diameter. An antireflux ileovesical anastomosis is also feasible. SUMMARY: Although long-term results are still lacking, an ileal tube constructed on the basis of the Yang-Monti principle seems ideal for ureteric substitution.     

Appendix interposition of the ureter

Under specific circumstances the appendix vermiformis may be an appropriate organ for plastic repair of a large ureteral defect. We report a situation in which all of the criteria were met and in which a long ureteral defect was bridged successfully with the appendix.     

Optimization of replacement of the ureter by ileum.

Fifty patients for whom an ileal replacement of the ureter was indicated were prospectively randomized among 2 treatment groups according to the surgical technique used. In group 1 the standard operation was performed. In group 2 a tailored and valved (modified) ileal ureter was used. Patients were followed every 3 to 6 months for 12 to 28 months. Kidney functions were evaluated by 99m technetium diethylenetriaminepentaacetic acid scans and by determination of the 24-hour creatinine clearance. Urine cultures were obtained, and urine viscosity and flow rates were measured. A urographic study, including ascending cystography, was done every 6 months. Results indicated that the modified operation is functionally superior to the standard procedure. It provides efficient unidirectional flow of urine from the kidney to the bladder with less mucus secretion. This was ultimately reflected as better renal function when it was quantitated by renography and/or chemical clearance.     

Long-term results of ileum interposition for ureteral obstruction

OBJECTIVE: To present the long-term results of ileum interposition in the ureter for uni- or bilateral ureteral obstruction. PATIENTS AND METHODS: Between 1981 and 2000, a total of 22 patients received an ileal segment interposition as a substitution for the ureter, of whom 18 were available for analysis. The mean age was 54 years (range 29-73). Patients were followed for a mean period of 65 months (range 2-196). Assessment included clinical examination, serum creatinine levels, renal ultrasonography, intravenous pyelography and isotopic renography. In eight patients, the ileal-ureteral substitution was the first reconstructive procedure. The other patients underwent up to four previous reconstructions of different types. Fourteen patients were treated for unilateral ureteral obstruction, four of whom had a functional or anatomical solitary kidney, the other four patients had bilateral obstruction. RESULTS: In 16 patients renal function improved after ileal-ureteral substitution. One patient underwent a nephrectomy because of a decreased renal function due to an obstruction at the level of the uretero-ileal anastomosis. One patient had a nephrectomy because of recurrent macroscopic hematuria caused by multiple arterio-venous malformations. Overall, 15 patients (83%) had a good functioning kidney after a mean period of 65 months. In three patients an early reintervention was necessary because of bleeding, small bowel obstruction and urinary leakage from a pyelo-ileal anastomosis. Six patients required a reintervention in the long-term: two had a nephrectomy, three had a re-anastomosis between the renal pelvis and the proximal ileal segment, while the sixth patient underwent a PNL for a kidney stone. Recurrent urinary tract infections were seen in six patients, of whom three had to undergo a reintervention. Metabolic acidosis was detected in two patients and was treated with sodium bicarbonate substitution. CONCLUSION: Ileal-ureteral substitution is a valuable procedure with good long-term results and an acceptable rate of secondary interventions in patients for whom other alternatives are not feasible.     

Primary localized amyloidosis of the ureter and bladder managed by ileal interposition

Amyloidosis of the ureter is a rare condition. It is even rarer when it involves both the ureter and bladder. The case presented is the second known case of combined amyloidosis of the bladder and ureter and the first combined case to be treated successfully by ileal ureter replacement. Historically, amyloidosis of the ureter has been treated by nephroureterectomy. Based on the benign nature of the disease, amyloidosis of the ureter is optimally treated with a kidney-sparing procedure such as ileal ureter replacement.     

Gastric pouch interposition between ileum and anus after total proctocolectomy

After a total proctocolectomy for familial adenomatous polyposis or for ulcerative colitis, an ileal pouch–anal anastomosis is not possible in some circumstances. In case of Crohn's disease (CD), an ileal pouch-anal-anastomosis is contraindicated by most authors. We have devised a means to avoid a permanent ileostomy in these situations. It consists of transposing between ileum and anus the left half of the vertical part of the stomach, in the shape of a pouch vascularized through the right gastroepiploic pedicle. This plasty was performed on a 35-year-old female after a proctocolectomy for CD. There was no post-operative complication. The functional results remained satisfactory after 9 months: two to five stools per 24 h, no urgency, occasional seepage during night. The main disadvantage was the necessity of high dose proton pump inhibitor therapy to prevent anal burning sensation.     

Total replacement of ureter with a segment of ileum

Replacement of ureter with a segment of ileum was successfully performed in two patients. One had ureteral cancer and the other recurrent calculi due to cystinuria. The first patient had only one kidney. In the second both ureters were replaced with ileum. Formation of a papilla at the distal end of the ileal segment in the bladder may reduce the risk of vesico-ileal reflux.     

Laparoscopy-assisted ileal ureter creation for multiple tuberculous strictures: report of two cases

We describe in detail the technique of laparoscopy-assisted ileal ureter creation for multiple tuberculous ureteral strictures in two patients. The proximal anastomosis included an ileocalicostomy in the first patient and an ileopyelostomy in the second patient. The first patient had bowel entrapment behind the mesentery of the ileal loop, but the second patient had an uneventful postoperative recovery. Short-term follow-up showed good patency of the ileal loop. The variations in the technique that can cause postoperative problems are discussed, and the future of this technique is postulated.     

Reconstruction of ureteral necrosis in kidney transplantation using an ileum interposition

PURPOSE: Ureteral necrosis is a serious problem in kidney transplantation. Sometimes re-ureterocystostomy is possible, while other cases require an elaborate reconstruction to maintain kidney function. We report our experience with ileum interposition for ureteral reconstruction. METHODS: After 9 years of dialysis treatment a 58-year-old patient was grafted using the left kidney of a 59-year-old donor with a cold ischemic time of 9.5 hours. The early postoperative course was uneventful apart from delayed graft function. Immunosuppression consisted of an IL-2-receptor antibody, calcineurin inhibitor, mycophenolate mofetil, and corticosteroids. Discharge serum creatinine was 2.3 mg/dL. In month 4 the patient showed a pararenal urinoma; cystoscopy revealed necrosis of the distal ureter. Operative revision showed urine leakage from the renal pelvis through the urinoma into the bladder. As the whole ureter was necrotic, a re-ureterocystostomy was not possible. The patient's own ureter had been extirpated, and the bladder was too small to do a direct anastomosis between it and the kidney. Consequently, an ileum interposition was performed. RESULTS: The postoperative course was uneventful. Kidney function was stable with a nadir creatinine concentration of 2.0 mg/dL 18 months' posttransplantation, and 14 months' post ileal interposition the kidney function was still satisfactory, with a creatinine level of 2.0 mg/dL. CONCLUSION: Ureteral necrosis is a serious complication following kidney transplantation. Whenever a re-ureterocystostomy or an uretero-ureterostomy is not possible, the interposition of the ileal segment represented a safe procedure to deal with this problem.     

腹腔镜辅助的全小肠内镜检查

目的:探讨腹腔镜辅助全小肠内镜检查的可行性。方法:腹腔镜辅助下用内镜逐段对实验猪小肠进行检查,发现模拟病变后切除。结果:内镜检查肠管长度250 ~540cm,平均( 320±140 )cm。手术时间40 ~120min,平均( 78±36 )min。动物内镜检查均发现模拟病变,完成模拟病变肠壁切除。结论:腹腔镜辅助全小肠镜检查技术上是可行的。     

腹腔镜辅助直肠癌根治术

中央入路于乙状结肠系膜内侧切开后腹膜,解剖Toldt’s间隙,分别向左、向尾侧、向头侧进一步游离、扩大该间隙,显露并注意保护左侧输尿管、左侧生殖血管。充分游离Toldt’s间隙后,放入小纱布以作标记。提起肠系膜下血管根部系膜组织,彻底分离清扫肠系膜下动脉根部淋巴脂肪组织。夹闭、切断肠系膜下动脉,注意保护生殖神经。向下游离,首先游离后方的直肠后间隙和前方的邓氏间隙,然后离断直肠侧韧带。最后按腹腔镜下全直肠系膜切除法+双吻合器法切除直肠肿瘤及重建肠道。     

Laparoscopy-assisted pelvi-scrotal vasovasostomy

Iatrogenic obstruction of the vas deferens within the inguinal canal can be managed by direct on-site vasovasostomy. However, in cases with large defect of the vas, the anastomosis may be under tension. Dissecting through the site of a previous hernia repair is tedious, and may lead to recurrence of the hernia. The present work reports an, first of a kind, alternative technique that avoids the latter drawbacks. Fifteen cases were operated upon. Under laparoscopic vision, the pelvic vas was dissected and the lateral-most end was clipped, cut and extruded from the abdomen through a port in the external inguinal ring. End-to-end vasovasostomy and microsurgical anastomosis for the vasal vessels were performed, bridging the retrieved stump of the pelvic vas with the scrotal vas. There were positive results in the form of sperm count ranging from 1.5 to 15 million ml(-1), an average of 7.25 (SD 5.44) in nine of 15 cases (60%), within the first 6 months following surgery. "Pelvi-scrotal vasovasostomy" can be offered as a cost-effective and successful alternative or supplement to intracytoplasmic sperm injection, for cases with iatrogenic large defects of the vas deferens within the inguinal canal.