Intestinal interposition for complex ureteral reconstruction: A comprehensive review

Abstract

Long ureteral defects have remained a challenge to urologists for a long time. Bowel interposition, including ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance, even though it is a complicated procedure and associated with some potential complications. Mucus obstruction and metabolic disorders are common complications of intestinal substitution. To circumvent these troubles, modified techniques, such as tapering the bowel graft, intestinal onlay flap and the Yang-Monti procedure, are used. In particular, Yang-Monti ileal ureter replacement is a highly effective option for ureteral reconstruction, and the incidence of complications would be significantly reduced in select patients. After being combined with the Boari flap or psoas hitch technique, the length of intestinal segment used can also be significantly reduced. Most recent long-term results suggest that ileal ureter replacement with antireflux anastomosis seems to be remarkably free of complications, and we highly praise the distal nipple valve technique. Appendiceal interposition is available for patients with normal appendix, and usually this procedure is limited to reconstructing the right ureter. Appendiceal onlay ureteroplasty has emerged as a feasible and effective option to manage patients with complex proximal and midureteral strictures of the right side. The colon is rarely used for ureteral reconstruction because of its large caliber and mucous surface area. However, a reconfigured colon segment is a good substitute to reconstruct long-segment ureteral defects, and longterm follow up confirmed minimal complications and improved renal function. This review provides a comprehensive perspective on complex ureteral reconstruction and replacement using intestinal segments, in particular, ileal ureter replacement.

Laparoscopic ileal ureteral replacement to preserve the natural anti‐reflux system: An initial case report

“…In our procedure, the distal side of the ileal segment was tapered to fit to the diameter of the ureter. A previous study demonstrated that tapering the cross‐sectional diameter of the ileal segment enhances peristalsis via early stretching of the peristalsis‐inducing muscle fiber 6 . Therefore, by enhancing peristalsis, our procedure may also smoothen urine passage in the ileal segment to prevent carcinogenesis 6,7 …”

“…A previous study demonstrated that tapering the cross-sectional diameter of the ileal segment enhances peristalsis via early stretching of the peristalsis-inducing muscle fiber. 6 Therefore, by enhancing peristalsis, our procedure may also smoothen urine passage in the ileal segment to prevent carcinogenesis. 6,7 The main limitation of the present study is that there is only one case with no long-term functional follow-up data available for reference.…”

“…6 Therefore, by enhancing peristalsis, our procedure may also smoothen urine passage in the ileal segment to prevent carcinogenesis. 6,7 The main limitation of the present study is that there is only one case with no long-term functional follow-up data available for reference. However, this is a proof-of-concept study that has demonstrated the feasibility of using laparoscopic surgery.…”

Stentless repair of left urethral defect with appendiceal interposition: A case report

“…There are different surgical methods according to the localization of the ureteral lesion. In long ureter defects, small intestine, appendix, and colon interposition complications are high, but they are used limitedly for the preservation of kidney functions [2] .…”

The application of the “omental wrapping” technique with autologous onlay flap/graft ureteroplasty for the management of long ureteral strictures

“…Long ureteral strictures, especially in the middle and proximal segments, are difficult to repair, frequently demanding the performance of complicated reconstruction techniques. Both intestinal interposition and kidney autotransplantation are alternative techniques but with significant morbidity associated with intestinal substitution and vascular complications (4,5). Ureteroplasty with oral mucosa grafts (buccal mucosa and lingual mucosa) and appendiceal onlay flaps (AOFs) are inspiring ways to repair narrow segments with less severe complications (6)(7)(8).…”