Combined Y-shaped common channel transureteroureterostomy with Boari flap to treat bilateral long-segment ureteral strictures
© Chen et al.; licensee BioMed Central Ltd. 2014
Received: 12 November 2013
Accepted: 13 August 2014
Published: 20 August 2014
Ureteral stricture is a complication of several etiologies including idiopathic retroperitoneal fibrosis, infection, radiotherapy, instrumentation, and surgical procedures. A variety of techniques have been reported for management. The transureteroureterostomy and bladder flap have been the standard procedures for repairing distal ureteral defects of unilateral ureter. Bilateral ureteral stricture is an uncommon condition that challenges usual reconstructive procedures. It is a difficult task to reconstruct the complex situation of bilateral ureteral strictures.
A 54-year-old female underwent concurrent chemoradiotherapy for stage IVB squamous cell carcinoma of cervix. Subsequently, she had stricture of bilateral distal ureters with bilateral hydroureteronephrosis which was found by computed tomography. The renal function deteriorated during the follow-up period. She had periodic change of double-J stents and percutaneous nephrostomy. However, the renal function still deteriorated. We performed a combined Y-shaped common channel transureteroureterostomy with Boari flap to reconstruct bilateral long-segment ureteral strictures. The patient recovered uneventfully.
Reconstruction of bilateral ureteral strictures is a difficult treatment. We developed a modified technique for the complex situation of bilateral ureteral strictures. To our knowledge, this has not been previously reported in the scientific literature and it is a feasible procedure to treat bilateral long-segment ureteral strictures.
Ureteral strictures can result from a variety of causes, including stone passage, infection, endoscopic procedures, trauma, radiotherapy, surgery, retroperitoneal fibrosis, and malignancy. Ureteral stricture can be managed by balloon dilatation and ureteral stent initially. However, most of the strictures will recur and will require definitively surgical management. The localization, length and etiology of stricture affect the surgical modality. Short segment defects can be treated by ureteroureterostomy or ureteroneocystostomy. Management of longer ureteral defects is a potentially challenging task when the ureteral length is insufficient for direct anastomosis or reimplantation. Longer ureteral defects usually require complex procedures such as transureteroureterostomy (TUU), vesicopsoas-hitch, Boari flap, ileal ureteral substitution, or autotransplantation . Bilateral ureteral stricture is an uncommon and a more challenging occurrence. We describe a case with long-segment stricture of both ureters where a complex reconstructive technique had to be employed and conventional procedures were not feasible.
She presented with deterioration of creatinine level from 2.6 to 4.0 mg/dL and repeated catheter-related infection in recent 1 year and transferred to our hospital. Consideration of the stricture length of bilateral ureters, we planned the surgical treatment of segmental resection of bilateral ureteral stricture accompanied with bilateral Boari flap and ureteroneocystostomy.
Open ureteral reconstruction is the gold standard for ureteral defects with a success rate over 90% and good long-term results . In recent years, laparoscopic and robotic ureteral reconstructive surgery has been reported with good results in the literature. However, in our case, the length of ureteral stricture was long and included both ureters. Additionally, the patient underwent concurrent chemoradiotherapy before. We speculated that open ureteral reconstruction might be better in our patient because of possibility of severe retroperitoneal fibrosis.
There are various procedures for treating ureteral strictures, depending on the length, complexity and location of the lesion. Boari developed an open bladder flap operation and succeeded in an animal model in 1894 . Boari flap utilizes only normal urinary tract without danger of the ipsilateral kidney nor contralateral ureter or kidney and can be done in patients with decreased renal function . Thompson and Ross reported a 91% long-term success rate in patients with strictures of the lower two-thirds of the ureter .
TUU is used to bypass a diseased distal ureter without damaging the recipient ureter and to maintain adequate urinary drainage from the donor kidney . Iwaszko reported a 96.4% long-term success rate with a patent anastomosis and a 3.6% failure rate in patients that underwent TUU for malignancy and had received radiation therapy to the pelvis before construction .
Radiation cystitis is a complicate problem in patients undergoing radiotherapy for gynaecological malignancies and acute condition can develop in 24-30% of patients . Though most of the patients are self-limiting, it may result in chronic condition [9, 10]. Ureteral stricture is a well-known complication secondary to radiotherapy-associated fibrosis in patients with cervical carcinoma . It has an incidence of 15% in patients undergoing standard doses of radiotherapy and 1% of patients developed severe ureteral fibrosis . The mechanisms are not definitively understood. Some authors suggest that radiation can result in progressive endarteritis of the small blood vessels that cause cellular hypoxia and damage to fibroblasts . In our opinion, the field of radiation, that extended from L4-5 interspace superiorly to 3–4 cm below the cervix and 1–2 cm lateral to the bilateral pelvic margins in our patient, also takes an important role of long-segment ureteral strictures secondary to radiotherapy-associated fibrosis.
Bilateral ureteral stricture is an uncommon occurrence and is a difficult surgical challenge. Combined use of bladder flap and TUU is an uncommon technique. Weems reported a case presented of bilateral distal ureteral stricture was successfully treated by this technique in restoring satisfactory drainage of the upper tracts and preserving use of the bladder . In our case, we performed a combined Y-shaped common channel TUU with Boari flap which provided a more blunt-angle anastomosis and a larger anastomosed-lumen than the typical procedure of TUU. The technique made more smoothly urinary drainage from the both kidney and avoided the risk of ureteroureteral reflux. We predicted that lower obstruction rate and long-term success rate of the procedure.
The combination of malignancy, prior radiation and multiple prior surgeries can increase the risk of vascular compromise of the ureter and likely contribute to the rate of postoperative complications including urine leak and recurrent stricture . In order to improve success rate and prevent complication of postoperative stricture, we extensively mobilized the both ureters, created a tension-free anastomosis, and preserved periureteral tissue to decrease damage of blood supply for protection from ischemic damage. And the larger common-channel of ureteral anastomosis also decreased risk of post-operative stricture. Furthermore, because of the larger common-channel, it might be possible to perform flexible ureteroscopy for further follow-up.
Reconstruction of bilateral ureteral strictures is a difficult surgical challenge. To our knowledge, this is the first reported case to use a “combined Y-shaped common channel TUU with Boari flap” for reconstruction of bilateral long-segment ureteral strictures involving middle third and lower third of ureter. This technique provides a good tension-free repair over the anastomosis. In conclusion, it is an efficacious and feasible procedure for long-segment strictures of both ureters.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
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