The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins, University School of Medicine, Baltimore, MD.
The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins, University School of Medicine, Baltimore, MD.
Urology. 2023 Jun;176:243-245. doi: 10.1016/j.urology.2023.02.027. Epub 2023 Mar 7.
Mid-to-proximal ureteral strictures pose a surgical challenge that historically required ileal ureter substitution, downward nephropexy, or renal autotransplantation. Ureteral reconstruction techniques involving buccal mucosa or appendix have gained traction with success rates approaching 90%.
In this video we describe surgical technique for a robotic-assisted augmented roof ureteroplasty using an appendiceal onlay flap.
Our patient is a 45-year-old male with recurrent impacted ureteral stones requiring multiple right-sided interventions including ureteroscopy with laser lithotripsy, ureteral dilation, and laser incision of ureteral stricture. Despite adequate treatment of his stone disease, he had deterioration of his renal split function with worsening right hydroureteronephrosis to the level of the mid-to-proximal ureter consistent with failed endoscopic management of his stricture. We proceeded with simultaneous endoscopic evaluation and robotic repair with plan for either ureteroureterostomy or augmented roof ureteroplasty using buccal mucosa or an appendiceal flap.
Reteroscopy and retrograde pyelogram revealed a 2-3 cm near-obliterative stricture in the mid-to-proximal ureter. The ureteroscope was left in situ and the patient was placed in the modified flank position to allow concurrent endoscopic access during reconstruction. The right colon was reflected revealing significant scar tissue overlying the ureter. With the ureteroscope in situ, we utilized firefly imaging to aid in our dissection. The ureter was spatulated and mucosa of the diseased segment of ureter excised in a nontransecting manner. The mucosal edges of the posterior ureter were re-approximated with the ureteral backing left in place. Intraoperatively, we identified a healthy, robust appearing appendix and thus planned for an appendiceal onlay flap. If an atretic or diseased appendix was encountered, a buccal mucosa graft with omental wrap would be utilized. The appendix was harvested on its mesentery, spatulated, and interposed in a pro-peristaltic fashion. A tension-free anastomosis was performed between ureteral mucosa and the open appendix flap. A double-J stent was placed under direct vision and Indocyanine Green (ICG) green was used to evaluate blood supply to the margins of the ureter and the appendix flap. The stent was removed 6 weeks postoperatively, and on 3-month follow-up imaging he had resolution of his right hydroureteronephrosis and has had no further episodes of stone formation, infections, or flank pain with 8-month follow-up.
Augmented roof ureteroplasty with appendiceal onlay is a valuable tool in the urologists arsenal of reconstructive techniques. Use of intraoperative ureteroscopy with firefly imaging can aid in delineating anatomy during difficult ureteral dissections.
中段至近端输尿管狭窄是一个外科挑战，传统上需要回肠代输尿管、向下肾固定术或自体肾移植。涉及颊黏膜或阑尾的输尿管重建技术成功率接近 90%，已得到广泛应用。
在本视频中，我们描述了一种使用阑尾瓣的机器人辅助增强顶壁输尿管成形术的手术技术。
我们的患者是一名 45 岁男性，因反复出现嵌顿性输尿管结石而需要多次右侧干预，包括输尿管镜激光碎石术、输尿管扩张和激光切开输尿管狭窄。尽管对他的结石病进行了充分的治疗，但他的肾功能出现恶化，右侧肾盂积水到中段至近端输尿管水平，这表明内镜治疗他的狭窄失败。我们进行了同时的内镜评估和机器人修复，计划进行输尿管-输尿管吻合术或使用颊黏膜或阑尾瓣进行增强顶壁输尿管成形术。
输尿管镜检查和逆行肾盂造影显示中段至近端输尿管有 2-3 厘米的近闭塞性狭窄。输尿管镜原位保留，患者置于改良侧卧位，以便在重建过程中同时进行内镜检查。将右结肠向上翻转，发现输尿管上方有明显的瘢痕组织。在输尿管镜原位保留的情况下，我们利用萤火虫成像来辅助我们的解剖。输尿管进行套入式切开，非横断方式切除病变段输尿管的黏膜。将后段输尿管的黏膜边缘重新接近，输尿管支架保持原位。术中，我们发现一个健康、强壮的阑尾，因此计划进行阑尾瓣覆盖。如果遇到阑尾闭锁或病变，将使用颊黏膜移植物加网膜包裹。在肠系膜上采集阑尾，进行套入式切开，并以顺蠕动方式插入。在输尿管黏膜和开放的阑尾瓣之间进行无张力吻合。在直视下放置双 J 支架，并使用吲哚菁绿 (ICG) 评估输尿管和阑尾瓣边缘的血供。术后 6 周取出支架，3 个月随访时，他的右侧肾盂积水得到缓解，8 个月随访时没有再次出现结石形成、感染或腰痛。
带阑尾瓣的增强顶壁输尿管成形术是泌尿科医生重建技术的有力工具。术中使用输尿管镜和萤火虫成像可以帮助在困难的输尿管解剖中描绘解剖结构。
