Department of Urology, Son Espases University Hospital, Palma, Balearic Islands, Spain.
Int Braz J Urol. 2024 Jan-Feb;50(1):108-109. doi: 10.1590/S1677-5538.IBJU.2023.0595.
The management of ureteral strictures longer than 1-2 cm must be treated by major surgery (1, 2). The strictures located at the distal part of the ureter can be managed by a ureteral reimplantation using a psoas hitch or a Boari flap depending on its proximity to the bladder (3). Those located at the proximal ureter can be treated by a pyeloplasty (4). The ureteric strictures in the mid-ureter are the ones that pose a greater challenge for the urologist because a ureteral substitution is needed, either using a segment of the intestine or a buccal mucosa graft (5, 6). Our main objective is to present the management and results at 36 months of a patient with a right mid-ureter stricture.
A 63-year-old male with chronic kidney disease (CKD) and a right single functioning kidney was referred to our department with the diagnosis of a 3 cm stricture in the right mid-ureter. He had a long-term JJ-stent in place but in the last year we had to replace it three times precociously and he even needed the placement of a nephrostomy tube due to the obstruction of the JJ-stent. Accordingly, a permanent resolution was sought and a laparoscopic onlay-flap ureteroplasty using cecal appendix was performed.
The first step was to identify the cecal appendix. Then we identified and dissected the ureter. With the ureter dissected, we performed a ureteroscopy to pinpoint the stricture. Once we knew where the stricture was, we proceeded with the ureterotomy and preparation of the cecal appendix. The final step was to perform the ureteroplasty between the ureter and the cecal appendix placing a JJ-stent before the last stitches were done. Total operative time was 190 minutes without any intraoperative complication. The JJ-stent was removed 7 weeks later. The follow-up of the patient was done with regular blood test and ultrasound to rule out deterioration of the CKD and worsening of the residual hydronephrosis. With a follow-up of 36 months, the patient is stent free, he hasn't had any further intervention and neither the CKD nor the hydronephrosis haven't worsened.
Laparoscopic onlay-flap ureteroplasty using cecal appendix is a feasible and well tolerated procedure for patients with right mid-ureter stricture. However, we must bear in mind the difficulty of these cases and they should be performed in expert centers.
输尿管长度超过 1-2 厘米的狭窄必须通过大手术治疗（1,2）。输尿管下段狭窄可通过腰大肌悬带或 Boari 皮瓣输尿管再植术治疗，具体取决于其与膀胱的距离（3）。输尿管上段狭窄可通过肾盂成形术治疗（4）。输尿管中段狭窄对泌尿科医生来说是一个更大的挑战，因为需要进行输尿管替代，使用肠段或颊黏膜移植物（5,6）。我们的主要目标是介绍一位右侧输尿管中段狭窄患者的治疗和 36 个月的结果。
一名 63 岁男性患有慢性肾脏病（CKD）和右侧单功能肾，因右侧输尿管中段 3 厘米狭窄被转诊至我科。他长期放置 JJ 支架，但在过去一年中，我们不得不提前更换了三次支架，甚至因 JJ 支架阻塞而需要放置肾造口管。因此，寻求永久性解决方案，行腹腔镜下阑尾瓣输尿管成形术。
首先，我们需要识别阑尾。然后，我们识别并分离输尿管。输尿管分离后，进行输尿管镜检查以确定狭窄部位。一旦确定狭窄部位，我们进行输尿管切开术和阑尾准备。最后一步是在最后缝线之前将输尿管和阑尾瓣之间进行输尿管成形术，并放置 JJ 支架。总手术时间为 190 分钟，无术中并发症。7 周后取出 JJ 支架。对患者进行定期血液检查和超声检查，以排除 CKD 恶化和残余肾积水加重。随访 36 个月，患者无支架，无进一步干预，CKD 及肾积水无恶化。
腹腔镜下阑尾瓣输尿管成形术是治疗右侧输尿管中段狭窄的一种可行且耐受良好的方法。然而，我们必须牢记这些病例的难度，并在有经验的中心进行手术。
