Desgrandchamps F, Duboust A, Teillac P, Idatte J M, Le Duc A
Department of Urology, Saint-Louis Hospital, Paris, France.
Transpl Int. 1998;11 Suppl 1:S150-1. doi: 10.1007/s001470050449.
Ureteral necrosis is a rare complication of renal transplantation, and is seldom cured by endoscopic management alone. To avoid the potential hazard to the graft created by an open ureteral reconstruction in cases of renal transplant ureteral necrosis, we have appiled a new minimally invasive technique of total ureteral replacement, initially described for the palliative treatment of ureteral obstructions. The subcutaneous bypass technique is based on the use of a silicone-PTFE-bonded tube tunnelled underneath the skin.
Total ureteral replacement by subcutaneous pyelovesical bypass was performed in three renal transplant patients (two men and one woman; mean age 41 years, (range 23-58) years with ureteral necrosis after failure of primary endoscopic treatment. The ureteral lesion was distal necrosis in two patients, and a total necrosis in the other. Under general anaesthesia and fluoroscopic guidance, a percutaneous tract was created and progressively dilated. The ureteral prosthesis was introduced into the pyelocaliceal cavities through a 30 F Amplatz sheet, then subcutaneously tracked down to the suprapubic area, and introduced into the bladder via a short incision.
There was no operative or postoperative morbidity. There was no obstruction, dislodgement or encrustation of the prosthesis. There were no bladder-related symptoms, or clinical reflux, and no abdominal wall complications. An asymptomatic episode of lower urinary tract infection (Staphylococcus epidermidis) was observed in the female patient. All the grafts were functioning with fine pyelocaliceal cavities, with a mean follow-up of 32 months (13-69 months).
Total ureteral replacement by subcutaneous pyelovesical bypass is a simple and safe technique of ureteral reconstruction in renal transplantation. Late encrustation of the prosthesis may occur, and the prosthesis may need to be changed in such cases. Subcutaneous pyelovesical bypass can be regarded as an alternative to an open procedure to treat ureteral necrosis after renal transplantation.
输尿管坏死是肾移植的一种罕见并发症，很少能仅通过内镜治疗治愈。为避免在肾移植输尿管坏死病例中开放输尿管重建对移植物造成潜在危害，我们应用了一种新的微创全输尿管置换技术，该技术最初用于输尿管梗阻的姑息治疗。皮下旁路技术基于使用一根硅酮 - 聚四氟乙烯粘结管在皮下隧道穿行。
对3例肾移植患者（2例男性，1例女性；平均年龄41岁，范围23 - 58岁）进行了皮下肾盂膀胱旁路全输尿管置换术，这些患者在初次内镜治疗失败后出现输尿管坏死。2例患者的输尿管病变为远端坏死，另1例为完全坏死。在全身麻醉和荧光透视引导下，建立经皮通道并逐步扩张。通过一个30F的安普茨导管将输尿管假体引入肾盂腔，然后在皮下追踪至耻骨上区域，并通过一个小切口引入膀胱。
无手术或术后并发症。假体无梗阻、移位或结痂。无膀胱相关症状或临床反流，也无腹壁并发症。女性患者出现了一次无症状的下尿路感染（表皮葡萄球菌）。所有移植物功能良好，肾盂腔正常，平均随访32个月（13 - 69个月）。
皮下肾盂膀胱旁路全输尿管置换术是肾移植中一种简单安全的输尿管重建技术。假体后期可能会结痂，在这种情况下可能需要更换假体。皮下肾盂膀胱旁路可被视为肾移植后输尿管坏死开放手术的一种替代方法。
