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Exemplary preoperative retrograde ureteropyelography with long segment proximal ureteric stricture (S). UPJ, uretero-pelvic junction; B, bladder.
Source publication
Purpose:
To report a single surgeon experience with one year follow-up after open ureteroplasty with buccal mucosa graft (OUBMG) in the rare situation of long segment proximal ureteral strictures.
Materials and methods:
Four patients with long segment proximal ureteral stricture underwent OU-BMG between February and July 2017. Functional outcome...
Context in source publication
Context 1
... OU-BMG between February and July 2017 was performed. Inclusion criteria involved proximal ureteral stricture without possibility for excision and primary anastomosis. All patients underwent retrograde pyelography and ureteroscopy including cytology under general anesthesia to assess the exact stricture length and to rule out urothelial cancer (Fig. 1). Then, a double-J stent was ...
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Purpose
Ureteric stents placed after ureteroscopy typically require cystoscopy for removal. Stent extraction strings allow the option of patient self-removal. This facilitates shorter stent dwell time, and cost-savings. Concerns regarding safety and limited evidence regarding patient acceptability are speculated reasons for infrequent clinical use...
Citations
... In recent years, mucosal grafts for open ureteral reconstruction have become more common, but experiences with the technique and outcome are still limited. The technique of open ureteral reconstruction with buccal mucosa graft (BMG) was first described by Naude in 1999, and only few case series have been published since, none reporting more than ten patients and all using omental wrapping [3][4][5][6][7][8][9]. ...
... The median time of surgery was 160 min (range 90-206). The median length of stay in hospital was 4 days (range [3][4][5][6][7][8][9][10][11][12]. No operative complications or immediate adverse events occurred. ...
... Other studies included endpoint radiologic diagnostics such as CT scan, magnetic resonance imaging (MRI), or kidney scintigraphy. Hefermehl et al., for instance, performed a renal scintigraphy 1 year postoperative, showing good renal function at follow-up [9]. We have renounced scintigraphy at follow-up because we believe it is redundant. ...
Purpose
Successful treatment options for ureteral strictures are limited. Surgical options such as ileal interposition and kidney autotransplantation are difficult and associated with morbidity and complications. Techniques such as Boari flap and psoas hitch are limited to distal strictures. Only limited case studies on the success of open buccal mucosa graft (BMG) ureteroplasty exist to this date. The purpose of this study was to evaluate the success of open BMG ureteroplasty without omental wrap.
Methods
In this single-center retrospective study between July 2020 and January 2023, we included 14 consecutive patients with ureteric strictures who were treated with open BMG ureteroplasty without omental wrap. The primary outcome was the success of open BMG ureteroplasty. Further endpoints were complications and hospital readmission. Outcome variables were assessed by clinical examination, kidney sonography, and patient anamnesis.
Results
Out of 14 patients, 13 were stricture and ectasia-free without a double-J stent at a median follow-up of 15 months (success rate 93%). No complications were observed at the donor site, and the complication rate overall was low with 3 out of 14 patients (21%) having mild-to-medium complications.
Conclusions
Open BMG ureteroplasty without omental wrap is a successful and feasible technique for ureteric stricture repair.
... The first BMG ureteroplasty in humans was described in 1999 (4). However, interest in this technique has renewed over the past decade, and the technique is now reported in numerous articles regarding its utility in open and robotic approaches (5)(6)(7). Unfortunately, there is a lack of papers dedicated to the laparoscopic BMG ureteroplasty of the complex upper ureteral stricture, being necessary to build a confident opinion on the pros and cons of different approaches (8,9). Therefore, we hypothesized that laparoscopic BMG ureteroplasty can be effectively and safely used for patients with complex proximal ureteral strictures, when ureteroureterostomy is impossible, or with recurrent ureteral strictures. ...
Introduction:
There is lack of papers dedicated to the laparoscopic buccal mucosa graft (BMG) ureteroplasty of the complex upper ureteral stricture. The aim of this study is to evaluate the results of laparoscopic BMG ureteroplasty in patients with complex proximal ureteral stricture.
Material and methods:
Twenty-four patients underwent laparoscopic ventral onlay BMG ureteroplasty for long or recurrent proximal ureteral stricture not amenable to uretero-ureteral anastomosis over 2019-2022. Patient demographics, operative time, estimated blood loss, length of stay, follow-up, intra- and postoperative complication rate and percentage of stricture-free at last visit were analyzed.
Results:
The mean stricture length was 3.6 cm. The mean operative time was 208.3 min, while mean blood loss was 75.8 mL. The length of hospital stay was 7.3 days. No intraoperative complications were observed. Postoperatively, seven patients developed complications (29.2%). Five patients experienced a Grade II (according to Clavien nomenclature). Two patients developed a Grade IIIa complication, which included leakage of the anastomosis site. The mean follow-up was on the 22 months with stricture free rate 87.5%.
Conclusion:
Patients with proximal ureteral strictures could be effectively treated by laparoscopic ventral onlay ureteroplasty with a buccal mucosa graft.
... However, compared with BMG, complications were difficult to manage, such as ureteral fistula requiring surgical intervention [14]. However, a large-scale [15]. Correct identification of the narrowing site to be repaired is critical to reconstruction, as failure to do so may lead to postoperative restenosis. ...
Although ureteroplasty with buccal mucosa graft for long-segmental ureteral stenosis has been developed long ago, evidence was still restricted to case series in published literature. This study aims to validate ureteroplasty with buccal mucosa graft (BMG) in long-segment stricture at the proximal and middle ureters under designed comparative methods. From April 2015 to January 2019, we performed robotic-assisted ureteroplasty with BMG with a two-phase design and compared ureteroplasty and BMG (phase 2 surgery) with endoscopic stenting (phase 1 surgery). Paired data of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), hydronephrosis grade, and physical and psychological domains of the World Health Organization Quality of Life (WHOQOL)–BREF were compared. A total of 29 patients were enrolled, and only three (10%) patients had hydronephrosis resolution after treatment with endoscopic stenting (p = 0.250 to baseline). Compared to endoscopic ureteral stent, Hedges’ g of ureteroplasty with BMG was 0.56 (95% CI 0.43–0.69), 0.63 (95% CI 0.46–0.80), 0.80 (95% CI 0.56–1.04), and 1.06 (95% CI 0.69–1.43) in EGFR, GFR, physical domain of WHOQOL–BREF, and psychological domain of WHOQOL–BREF, respectively (All significance; p < 0.001). After 12-month follow-ups, no recurrence of stricture was reported. In conclusion, Robotic-assisted ureteroplasty with BMG onlay is efficient in reconstruction of long-segment stricture of the proximal and middle ureters.
... BMG can be easily harvested from the donor site, and no complications have been reported, except for restenosis at the recipient site. To date, only one patient complained of di culty in whistling [15]. ...
Although ureteroplasty with buccal mucosa graft for long-segmental ureteral stenosis has been developed long ago, evidence was still restricted to case series in published literature. This study aims to validate ureteroplasty with buccal mucosa graft (BMG) in long-segment stricture at the proximal and middle ureters under designed comparative methods. From April 2015 to January 2019, we performed robotic-assisted ureteroplasty with BMG with a two-phase design and compared ureteroplasty and BMG (phase 2 surgery) with endoscopic stenting (phase 1 surgery). Paired data of effective renal plasma flow (ERPF), glomerular filtration rate (GFR), hydronephrosis grade, and physical and psychological domains of the World Health Organization Quality of Life (WHOQOL)-BREF were compared. A total of 29 patients were enrolled, and only three (10%) patients had hydronephrosis resolution after treatment with endoscopic stenting (p = 0.250 to baseline). Compared to endoscopic ureteral stent, Hedges’ g of ureteroplasty with BMG was 0.56 (95% CI: 0.43-0.69), 0.63 (95% CI: 0.46-0.80), 0.80 (95% CI: 0.56-1.04), and 1.06 (95% CI: 0.69-1.43) in EGFR, GFR, physical domain of WHOQOL-BREF, and psychological domain of WHOQOL-BREF, respectively (All significance; p<0.001). After 12-month follow-ups, no recurrence of stricture was reported. In conclusion, Robotic-assisted ureteroplasty with BMG onlay is efficient in reconstruction of long-segment stricture of the proximal and middle ureters.
... L. J. Hefermehlo ir bendraautorių naujausioje studijoje [20] aptarti 4 pacientų rezultatai. Šiems pacientams dėl ilgos poksimalinio šlapimtakio striktūros atlikta atviroji BG lopo plastika. ...
... Vis dar nėra nustatyta, kokia operacijos technika (atviroji, laparoskopinė ar roboto asistuojama laparoskopinė) yra geriausia BG lopo plastikai. Pasirenkant operacijos metodą, būtina įvertinti, kad dauguma pacientų jau yra turėję šlapimtakio srities operacijų ir tai gali apsunkinti techninį operacijos atlikimą [20]. Tai sudėtingos ir kaskart naujų iššūkių keliančios operacijos, atliekamos didžiausią patirtį turinčiuose centruose. ...
Background. Recurrent proximal ureteral stricture is a complex rare disease that is difficult to treat. Post-operative scarring, impaired blood supply to the ureter, stricture-related stones, and chronic infection – all factors make the treatment even more complicated. Methods. There are various surgical procedures for ureteral reconstruction, however, most of them are very traumatic and quite often ineffective. Our case reports the first experience of treating a complicated recurrent proximal ureteral stricture with ureteroplasty using a buccal mucosa graft. Results. The patient had a 12-month post-operative follow-up. No stricture recurrence was observed and hydronephrosis decreased. Although the excretory function of the left kidney remained lower, serum creatinine became normal. The most important clinical outcome was the withdrawal of left flank pain. Conclusions. We are lacking high volume clinical trials for appropriate ureteral stricture treatment modality. All available publications in this field compare single cases or low volume studies. While buccal mucosa graft procedures are well established in urethral reconstruction, our case proves that buccal mucosa graft method can be successfully used for ureteroplasty as well, providing good post-operative functional outcomes.
... Some urologists reported that tubularized grafts might be associated with a higher rate of restricture or fibrosis formation than onlay grafts for the ureteral reconstruction of the same length [40,41]. Failure of the tubularized graft may be mainly attributed to the poor blood supply, resulting in an inadequate graft "take." ...
Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.
Objective
To assess the augmented anastomotic ureteral reconstruction using buccal mucosal graft based on omental flap for managing ureteral stricture.
Subjects and methods
This prospective cohort study was conducted on 13 patients with ureteric strictures of different lengths secondary to Bilhalziasis, iatrogenic (post endoscopy) and post inflammatory etiology in upper and mid ureteral segments were treated with buccal mucosal patch grafts and The graft is fixed to the undersurface or the posterior surface of the omentum before doing graft anastomosis to the ureteral walls as to ensure the process of graft take sticky to the principles of tissue transfer. All patients were subjected to full history taking, clinical examination for assessment of pain, lower or upper urinary track symptoms and laboratory investigation (complete blood count, CRP, liver function test and kidney function test (serum urea and creatinine).
Results
The mean operative time was 148.85 min and mean hospital stay was 3 days. Mean blood loss was ranged from 20 to 210 ml and Stent was removed after 8–12 weeks. The mean follow up was 13 months, all patients had a non-obstructive RI value <0.7 with a non-obstructed drainage pattern on the diuretic renogram except one patient who had severe postoperative UTI necessitating nephrostomy tube insertion his drainage curve was plateau.
Conclusion
BMG ureteroplasty is a valuable option for a carefully selected patient. The fixation of the graft on the back surface of the omentum allows for better anatomical reconstruction without any twisting to the omental pedicle.
Introduction
Upper ureteric stricture is always a challenging case to treat for any urologist. Due to chronic inflammation and multiple interventions, it becomes a complex entity to treat. Buccal Mucosal Graft (BMG) Ureteroplasty is a reconstructive surgery used to treat upper ureteric stricture but the results and experience with this modality is less explored so far. We present here our study of 16 cases of BMG ureteroplasty and its outcomes done by the laparoscopic and robotic approaches.
Patients and Methods
We analysed 16 cases of BMG ureteroplasty, which were performed both laparoscopically and robotically. All these cases were long ureteric strictures, not amenable to excision or endoscopic intervention. We performed using an onlay BMG without complete mobilisation of the ureter. The omentum or nearby fat was used as a bed for onlay BMG.
Results
All 16 patients underwent onlay ureteroplasty. The reconstructed ureter was wrapped with omentum in nine of the cases, while in seven patients, nearby fat was used. The median stricture length was 5.28 cm, and the median operative time was 143.5 min. The mean operative time was 143.5 min. 15 of 16 (93.75%) cases were successfully clinically and radiologically on follow-up.
Conclusion
Long-segment upper ureteric strictures are a difficult entity to operate on. BMG ureteroplasty is a safe and effective way of managing such strictures. Robot-assisted ureteroplasty provides the benefits of improved ergonomics, easy manoeuvrability and precision surgery to the patients. Our experience with both laparoscopic and robotic ureteroplasty would encourage urologists all over to use BMG ureteroplasty as an effective long-term procedure for ureteral reconstruction.
Surgical treatment of organic obstruction of the upper urinary tract is a complex problem in modern urology. The aim of the study was to analyze the assessment of the late postoperative period after ureteral replacement with a buccal graft. We followed up 32 patients who underwent buccal ureteroplasty (BU). The effectiveness of this surgical intervention was assessed by the absence of recurrence of the disease and the need to reuse ureteral stenting or percutaneous nephrostomy. Recurrence of urinary tract obstruction was later detected in 3 (9.4 %) patients. Also, after removal of the stent in 18 patients, the following indicators were evaluated: glomerular filtration rate, maximum systolic blood flow velocity in the interlobar arteries of the kidney, thickness of the kidney parenchyma, ureteroscopy, and pain in the lumbar region. After 6 months, the established parameters were re-determined, and in case of improvement or unchanged primary indicators, each of the parameters was scored 1 point, in case of deterioration of the primary indicators, each of the parameters was scored 0 points. If the total score is 3 or more, then the course of the postoperative period after reconstructive surgery on the upper urinary tract using a buccal graft is considered favorable and conservative therapy is continued. Two of the 18 patients had a score of 2, which led to a change in the tactics of postoperative follow-up. Thus, this method for assessing parameters in operated patients allows timely correction of renal dysfunction.
Introduction. The review is aimed at analyzing the worldwide experience in the use of the oral mucosa in ureteroplasty due to benign ureteral strictures.
Objective. To study the features of the use of the oral mucosa in ureteral reconstruction based on a review of the worldwide literature.
Materials and methods. The review was conducted using the PubMed, EMBASE, and the Russian Science Citation Index database. In the first stage, 1013 sources were found, of which 38 articles were selected for inclusion in the review. Of these, 13 studies used an open approach, 15 — robotic, 6 — laparoscopic, 3 — laparoscopic and robotic, 1 — open and laparoscopic. A buccal graft was used in 29 studies and a lingual graft was used in 9 studies.
Results. In total, oral mucosal ureteroplasty was performed 308 times in 306 patients: open technique — 64 times, robotic — 145 times, laparoscopic — 99 times. A buccal graft was used in 67.9% (209/308) of the cases, a lingual graft was used in 32.1% (99/308). Postoperative complications were observed in 15.9% (49/308) of the cases: 12.2% after the open technique, 10.4% after the robotic technique and 20.2% after the laparoscopic technique. With a postoperative follow-up period of 1 to 85 months (average 15.3 months), treatment success was achieved in 92.5% (285/308) of the cases: 93.8% for open technique, 88.2% for robotic, 98.0% for laparoscopic.
Conclusion. The use of the oral mucosa for ureteroplasty due to benign ureteral stricture allows high rates of efficiency and safety. The results of ureteroplasty do not depend on the choice of surgical approach, type of graft and graft transplantation technique.
