Scandinavian Journal of Urology
ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: http://www.tandfonline.com/loi/isju20
Yang–Monti ileal ureter reconstruction Thomas Maigaard & Hans Joergen Kirkeby To cite this article: Thomas Maigaard & Hans Joergen Kirkeby (2015) Yang–Monti ileal ureter reconstruction, Scandinavian Journal of Urology, 49:4, 313-318, DOI: 10.3109/21681805.2014.882980 To link to this article: http://dx.doi.org/10.3109/21681805.2014.882980
Published online: 11 Feb 2015.
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Date: 09 October 2017, At: 12:08
Scandinavian Journal of Urology. 2015; 49: 313–318
ORIGINAL ARTICLE
Yang–Monti ileal ureter reconstruction
THOMAS MAIGAARD & HANS JOERGEN KIRKEBY
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Department of Urology, Aarhus University Hospital Skejby, Denmark
Abstract Objective. The aim of this study was to present experience with ureteral reconstruction using the Yang–Monti technique with reconfigured ileal segments. Material and methods. Between 2006 and 2010, five patients underwent complete unilateral ureteral substitution with the Yang–Monti technique, whereby short segments of ileum were incised paramesenterically, joined and transversely tubularized to form a neoureter of suitable length and cross-sectional diameter to bridge large ureteral defects. The causes of the ureteral defects were strictly iatrogenic. Two of the five patients were reconstructed acutely, while the others were repaired after 3–5 months with a nephrostomy diversion in the intervening period. Results. Four of the five patients had patent neoureters, while one sustained a stricture, necessitating permanent double-J stenting. Mean follow-up was 41 months (range 13–62 months). Split renal function for two of the patients was markedly reduced but notably with no elevation in creatinine or apparent loss of renal function. Three of the five patients had immediate postoperative urinary leakage at the proximal anastomosis, necessitating drainage, prolonged double-J stenting and/or nephrostomy diversion. Conclusion. In cases of ureteral defects deemed too extensive for traditional reconstruction techniques such as the psoas hitch and/or Boari flap, the technique demonstrated here, using reconfigured ileal segments, is a viable alternative to nephrectomy and autotransplantation. Acute reconstruction within 24 h after the ureteral lesion is also feasible. In general, care must be taken to avoid urinary leakage, particularly at the proximal anastomosis, which may result in prolonged hospitalization and double-J stenting. The protocol should include frequent follow-up to avoid long-term loss of renal function.
Key Words: ileum, reconstruction, ureter, ureteral substitution, Yang–Monti
Introduction Reconstruction of ureteral defects or stenotic sections too large to bridge using intrinsic urinary tract tissue with a psoas hitch, Boari flap or transureter ureterostomy has traditionally required nephrectomy, renal autotransplantation or replacement with a long simple ileal segment. In the past decade, however, there has been a trend towards using reconfigured small sections of either ileum or colon for reconstruction. The reconfigurement of bowel segments into tubes of suitable length and diameter was originally described by Yang in 1993 [1] and verified by Monti et al. in 1997 [2] as an alternative to using the appendix for continent urinary diversions. Pope and Koch were the first to
report the use of reconfigured bowel segment (colon) for ureteral substitution in a single patient in 1996 [3]. This principle was later evaluated experimentally and clinically by D’Elia et al. and Ali-el-Dein and Ghoneim [4,5]. More clinical reports of using this Yang–Monti principle in bridging large ureteral defects are emerging. Including the present report, a Medline search yields a total of 52 reported cases [5–9]. The aetiology behind ureteral defects necessitating such extensive reconstruction is mainly iatrogenic, due to endourological, gynaecological and intestinal surgical procedures or radiotherapy. Other causes include strictures due to retroperitoneal fibrosis (Ormond’s disease), or following bilharzia or tuberculosis infection [6].
Correspondence: T. Maigaard, Department of Urology, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, Aarhus, 8200, Denmark. E-mail: [email protected]
(Received 4 November 2013; accepted 5 January 2014) ISSN 2168-1805 print/ISSN 2168-1813 online Ó 2015 Informa Healthcare DOI: 10.3109/21681805.2014.882980
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Yang–Monti reconfigured bowel technique A section of approximately 5–7.5 cm, depending on the length of ureteral damage, of bowel (typically ileum) (Figure 1) is isolated on its mesenteric branch. Intestinal continuity is restored with either a side-toside or an end-to-end anastomosis, typically using a traditional Davos technique. The isolated ileal segment is then divided into two or three ileal pieces of approximately 2.5 cm width with accompanying mesenteric blood supply. These rings are opened with an incision at the paramesenteric border. The strips of ileal tissue are unfolded, now measuring approximately 2.5 cm in width and 6–7 cm in length (Figure 2). These two or three strips are joined at the 2.5 cm ends, typically with 4-0 absorbable suture (Figure 3), to make a rectangular piece of 12– 18 cm in length, which is then tubularized around a 12 Fr catheter to form a tube of suitable length and a cross-sectional diameter comparable to that of a native ureter (Figure 4). In the case of a left ureter replacement the tube is tunnelled through an opening in the mesentery of the descending colon. The reconfigured ileal neoureter is then anastomosed to the proximal ureteric stump or renal pelvis in a spatulated, end-to-end fashion and distally to the native bladder mucosa in a Lich–Gregoir fashion to prevent reflux during micturition. The paramesenteric incision of the bowel ring segments allows for a relatively mesentery-free part of the ileal tube to be tunnelled into the bladder wall (Figure 5). There are several explanations for the apparent increased popularity of the Yang–Monti technique compared with the non-reconfigured (simple) ileal ureter replacement.
Two ileal strips
Figure 2. Intestinal sections incised at the paramesenteric border, leaving two strips of tissue.
In the simple ileal ureter replacement, a bowel segment matching the length of the ureteral defect is needed, often 12–18 cm or more, compared with only 5–7.5 cm for the reconfigured bowel. The surface of intestinal mucosa in contact with the urine is significantly reduced with the latter technique. These
Suitable ileal segments Joined end-to-end
Figure 1. Intestinal sections isolated with their mesenteric branch. The continuity of the small intestine is restored.
Figure 3. Intestinal strips joined end to end.
Yang–Monti ileal ureter reconstruction 12 Fr. Catheter
Neo-ureter
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Mesentery branch
Figure 4. The tissue plate tubularized around a 12 Fr catheter to form the neoureter.
conditions reduce the risk of metabolic disturbances such as hyperchloraemic acidosis, which have been reported when using a long simple ileal segment [10– 12]. No patient in the reported 37 cases with reconfigured bowel segments, where follow-up included blood gas parameters, suffered from metabolic disturbances. Another advantage of the reduced surface
315
area of mucosa is less mucus secretion. No incidents of obstruction due to mucus were reported for reconfigured neoureter, in contrast to the non-reconfigured ureter [13]. The decreased tube diameter further allows for an efficient antireflux implantation in the bladder. Postoperative cystography/micturating cystourethrography (MCU) showed reflux in only two of 31 cases with antireflux bladder implantation in the collective reports of Ali-el-Dein, Esmat and Steffens [5–7]. It is the general assumption that the smaller diameter tube facilitates the transport of urine from renal pelvis to bladder in a more physiological manner with little functional obstruction, in contrast to reports from the simple ileal ureter anastomosis to the bladder [11]. A unidirectional propulsion of the urinary bolus by the reorganized circular and longitudinal muscle layers of the intestinal segments has been postulated [2]. The use of colonic segments has also been reported, as first described by Pope and Koch in 1996 [3]. More reports have emerged since then, with Lazica et al. providing the largest series of 14 patients reconstructed with a colonic segment [14]. Proponents of this technique highlight certain advantages, such as the larger diameter of the colonic segments, providing longer reconfigured neoureter segments compared with the ileal segments, and the close
Neo-ureter bridging a large defect between bladder and proximal ureter-with double J stent
Figure 5. Proximally, the neoureter is joined to the native ureter; distally, it is tunnelled under the detrusor muscle.
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T. Maigaard & H. J. Kirkeby
proximity of the colon to the ureter in general [15]. In the case of prior radiotherapy involving the small bowel field or extensive small bowel adhesion, colon could be used as an alternative to ileum. Although reported cases of reconfigured colonic neoureters have now reached a total of 20 patients worldwide [3,8,14,15], experience with ileal segments is still greater (52 cases).
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Material and methods This study reports the authors’ experience from 2006 to 2010 with five patients in whom a large ureteral defect or stenotic section was replaced with reconfigured ileal segments using the Yang–Monti technique described above. It should be noted that antireflux anastomosis at the bladder was not carried out in this patient group. Only two ileal segments were used in all five patients, necessitating a psoas hitch and/or Boari flap in three of the five patients. All data were collected retrospectively. One woman and four men underwent the procedure. Mean age was 47 years (range 25–62 years). In four of the five cases the cause of ureteral damage was total avulsion of the left ureter during endourological stone removal. The last patient had experienced a 4-year long course of disease with retroperitoneal fibrosis after radiation therapy for testicular cancer in his youth, undergoing ureterolysis and subsequent Memocath stenting before reconstruction. Two of the four patients with endourological ureteral avulsion were reconstructed acutely, i.e. within 24 h of the endourological procedure. The other two were operated on after 4 months with a nephrostomy diversion. Only one patient had a renal isotope scan performed before the ureteral lesion. Possible metabolic disturbances (measurements of the degree of acidosis or B12 vitamin levels) were not evaluated. Follow-up included evaluation of renal function and obstruction by computed tomographic (CT) urography, ultrasound, renal isotope scans and measurement of creatinine levels. Results Mean follow-up was 41 months (range 13– 62 months). Mean length of stay was 13 days, while mean time until double-J stent removal was 100 days (range 65–150 days). One patient developed a severe stricture at the proximal (ileal–pelvic) anastomosis, requiring continued use of the double-J stent at the most recent follow-up at 57 months following reconstruction. There were no non-urinary tract-related complications, apart from one superficial wound haematoma,
which resolved spontaneously with conservative treatment. Notably, there were no intestinal complications. One patient developed postoperative renal insufficiency (ATIN), presumably due to a combination of hypertension, angiotensin-converting enzyme inhibitor treatment and gentamicin prophylaxis during surgery. Kidney function gradually resolved to preoperative level after 4–5 weeks. Three patients were treated for mild postoperative urinary tract infection (UTI), resolving after one course of antibiotics. There were no reports of recurrent UTI in any patient and there was no excessive mucus secretion causing obstruction. Three of the five patients were identified as having urinary leakage at the proximal anastomosis on pyelography through their nephrostomy. This led to additional external drainage of the urinoma and prolonged nephrostomy and double-J stenting. Leakage resolved after a mean of 15 days with the nephrostomy (20, 10 and 17 days). One patient with leakage retained his nephrostomy for 3 months owing to persistent failure of the urine to pass through the reconfigured ileal ureter. This was apparently due to a combination of blood clotting in the proximal ureter and a relative stricture around a clotted double-J stent. The problem subsided following stent removal and nephrostomy. There was no apparent stricture on retrograde pyelography and ureteroscopy on follow-up. Renal function and creatinine Patient no. 1 (endourological avulsion) showed no loss of renal function at the 3 year follow-up renal isotope scan, with a split kidney function of 49/51% and a creatinine level that remained stable and normal throughout the entire 62 month follow-up. Patient no. 2 (endourological avulsion) had a double-J stent for 5 months, while CT urography at 6 months showed reduced kidney size and slight dilatation of the renal pelvis, but no apparent stricture. Renal isotope scanning at 9 months revealed a split function of only 12% to the left kidney. There was no preoperative renal scan to compare with these findings. The patient was admitted with urinary sepsis and pyonephrosis due to obstruction from the stone in the ureteropelvic junction (UPJ) 1 month before the endourological procedure, and this may have contributed to the loss of renal function. The creatinine level was stable and normal at the most recent follow-up, 55 months postoperatively. Patient no. 3 (endourological avulsion) had a split renal function of 27% to the affected side at the 4 month follow-up renal isotope scan and slow elimination, but no apparent obstruction. The last renal
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Yang–Monti ileal ureter reconstruction scan at 17 months revealed a preserved function of 25%. However, no preoperative renal isotope scan was performed and his polycystic renal disease may have contributed to the reduced function on the affected left side. Creatinine levels showed little deviation, with 95 mol/l before and 106 mol/l at the most recent follow-up at 17 months. Patient no. 4 (endourological avulsion) had slight dilatation of the renal pelvis on CT urography at the 5 month follow-up, with discrete symptoms from the left loin. Renal isotope scanning at the 10 month follow-up showed a split function of 38% to the affected side and no apparent obstruction. At the last follow-up, at 13 months, the split function was 43% and the intermittent symptoms had improved. Patient no. 5 (reconstruction after radiotherapy and ureterolysis) had stricture at both the distal and proximal anastomosis, still requiring a double-J stent at 57 months of follow-up. The creatinine level, however, was stable compared with the preoperative value (166 mol/l and 179 mol/l respectively). No renal isotope scan was performed at any time. Discussion The majority of ureteral lesions are a result of gynaecological procedures [16,17]. These can often be repaired either by direct reimplantation of the affected ureter in the bladder or by bridging the defect with a psoas hitch or Boari flap and in selected cases simply with a temporary double-J stent. This is primarily due to the distal localization of these injuries. Four of the five patients in this series required repair because of avulsion of the left ureter during an endourological procedure. This is consistent with the large series reported by Esmat et al. [6], in which 12 of the reported 16 cases of ureteral injury were due to endourological procedures. Steffens et al. [7] reported 18 cases, of which three were due to endourology, and the remainder to gynaecological and general surgery, radiotherapy or retroperitoneal fibrosis. Ali-el-Dein and Ghoneim [5] reported 10 patients, of whom nine had lesions due to endemic bilharzia or tuberculosis, thus demonstrating the diversity in aetiology behind these lesions. It should be noted that our Yang–Monti reconfiguration of the ileal segments does not include an antireflux anastomosis to the bladder, in the manner of Lich–Gregoir. Furthermore, only two ileal segments were used for the reconstruction. This further necessitated a psoas hitch and/or Boari flap in four out of five patients. Postoperative leakage was identified in three of the five patients regardless of a functioning nephrostomy and double-J stent. These leaks were all located at the proximal anastomosis between the ileal
317
segment and the renal pelvis/UPJ and not along the ileal segments or the junction between them. It has been noted that performing the incision of the bowel ring segments antimesenterically instead of paramestenterically may improve blood supply to the anastomosing ends of the reconfigured bowel tubes [14]. This remains speculative, but the authors’ experience with proximal leakages suggests and stresses the need for meticulous, tension-free surgical technique when performing these anastomoses. A double-J stent and a nephrostomy are also recommended. Since no leakages have been reported between or along the actual ileal segments, it seems intuitively safe to use three ileal segments instead of two, thus avoiding the need for a hitch or Boari flap and also providing an opportunity for antireflux implantation in the bladder [6]. Of the 33 cases reported by Esmat, Ali-el-Dein and Steffens with antirefluxing implantation, there were only two cases of reflux identified by MCU/retrograde cystography. The present material cannot contribute to these data because of the lack of MCU on followup. However, there have been no reports of functional stricture at the Lich–Gregoir-type vesicoileal anastomoses in previously published series. This technique appears safe to perform and intuitively is reasonable in mimicking the course of the native ureter through the bladder wall. One patient in this series required double-J stenting and another had a split renal function of 12% on the affected side at follow-up, even though creatinine levels remained normal. Only one patient had a preoperative renal isotope scan, partly due to the acute reconstruction in two of the five patients, which limits the evaluation of the procedure in this series. Other causes, such as polycystic renal disease in one and pyonephrosis before reconstruction in another patient, may have contributed to the reduced split renal function after surgery. In conclusion, four out of five ureteral reconstructions using the Yang–Monti technique described herein were patent after follow-up at 13–42 months. There were no intestinal complications, no recurrent UTIs and no complaints of excessive mucus secretion. Importantly, acute reconstruction of the ureteral lesions appears to be feasible. Three of the five patients in this series suffered leakage at the proximal anastomosis, suggesting the need for special attention at this stage of the procedure. The authors recommend frequent follow-up for this patient group, owing to the extensive nature of the reconstructive procedure. The Yang–Monti reconfigured ileal segments offer a feasible reconstruction of large ureter defects, with a reported and updated experience of 52 cases.
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Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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References [1] Yang WH. Yang needle tunneling technique in creating antireflux and continent mechanisms. J Urol 1993;150: 830–4. [2] Monti PR, Lara RC, Dutra MA, de Carvalho JR. New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology 1997;49:112–15. [3] Pope J, Koch MO. Ureteral replacement with reconfigured colon substitute. J Urol 1996;155:1693–5. [4] D’Elia G, Ali-el-Dein B, Thuroff J, El-Mekresh M, El-Baz M, Ghoneim MA. Reconfigured anti-refluxive ileal ureter: a novel surgical technique. BJU Int 2001;88(Suppl): 75. [5] Ali-el-Dein B, Ghoneim MA. Bridging long ureteral defects using the Yang–Monti principle. J Urol 2003;169:1074–7. [6] Esmat M, Abdelaal A, Mostafa D. Application of Yang– Monti principle in ileal ureter substitution: is it a beneficial modification? Int Braz J Urol 2012;38:779–85; discussion 785–7. [7] Steffens JA, Anheuser P, Reisch B, Treiyer AE. Ureteric reconstruction with reconfigured ileal segments according to Yang–Monti. A 4-year prospective report. Urologe A 2010; 49:262–7.
[8] Castellan M, Gosalbez R. Ureteral replacement using the Yang–Monti principle: long-term follow-up. Urology 2006; 67:476–9. [9] Kamat NN, Khandelwal P. Laparoscopy-assisted reconstruction of a long-segment ureteral stricture using reconfigured ileal segment: application of the Yang Monti principle. J Endourol 2007;21:1455–60. [10] Armatys SA, Mellon MJ, Beck SD, Koch MO, Foster RS, Bihrle R. Use of ileum as ureteral replacement in urological reconstruction. J Urol 2009;181:177–81. [11] Shokeir AA, Gaballah MA, Ashamallah AA, Ghoneim MA. Optimization of replacement of the ureter by ileum. J Urol 1991;146:306. [12] Verduyckt FJ, Heesakkers JP, Debruyne FM. Long-term results of ileum interposition for ureteral obstruction. Eur Urol 2002;42:181–7. [13] Bonfig R, Gerharz EW, Riedmiller H. Ileal ureteric replacement in complex reconstruction of the urinary tract. BJU Int 2004;93:575–80. [14] Lazica DA, Ubrig B, Brandt AS, von Rundstedt FC, Roth S. Ureteral substitution with reconfigured colon: long-term followup. J Urol 2012;187:542–8. [15] Ubrig B, Waldner M, Roth S. Reconstruction of ureter with transverse retubularized colon segments. J Urol 2001;166: 973. [16] Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004;94:277–89. [17] Lynch TH, Martínez-Piñeiro L, Plas E, Serafetinides E, Türkeri L, Santucci RA, et al. EAU guidelines on urological trauma. Eur Urol 2005;47:1–15.
ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: http://www.tandfonline.com/loi/isju20
Yang–Monti ileal ureter reconstruction Thomas Maigaard & Hans Joergen Kirkeby To cite this article: Thomas Maigaard & Hans Joergen Kirkeby (2015) Yang–Monti ileal ureter reconstruction, Scandinavian Journal of Urology, 49:4, 313-318, DOI: 10.3109/21681805.2014.882980 To link to this article: http://dx.doi.org/10.3109/21681805.2014.882980
Published online: 11 Feb 2015.
Submit your article to this journal
Article views: 153
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju20 Download by: [Southern Cross University]
Date: 09 October 2017, At: 12:08
Scandinavian Journal of Urology. 2015; 49: 313–318
ORIGINAL ARTICLE
Yang–Monti ileal ureter reconstruction
THOMAS MAIGAARD & HANS JOERGEN KIRKEBY
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Department of Urology, Aarhus University Hospital Skejby, Denmark
Abstract Objective. The aim of this study was to present experience with ureteral reconstruction using the Yang–Monti technique with reconfigured ileal segments. Material and methods. Between 2006 and 2010, five patients underwent complete unilateral ureteral substitution with the Yang–Monti technique, whereby short segments of ileum were incised paramesenterically, joined and transversely tubularized to form a neoureter of suitable length and cross-sectional diameter to bridge large ureteral defects. The causes of the ureteral defects were strictly iatrogenic. Two of the five patients were reconstructed acutely, while the others were repaired after 3–5 months with a nephrostomy diversion in the intervening period. Results. Four of the five patients had patent neoureters, while one sustained a stricture, necessitating permanent double-J stenting. Mean follow-up was 41 months (range 13–62 months). Split renal function for two of the patients was markedly reduced but notably with no elevation in creatinine or apparent loss of renal function. Three of the five patients had immediate postoperative urinary leakage at the proximal anastomosis, necessitating drainage, prolonged double-J stenting and/or nephrostomy diversion. Conclusion. In cases of ureteral defects deemed too extensive for traditional reconstruction techniques such as the psoas hitch and/or Boari flap, the technique demonstrated here, using reconfigured ileal segments, is a viable alternative to nephrectomy and autotransplantation. Acute reconstruction within 24 h after the ureteral lesion is also feasible. In general, care must be taken to avoid urinary leakage, particularly at the proximal anastomosis, which may result in prolonged hospitalization and double-J stenting. The protocol should include frequent follow-up to avoid long-term loss of renal function.
Key Words: ileum, reconstruction, ureter, ureteral substitution, Yang–Monti
Introduction Reconstruction of ureteral defects or stenotic sections too large to bridge using intrinsic urinary tract tissue with a psoas hitch, Boari flap or transureter ureterostomy has traditionally required nephrectomy, renal autotransplantation or replacement with a long simple ileal segment. In the past decade, however, there has been a trend towards using reconfigured small sections of either ileum or colon for reconstruction. The reconfigurement of bowel segments into tubes of suitable length and diameter was originally described by Yang in 1993 [1] and verified by Monti et al. in 1997 [2] as an alternative to using the appendix for continent urinary diversions. Pope and Koch were the first to
report the use of reconfigured bowel segment (colon) for ureteral substitution in a single patient in 1996 [3]. This principle was later evaluated experimentally and clinically by D’Elia et al. and Ali-el-Dein and Ghoneim [4,5]. More clinical reports of using this Yang–Monti principle in bridging large ureteral defects are emerging. Including the present report, a Medline search yields a total of 52 reported cases [5–9]. The aetiology behind ureteral defects necessitating such extensive reconstruction is mainly iatrogenic, due to endourological, gynaecological and intestinal surgical procedures or radiotherapy. Other causes include strictures due to retroperitoneal fibrosis (Ormond’s disease), or following bilharzia or tuberculosis infection [6].
Correspondence: T. Maigaard, Department of Urology, Aarhus University Hospital Skejby, Brendstrupgaardsvej 100, Aarhus, 8200, Denmark. E-mail: [email protected]
(Received 4 November 2013; accepted 5 January 2014) ISSN 2168-1805 print/ISSN 2168-1813 online Ó 2015 Informa Healthcare DOI: 10.3109/21681805.2014.882980
314
T. Maigaard & H. J. Kirkeby
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Yang–Monti reconfigured bowel technique A section of approximately 5–7.5 cm, depending on the length of ureteral damage, of bowel (typically ileum) (Figure 1) is isolated on its mesenteric branch. Intestinal continuity is restored with either a side-toside or an end-to-end anastomosis, typically using a traditional Davos technique. The isolated ileal segment is then divided into two or three ileal pieces of approximately 2.5 cm width with accompanying mesenteric blood supply. These rings are opened with an incision at the paramesenteric border. The strips of ileal tissue are unfolded, now measuring approximately 2.5 cm in width and 6–7 cm in length (Figure 2). These two or three strips are joined at the 2.5 cm ends, typically with 4-0 absorbable suture (Figure 3), to make a rectangular piece of 12– 18 cm in length, which is then tubularized around a 12 Fr catheter to form a tube of suitable length and a cross-sectional diameter comparable to that of a native ureter (Figure 4). In the case of a left ureter replacement the tube is tunnelled through an opening in the mesentery of the descending colon. The reconfigured ileal neoureter is then anastomosed to the proximal ureteric stump or renal pelvis in a spatulated, end-to-end fashion and distally to the native bladder mucosa in a Lich–Gregoir fashion to prevent reflux during micturition. The paramesenteric incision of the bowel ring segments allows for a relatively mesentery-free part of the ileal tube to be tunnelled into the bladder wall (Figure 5). There are several explanations for the apparent increased popularity of the Yang–Monti technique compared with the non-reconfigured (simple) ileal ureter replacement.
Two ileal strips
Figure 2. Intestinal sections incised at the paramesenteric border, leaving two strips of tissue.
In the simple ileal ureter replacement, a bowel segment matching the length of the ureteral defect is needed, often 12–18 cm or more, compared with only 5–7.5 cm for the reconfigured bowel. The surface of intestinal mucosa in contact with the urine is significantly reduced with the latter technique. These
Suitable ileal segments Joined end-to-end
Figure 1. Intestinal sections isolated with their mesenteric branch. The continuity of the small intestine is restored.
Figure 3. Intestinal strips joined end to end.
Yang–Monti ileal ureter reconstruction 12 Fr. Catheter
Neo-ureter
Downloaded by [Southern Cross University] at 12:08 09 October 2017
Mesentery branch
Figure 4. The tissue plate tubularized around a 12 Fr catheter to form the neoureter.
conditions reduce the risk of metabolic disturbances such as hyperchloraemic acidosis, which have been reported when using a long simple ileal segment [10– 12]. No patient in the reported 37 cases with reconfigured bowel segments, where follow-up included blood gas parameters, suffered from metabolic disturbances. Another advantage of the reduced surface
315
area of mucosa is less mucus secretion. No incidents of obstruction due to mucus were reported for reconfigured neoureter, in contrast to the non-reconfigured ureter [13]. The decreased tube diameter further allows for an efficient antireflux implantation in the bladder. Postoperative cystography/micturating cystourethrography (MCU) showed reflux in only two of 31 cases with antireflux bladder implantation in the collective reports of Ali-el-Dein, Esmat and Steffens [5–7]. It is the general assumption that the smaller diameter tube facilitates the transport of urine from renal pelvis to bladder in a more physiological manner with little functional obstruction, in contrast to reports from the simple ileal ureter anastomosis to the bladder [11]. A unidirectional propulsion of the urinary bolus by the reorganized circular and longitudinal muscle layers of the intestinal segments has been postulated [2]. The use of colonic segments has also been reported, as first described by Pope and Koch in 1996 [3]. More reports have emerged since then, with Lazica et al. providing the largest series of 14 patients reconstructed with a colonic segment [14]. Proponents of this technique highlight certain advantages, such as the larger diameter of the colonic segments, providing longer reconfigured neoureter segments compared with the ileal segments, and the close
Neo-ureter bridging a large defect between bladder and proximal ureter-with double J stent
Figure 5. Proximally, the neoureter is joined to the native ureter; distally, it is tunnelled under the detrusor muscle.
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T. Maigaard & H. J. Kirkeby
proximity of the colon to the ureter in general [15]. In the case of prior radiotherapy involving the small bowel field or extensive small bowel adhesion, colon could be used as an alternative to ileum. Although reported cases of reconfigured colonic neoureters have now reached a total of 20 patients worldwide [3,8,14,15], experience with ileal segments is still greater (52 cases).
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Material and methods This study reports the authors’ experience from 2006 to 2010 with five patients in whom a large ureteral defect or stenotic section was replaced with reconfigured ileal segments using the Yang–Monti technique described above. It should be noted that antireflux anastomosis at the bladder was not carried out in this patient group. Only two ileal segments were used in all five patients, necessitating a psoas hitch and/or Boari flap in three of the five patients. All data were collected retrospectively. One woman and four men underwent the procedure. Mean age was 47 years (range 25–62 years). In four of the five cases the cause of ureteral damage was total avulsion of the left ureter during endourological stone removal. The last patient had experienced a 4-year long course of disease with retroperitoneal fibrosis after radiation therapy for testicular cancer in his youth, undergoing ureterolysis and subsequent Memocath stenting before reconstruction. Two of the four patients with endourological ureteral avulsion were reconstructed acutely, i.e. within 24 h of the endourological procedure. The other two were operated on after 4 months with a nephrostomy diversion. Only one patient had a renal isotope scan performed before the ureteral lesion. Possible metabolic disturbances (measurements of the degree of acidosis or B12 vitamin levels) were not evaluated. Follow-up included evaluation of renal function and obstruction by computed tomographic (CT) urography, ultrasound, renal isotope scans and measurement of creatinine levels. Results Mean follow-up was 41 months (range 13– 62 months). Mean length of stay was 13 days, while mean time until double-J stent removal was 100 days (range 65–150 days). One patient developed a severe stricture at the proximal (ileal–pelvic) anastomosis, requiring continued use of the double-J stent at the most recent follow-up at 57 months following reconstruction. There were no non-urinary tract-related complications, apart from one superficial wound haematoma,
which resolved spontaneously with conservative treatment. Notably, there were no intestinal complications. One patient developed postoperative renal insufficiency (ATIN), presumably due to a combination of hypertension, angiotensin-converting enzyme inhibitor treatment and gentamicin prophylaxis during surgery. Kidney function gradually resolved to preoperative level after 4–5 weeks. Three patients were treated for mild postoperative urinary tract infection (UTI), resolving after one course of antibiotics. There were no reports of recurrent UTI in any patient and there was no excessive mucus secretion causing obstruction. Three of the five patients were identified as having urinary leakage at the proximal anastomosis on pyelography through their nephrostomy. This led to additional external drainage of the urinoma and prolonged nephrostomy and double-J stenting. Leakage resolved after a mean of 15 days with the nephrostomy (20, 10 and 17 days). One patient with leakage retained his nephrostomy for 3 months owing to persistent failure of the urine to pass through the reconfigured ileal ureter. This was apparently due to a combination of blood clotting in the proximal ureter and a relative stricture around a clotted double-J stent. The problem subsided following stent removal and nephrostomy. There was no apparent stricture on retrograde pyelography and ureteroscopy on follow-up. Renal function and creatinine Patient no. 1 (endourological avulsion) showed no loss of renal function at the 3 year follow-up renal isotope scan, with a split kidney function of 49/51% and a creatinine level that remained stable and normal throughout the entire 62 month follow-up. Patient no. 2 (endourological avulsion) had a double-J stent for 5 months, while CT urography at 6 months showed reduced kidney size and slight dilatation of the renal pelvis, but no apparent stricture. Renal isotope scanning at 9 months revealed a split function of only 12% to the left kidney. There was no preoperative renal scan to compare with these findings. The patient was admitted with urinary sepsis and pyonephrosis due to obstruction from the stone in the ureteropelvic junction (UPJ) 1 month before the endourological procedure, and this may have contributed to the loss of renal function. The creatinine level was stable and normal at the most recent follow-up, 55 months postoperatively. Patient no. 3 (endourological avulsion) had a split renal function of 27% to the affected side at the 4 month follow-up renal isotope scan and slow elimination, but no apparent obstruction. The last renal
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Yang–Monti ileal ureter reconstruction scan at 17 months revealed a preserved function of 25%. However, no preoperative renal isotope scan was performed and his polycystic renal disease may have contributed to the reduced function on the affected left side. Creatinine levels showed little deviation, with 95 mol/l before and 106 mol/l at the most recent follow-up at 17 months. Patient no. 4 (endourological avulsion) had slight dilatation of the renal pelvis on CT urography at the 5 month follow-up, with discrete symptoms from the left loin. Renal isotope scanning at the 10 month follow-up showed a split function of 38% to the affected side and no apparent obstruction. At the last follow-up, at 13 months, the split function was 43% and the intermittent symptoms had improved. Patient no. 5 (reconstruction after radiotherapy and ureterolysis) had stricture at both the distal and proximal anastomosis, still requiring a double-J stent at 57 months of follow-up. The creatinine level, however, was stable compared with the preoperative value (166 mol/l and 179 mol/l respectively). No renal isotope scan was performed at any time. Discussion The majority of ureteral lesions are a result of gynaecological procedures [16,17]. These can often be repaired either by direct reimplantation of the affected ureter in the bladder or by bridging the defect with a psoas hitch or Boari flap and in selected cases simply with a temporary double-J stent. This is primarily due to the distal localization of these injuries. Four of the five patients in this series required repair because of avulsion of the left ureter during an endourological procedure. This is consistent with the large series reported by Esmat et al. [6], in which 12 of the reported 16 cases of ureteral injury were due to endourological procedures. Steffens et al. [7] reported 18 cases, of which three were due to endourology, and the remainder to gynaecological and general surgery, radiotherapy or retroperitoneal fibrosis. Ali-el-Dein and Ghoneim [5] reported 10 patients, of whom nine had lesions due to endemic bilharzia or tuberculosis, thus demonstrating the diversity in aetiology behind these lesions. It should be noted that our Yang–Monti reconfiguration of the ileal segments does not include an antireflux anastomosis to the bladder, in the manner of Lich–Gregoir. Furthermore, only two ileal segments were used for the reconstruction. This further necessitated a psoas hitch and/or Boari flap in four out of five patients. Postoperative leakage was identified in three of the five patients regardless of a functioning nephrostomy and double-J stent. These leaks were all located at the proximal anastomosis between the ileal
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segment and the renal pelvis/UPJ and not along the ileal segments or the junction between them. It has been noted that performing the incision of the bowel ring segments antimesenterically instead of paramestenterically may improve blood supply to the anastomosing ends of the reconfigured bowel tubes [14]. This remains speculative, but the authors’ experience with proximal leakages suggests and stresses the need for meticulous, tension-free surgical technique when performing these anastomoses. A double-J stent and a nephrostomy are also recommended. Since no leakages have been reported between or along the actual ileal segments, it seems intuitively safe to use three ileal segments instead of two, thus avoiding the need for a hitch or Boari flap and also providing an opportunity for antireflux implantation in the bladder [6]. Of the 33 cases reported by Esmat, Ali-el-Dein and Steffens with antirefluxing implantation, there were only two cases of reflux identified by MCU/retrograde cystography. The present material cannot contribute to these data because of the lack of MCU on followup. However, there have been no reports of functional stricture at the Lich–Gregoir-type vesicoileal anastomoses in previously published series. This technique appears safe to perform and intuitively is reasonable in mimicking the course of the native ureter through the bladder wall. One patient in this series required double-J stenting and another had a split renal function of 12% on the affected side at follow-up, even though creatinine levels remained normal. Only one patient had a preoperative renal isotope scan, partly due to the acute reconstruction in two of the five patients, which limits the evaluation of the procedure in this series. Other causes, such as polycystic renal disease in one and pyonephrosis before reconstruction in another patient, may have contributed to the reduced split renal function after surgery. In conclusion, four out of five ureteral reconstructions using the Yang–Monti technique described herein were patent after follow-up at 13–42 months. There were no intestinal complications, no recurrent UTIs and no complaints of excessive mucus secretion. Importantly, acute reconstruction of the ureteral lesions appears to be feasible. Three of the five patients in this series suffered leakage at the proximal anastomosis, suggesting the need for special attention at this stage of the procedure. The authors recommend frequent follow-up for this patient group, owing to the extensive nature of the reconstructive procedure. The Yang–Monti reconfigured ileal segments offer a feasible reconstruction of large ureter defects, with a reported and updated experience of 52 cases.
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T. Maigaard & H. J. Kirkeby
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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References [1] Yang WH. Yang needle tunneling technique in creating antireflux and continent mechanisms. J Urol 1993;150: 830–4. [2] Monti PR, Lara RC, Dutra MA, de Carvalho JR. New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology 1997;49:112–15. [3] Pope J, Koch MO. Ureteral replacement with reconfigured colon substitute. J Urol 1996;155:1693–5. [4] D’Elia G, Ali-el-Dein B, Thuroff J, El-Mekresh M, El-Baz M, Ghoneim MA. Reconfigured anti-refluxive ileal ureter: a novel surgical technique. BJU Int 2001;88(Suppl): 75. [5] Ali-el-Dein B, Ghoneim MA. Bridging long ureteral defects using the Yang–Monti principle. J Urol 2003;169:1074–7. [6] Esmat M, Abdelaal A, Mostafa D. Application of Yang– Monti principle in ileal ureter substitution: is it a beneficial modification? Int Braz J Urol 2012;38:779–85; discussion 785–7. [7] Steffens JA, Anheuser P, Reisch B, Treiyer AE. Ureteric reconstruction with reconfigured ileal segments according to Yang–Monti. A 4-year prospective report. Urologe A 2010; 49:262–7.
[8] Castellan M, Gosalbez R. Ureteral replacement using the Yang–Monti principle: long-term follow-up. Urology 2006; 67:476–9. [9] Kamat NN, Khandelwal P. Laparoscopy-assisted reconstruction of a long-segment ureteral stricture using reconfigured ileal segment: application of the Yang Monti principle. J Endourol 2007;21:1455–60. [10] Armatys SA, Mellon MJ, Beck SD, Koch MO, Foster RS, Bihrle R. Use of ileum as ureteral replacement in urological reconstruction. J Urol 2009;181:177–81. [11] Shokeir AA, Gaballah MA, Ashamallah AA, Ghoneim MA. Optimization of replacement of the ureter by ileum. J Urol 1991;146:306. [12] Verduyckt FJ, Heesakkers JP, Debruyne FM. Long-term results of ileum interposition for ureteral obstruction. Eur Urol 2002;42:181–7. [13] Bonfig R, Gerharz EW, Riedmiller H. Ileal ureteric replacement in complex reconstruction of the urinary tract. BJU Int 2004;93:575–80. [14] Lazica DA, Ubrig B, Brandt AS, von Rundstedt FC, Roth S. Ureteral substitution with reconfigured colon: long-term followup. J Urol 2012;187:542–8. [15] Ubrig B, Waldner M, Roth S. Reconstruction of ureter with transverse retubularized colon segments. J Urol 2001;166: 973. [16] Brandes S, Coburn M, Armenakas N, McAninch J. Diagnosis and management of ureteric injury: an evidence-based analysis. BJU Int 2004;94:277–89. [17] Lynch TH, Martínez-Piñeiro L, Plas E, Serafetinides E, Türkeri L, Santucci RA, et al. EAU guidelines on urological trauma. Eur Urol 2005;47:1–15.
