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Onlay Repair Technique for the Management of Ureteral Strictures: a Comprehensive Review

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Onlay Repair Technique for the Management of Ureteral Strictures: a Comprehensive Review Hindawi BioMed Research International Volume 2020, Article ID 6178286, 11 pages https://doi.org/10.1155/2020/6178286 Review Article Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review Shengwei Xiong ,1,2,3 Jie Wang,1,2,3 Weijie Zhu,1,2,3 Kunlin Yang,1,2,3 Guangpu Ding,1,2,3 Xuesong Li ,1,2,3 and Daniel D. Eun 4 1Department of Urology, Peking University First Hospital, No. 8 Xishiku St, Xicheng District, Beijing 100034, China 2Institute of Urology, Peking University, No. 8 Xishiku St, Xicheng District, Beijing 100034, China 3National Urological Cancer Center, No. 8 Xishiku St, Xicheng District, Beijing 100034, China 4Department of Urology, Temple University School of Medicine, 255S 17th Street, 7th Floor Medical Tower, Philadelphia, PA 19103, USA Correspondence should be addressed to Xuesong Li; [email protected] and Daniel D. Eun; [email protected] Received 5 March 2020; Revised 29 June 2020; Accepted 6 July 2020; Published 28 July 2020 Academic Editor: Achim Langenbucher Copyright © 2020 Shengwei Xiong et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 1. Introduction tomosis either in the form of pyeloureteroplasty or ureter- oureterostomy [5, 6]. If a longer segment stricture is A ureteral stricture is characterized by a narrowing of the present, more advanced surgical techniques, such as renal ureter that causes a functional obstruction. As urinary drain- mobilization and downward nephropexy, ileal ureter replace- age becomes restrained, the urine is stagnated in the upper ment, transureteroureterostomy, and autotransplantation of tract and renal pelvis. This condition may cause renal pain the kidney, are necessary to provide a tension-free anastomo- and may lead to urinary tract infections or even renal failure sis. Unlike a proximal stricture, a distal ureteral stricture is if left untreated [1–3]. Ureteral strictures can be classified usually managed with ureteral reimplantation, achieving into proximal, middle, and distal ureteral strictures; panuret- additional length with a downward nephropexy procedure, eral strictures; and ureteropelvic junction obstruction a psoas hitch, or a Boari flap technique [7]. (UPJO), according to the sites of stricture [4]. Short- However, kidney autotransplantation requires high segment strictures of the proximal and middle ureter are usu- expertise during transplant surgery and may cause suscepti- ally reconstructed by endourological management or surgical bility to significant renovascular morbidity [8]. In addition, operations involving primary excision and end-to-end anas- the incorporation of a long bowel segment into the urinary 2 BioMed Research International tract is associated with severe metabolic and intestinal ronment. The common sites of oral mucosa graft (OMG) complications [9]. These issues pose a difficult manage- harvesting include the inner cheek or lip (buccal mucosa) ment dilemma for proximal and middle stricture, and and the lateral or ventral surface of the tongue (lingual muco- alternative options are urgently needed. Although the sae). The buccal and lingual mucosae have the same tissue strictured ureter is insufficient to achieve completely pat- characteristics, including a thick epithelium, high content of ent drainage, it can still provide a “ureteral plate” with elastic fibers, thin lamina propria, and high capillary density, minimally destructed blood supply after excising partial which are beneficial for promoting revascularization. Using circumference. Based on this theory, an onlay repair tech- buccal mucosa as a tube or an onlay/inlay graft for the treat- nique emerged. Recently, onlay ureteroplasty with grafts or ment of complex ureteral strictures has been reported previ- flaps has been attempted by many reconstructive urologists ously. Onlay repair means a graft applied or laid on the and has yielded encouraging outcomes. Herein, we mainly surface of a structure, while inlay repair means a graft inlaid evaluate the efficacy of some autologous materials and or inserted in the cavity of a structure [16]. And tubularized tissue-engineered material for onlay ureteroplasty in the repair means a graft reconfigured in tubular form. Currently, management of ureteral strictures and present an updated buccal mucosa graft (BMG) has gained wide acceptance as a review of this innovative technique. graft choice for onlay ureteroplasty. The pioneering attempt at using BMG as a nonpedicled, full-thickness tubularized 2. Histologic Considerations of graft for ureteral reconstruction was implemented on three Tissue Transferring baboons by Somerville and Naude in 1983 [17]. Encouraged by the results of buccal mucosal ureteral replacement in ani- A unique aspect of a graft in ureteral reconstruction is that mal studies and the recognized new gold standard of BMG the tissue is excised from the donor site and transferred to urethroplasty for the repair of urethral strictures or hypospa- the recipient site where a new blood supply develops [10]. dias [18], the initial experience with human ureteroplasty A flap is vascularized tissue that is transferred to the recipient with BMG was reported by Naude in 1999 [19]. Five patients site, maintaining its own blood supply [11]. The selection of who had complicated ureteral strictures caused by various the tissues for ureteroplasty is based on the characteristics of diseases were treated with buccal mucosa patch grafts and the ureteral strictures and the patient’s global situation. The an omental wrap. In all patients, the grafts maintained good morbidity of the donor site and the function of the site to patency and drainage, and there were no stricture recur- be reconstructed should also be considered. The success of rences after long-term follow-up [19]. tissue transfer technique is dependent on a good “take” pro- Till now, many single case reports [20–23] and case series cess through the rapid onset of the plasmatic imbibition and reports (as shown in Table 1) described the success of BMG inosculation phases, which are optimized with well- onlay ureteroplasty. The follow-up was from 3 to 85 months vascularized recipient beds, good apposition, and the immo- with success rates of 71.4%-100%. The length of ureteral bilization of the grafts [11]. In addition, grafts or flaps with a repair ranged from 1.5 cm to 11 cm. Kroepfl et al. reported thick epithelium, a thin lamina propria, and an abundant the reconstruction of long ureteral strictures utilizing buccal capillary plexus accelerate the imbibition and inosculation mucosal patch grafts and omental wrapping in six patients phases [12]. Graft failure is usually caused by fluid accumula- [24]. And they described the longest length (11 cm) of tion, such as hematoma or seroma, under the graft. This sit- ureteral stricture reconstructed by BMG ureteroplasty. All uation can be prevented through creating perforations in the patients showed good functional outcomes at an graft, graft meshing, and bolster dressing or vacuum-assisted intermediate-term follow-up. Recurrent strictures below the closure [13]. reconstructed ureter segment, causing impaired urinary To be suitable for incorporation into the urinary tract, a drainage, were found in both the patients with the longest graft should be hairless, easy to access and harvest, and viable segment BMG ureteroplasty and those with bilateral BMG in a urinary environment. A number of different tissues that ureteroplasty. However, how the reconstructed length and can be categorized as either mucosal grafts or skin grafts have position of the ureter influence urinary drainage remains been used for the purpose of ureteral reconstruction. After speculative. The authors assumed that this situation most long-term exposure to urine, some mucosal grafts retained likely resulted from the misjudgment of the distal
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