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Reconstructive Urology Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction Matthias D

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Reconstructive Urology Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction Matthias D Reconstructive Urology Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction Matthias D. Hofer,1 Hugo J. Aguilar-Cruz,1 Nirmish Singla, Billy H. Cordon, Jeremy M. Scott, and Allen F. Morey OBJECTIVE To evaluate renal mobilization with downward nephropexy as an adjunct maneuver to facilitate various methods of reconstruction of the upper urinary tract with limited ureteral length. MATERIALS AND We retrospectively reviewed all upper urinary tract reconstructive procedures performed from 2007 METHODS to 2015 to identify those requiring downward renal mobilization with nephropexy. Data includ- ing concomitant maneuvers, stricture location, prior surgeries, and intraoperative details were ana- lyzed. Success rates, defined by resolution of symptoms and avoidance of further intervention, and complications were evaluated. RESULTS Of 92 patients undergoing ureteral reconstruction during the study period, 18 (19.6%) involved renal mobilization with downward nephropexy to gain additional ureteral length (5/7 [71.4%] of ureterocalycostomies, 8/26 [30.1%] of Boari flap bladder reconfigurations, 4/12 [33.3%] of ureteroureterostomies, and 1/12 [8.3%] of ileal ureters). Two-thirds of patients (12/18, 66.7%) had undergone unsuccessful prior open, laparoscopic, or endoscopic reconstruction attempts. Renal mobilization was performed open in 15/18 (83.3%) cases and laparoscopically in 3/18 (16.7%). After renal mobilization, the average distance of downward movement achieved was 3.3 cm (range 3-5 cm). With a mean follow-up of 50.4 months (range 3-87 months), overall success rate defined as ureteral patency was 88.9%, with 2/18 patients (11.1%) requiring a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis. CONCLUSION Downward renal mobilization and nephropexy is a safe and versatile technique that can be ef- fectively combined with many other reconstructive maneuvers. UROLOGY 94: 232–236, 2016. © 2016 Elsevier Inc. he frequency of ureteral reconstructive cases has in- formed options for upper tract reconstruction with insuf- creased in the past two decades predominantly due ficient ureteral length include ureteral interposition to the increasing use of endourological proce- (eg, ileal ureter) and renal autotransplant or trans- T 1 dures with subsequent iatrogenic injury as well as increas- ureteroureterostomy, provided sufficient length of the proxi- ing trauma rates.2 Reconstruction of the ureter can be mal stump is present.3,4 However, these procedures can be challenging if the injured segment is too long for primary technically difficult to perform, may be contraindicated, reanastomosis, despite ancillary maneuvers such as bladder and have considerable associated morbidity.5-8 hitching or Boari bladder flaps. Similar difficulties can arise We have increasingly opted to reconstruct challenging during reconstruction of the obstructed renal pelvis when upper ureteral defects using renal mobilization with down- insufficient pelvic tissue for reconfiguration is present, as ward nephropexy (RMDN) to help bridge the defect. Origi- in cases with an intrarenally located pelvis. Currently per- nally described for the treatment of nephroptosis with associated symptomatic hydronephrosis, downward neph- 1Both authors contributed equally. ropexy was among the most frequently performed uro- Financial Disclosure: Dr. Allen Morey receives honoraria as a guest lecturer/meeting logic surgeries in the late 19th century.9,10 It was reintroduced participant for American Medical Systems and Coloplast Corp. The remaining authors 11 declare that they have no relevant financial interests. in ureteral reconstruction in the 1960s by Popescu and From the Department of Urology, UT Southwestern, Dallas, TX Harada et al.12 Although the bridging of ureteral defects Address correspondence to: Allen F. Morey, M.D., Department of Urology, UT South- of up to 12 centimeters with favorable outcomes has been western, Moss Building, 8th Floor, Suite 124, 5323 Harry Hines Blvd, Dallas, TX 75390- 12 7201. E-mail: [email protected] reported, the adaption of this technique has been very Submitted: March 4, 2016, accepted (with revisions): April 5, 2016 limited. It was only in 1994 when Passerini-Glazel et al 232 © 2016 Elsevier Inc. http://dx.doi.org/10.1016/j.urology.2016.04.008 All rights reserved. 0090-4295 published an extended operative series of 22 upper tract Table 1. Patient and surgical characteristics reconstructions performed between 1979 and 1992 in which Patient Characteristics N = 18 they utilized RMDN in 10 of those patients, combining it with ureteropelvic anastomoses, psoas hitch bladder Age at surgery (mean years, range) 48.6 (20-68) 13 Follow-up (mean months, range) 50.4 (3-87) reconfiguration, and transureterouterostomy. We previ- Mean BMI 27.3 (17-42) ously reported our initial favorable experience with RMDN Gender as an adjunct procedure during ureteral reimplantation in Male 7 (38.9%) Boari flaps,14 and we have since increasingly utilized RMDN Female 11 (61.1%) in upper tract reconstructive surgery, combining it with a Laterality Left 10 (55.5%) wide variety of other reconstructive maneuvers. In the Right 8 (44.4%) current study, we present our updated experience and out- Location comes using RMDN as an adjunctive maneuver to facili- UPJ 5 (27.8%) tate various methods of ureteral reconstruction. L1 1 (5.6%) L2 2 (11.1%) L3 4 (33.3%) L4 4 (33.3%) MATERIALS AND METHODS L5 2 (11.1%) Following institutional review board approval, we retrospec- Prior procedures involving ureter (n = 12) tively reviewed 92 consecutive upper tract reconstruction cases Open 4 (33.3%) performed by a single surgeon from 2007 to 2015. Cases in which Robotic 2 (16.7%) RMDN was utilized were selected for analysis. All patients un- Endoscopic 6 (50.0%) Prior radiation 2 (11.1%) derwent preoperative imaging with intravenous pyelogram, Etiology antegrade nephrostogram, and/or retrograde pyelogram. Ad- Stone treatment 8 (44.4%) equate ipsilateral differential renal function (>20%) was con- Iatrogenic 5 (27.8%) firmed with nuclear renography, and adequate bladder capacity Idiopathic 2 (11.1%) was confirmed by cystography. Other 3 (16.7%) Associated procedure Operative Technique Boari flap 8 (44.4%) For open renal mobilization, an extended Gibson incision was Ureterocalicostomy 5 (27.8%) Ureteroureterostomy 4 (22.2%) used for mid-ureteral injuries, and a flank incision was used for Ileal ureter 1 (5.6%) upper ureteral and ureteropelvic junction reconstruction. Lapa- Surgical characteristics roscopic mobilization was performed using a standard port place- Mean hospital stay (days) 5.9 (2-12) ment and blunt and sharp dissection similar to a nephrectomy, Mean estimated blood loss (mL) 262 (80-600) followed by a Gibson incision for bladder mobilization. After mo- Mean downward movement (cm) 3.3 (3-5) bilizing the kidney within Gerota’s fascia leaving the vascular Failure 2 (11.1%) pedicle as the remaining attachment, the kidney was moved cau- Complications dally and anchored to the ipsilateral psoas muscle. Clavien Grade II 2 (11.1%) Clavien Grade IIIa 1 (5.6%) Outcomes BMI, body mass index. Patient demographics, stricture location, concomitant opera- tive maneuvers, prior surgeries, and intraoperative details were collected and analyzed. Failure was defined as recurrence of ob- structive symptoms that in both cases required subsequent sur- thirds of the ureter and were equally distributed along its gical intervention. We did not routinely obtain follow-up imaging course (at the UPJ-L1 [6/18, 33.3%], L2-3 [6/18, 33.3%], in the absence of symptoms. Adverse events were assessed and and L4-5 [6/18, 33.3%] locations). The most common eti- grouped by the Clavien-Dindo classification. Statistical analysis ology of ureteral stenosis was stone passage followed by pre- was performed using SPSS version 22.0 (IBM, Armonk, NY). vious abdominal or endoscopic surgery (13/18, 72.2%), sequelae of gunshot wounds (2/18, 11.1%), idiopathic eti- ology (2/18 11.1%), and ureteroscopic resection of urothelial RESULTS carcinoma (1/18, 5.6%). Detailed patient characteristics We performed a renal mobilization in 18 of 92 upper tract are presented in Table 1. reconstruction surgeries (19.6%) when other reconstruc- Renal mobilization allowed a mean downward move- tive maneuvers alone failed to allow for a tension-free anas- ment of the kidney of 3.3 cm (range 3-5 cm) that was mea- tomosis. We did not need to dissect out the renal hilum sured from proximal ureteral stump or the UPJ if a stump or divide inferior adrenal vessels in any of our cases to gain was missing. There was no difference in downward move- sufficient mobility. In 3/18 patients (16.7%), the kidney ment between a right or a left nephropexy (3.8 cm vs was mobilized laparoscopically, which allowed for a de- 3.5 cm, P = .563). We combined this maneuver with a crease in the length of flank incision as we did not require variety of reconstructive procedures (Figs. 1-3), includ- open access to the kidney for mobilization, which was re- ing Boari flap with psoas hitch (8/18, 44.4%), quired in the remaining 15 cases (83.3%). In all 18 pa- ureteroureterostomy (4/18, 22.2%), ureterocalicostomy (5/ tients, the ureteral stenoses were located in the upper two 18, 27.8%), and ileal ureter (1/18, 5.6%). Perioperative UROLOGY 94, 2016 233 Download English Version: https://daneshyari.com/en/article/3897838 Download Persian Version: https://daneshyari.com/article/3897838 Daneshyari.com.
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