Management of Ureteral Strictures

NYU Case of the Month, October 2018

Case of the Month Management of Ureteral Strictures NYU Case of the Month, October 2018 Lee C. Zhao, MD NYU Langone Health, New York, NY [Rev Urol. 2018;20(4):177–178 doi: 10.3909/riu0824B] ® © 2019 MedReviews , LLC A 40-year-old man developed a 4-cm proximal ureteral stricture following ureteroscopy and laser lithotripsy for an impacted ureteral stone at an outside institution. The patient underwent ureteral dilation, endoureterotomy, and stent placement. After stent removal, he developed pain and hydronephrosis and underwent nephrostomy placement. Evaluation at NYU Langone Health Antegrade nephrostogram and retrograde pyelogram were performed (Figure 1), showing a 4-cm proximal ureteral stricture. Management Because of the length of the stricture, a primary repair was considered the optimal management strategy. The patient was brought to the OR and put in the flank position while allowing access for ureteroscopy. Four robotic trocars were placed. Intraoperative ureteroscopy with Firefly® fluorescence imaging (Intuitive Surgical, Sunnyvale, CA) was performed to identify the location of the stricture (Figure 2). A 4-cm incision was made on the anterior surface of the narrowed segment of the ureter (Figure 3). A buccal mucosa graft was harvested and passed into the abdomen. The graft was then sutured as an onlay until the graft completely covered the ureteral Figure 1. Antegrade and retrograde pyelogram showing a 4-cm proximal ureteral stricture. Vol. 20 No. 4 • 2018 • Reviews in Urology • 177 4170018_00_RIU0824B_V4_rev02.indd 177 11/01/19 7:02 pm Management of Ureteral Strictures continued The patient had complete resolution of flank pain. Subsequent renal ultrasound showed no hydronephrosis, and renal scan demonstrated good drainage. Discussion Figure 2. Ureteroscopy performed to identify the exact location of the stricture. Turning on Firefly fluorescence imaging mode allowed for visualization of the ureteral stricture. Figure 3. Incision of the narrowed ureter reveals a 4-cm segment of stricture. Figure 4. The buccal mucosa graft sutured as an onlay to reconstruct the ureteral segment. defect (Figure 4). An omental flap was wrapped and sutured to the graft to provide vascularity. Follow-up The patient was discharged on postoperative day 1, and the ureteral stent was removed after 4 weeks. Ureteral strictures may arise from radiation, ischemia, trauma, nephrolithiasis, and iatrogenic injury.1 The management of strictures of the ureter is dictated by their etiology, length, and location. The exact location may be identified via antegrade and retrograde pyelogram or ureteroscopy. The initial management of ureteral strictures often involves endoscopic treatment2 via dilation or endopyelotomy. When ureteral strictures are refractory to endoscopic management or the likelihood of endoscopic failure is high, reconstructive surgery should be offered. Advances in robotics, especially with improved visualization, precise suturing, and small incisions, have reduced the morbidity associated with ureteral reconstructive surgery.3 The principles of reconstruction include restoration of the ureteral lumen while preserving viable ureter in case subsequent surgery is necessary. Substitution of the ureter can be performed with primary anastomosis, flaps, or grafts. Stents may obscure the delineation between the strictured segment and the normal ureter. Thus, prior to reconstruction at NYU Langone Health, we prefer to remove the ureteral stent to allow the stricture to mature. In patients who are dependent on ureteral stents, we place a nephrostomy tube before stent removal. For distal ureteral strictures, we typically perform ureteroneocystostomy. Boari flaps may be performed in patients with midureteral strictures and sufficient bladder capacity. A measurement of bladder capacity is important prior to harvesting of the Boari flap. For proximal ureteral strictures, if the stricture location is amenable to reconstruction by direct connection from the ureter to the renal pelvis, then pyeloplasty is performed. We have performed proximal ureteral strictures through onlay of buccal mucosa graft4 or appendix flap.5 In situations where there is a long segment of missing ureter, such as after resection from colon surgery, an ileal ureter replacement is performed. As a last resort, autotransplantation may be performed, although there is a risk of vascular injury to the recipient vessels. Conclusion Ureteral strictures may be treated with a variety of reconstructive techniques, usually carried out via a minimally invasive robot-assisted laparoscopic approach. Recent innovations such as buccal mucosa grafts for ureteroplasty allow for simplified treatment of complex ureteral strictures with minimal morbidity. References 1. 2. 3. 4. 5. Abboudi H, Ahmed K, Royle J, et al. Ureteric injury: a challenging condition to diagnose and manage. Nat Rev Urol. 2013;10:108-115. Lucas JW, Ghiraldi E, Ellis J, Friedlander JI. Endoscopic management of ureteral strictures: an update. Curr Urol Rep. 2018;19(4):24. Marien T, Bjurlin MA, Wynia B, et al. Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients. BJU Int. 2015;116:604-611. Zhao LC, Weinberg AC, Lee Z, et al. Robotic ureteral reconstruction using buccal mucosa grafts: a multiinstitutional experience. Eur Urol. 2018;73:419-426. Duty BD, Kreshover JE, Richstone L, Kavoussi LR. Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients. BJU Int. 2015;115:282-287. 178 • Vol. 20 No. 4 • 2018 • Reviews in Urology 4170018_00_RIU0824B_V4_rev02.indd 178 11/01/19 7:02 pm