The experience and clinical efficacy of intestinal ureteral replacement for the treatment of long segment ureteral stenosis
Objective To summarize the experience of intestinal tract in repairing and reconstructing upper urinary tract,and to explore the clinical efficacy of intestinal ureter replacement.Methods From June 2016 to December 2021,a total of 138 patients(66 men and 72 women,129 adults and 9 children)with a mean age of(35.54±21.35)years[(10.78±4.41)years in 9 children aged of 4-16 years]were diagnosed as long segmental ureteral stenosis and underwent ureteral reimplantation using ileal or colonic segments in six tertiary A class hospitals in China.Of the 138 patients,65,38,and 34 stenosis presented in left,right or both sides,and 26,2,and 24 stenosis located in upper,middle or lower ureter,respectively.Full length and multi-segmental stenosis occurred in 14 and 54 patients respectively.There were 12 stenosis presented in solitary kidney,and 22 patients undergoing nephrostomy and another 88 cases undergoing double J stenting.Length of stenosis ranged from 9 to 25cm[mean(15.93±4.67)cm]measured by ultrasound,enhanced CT,CTU,MRU,or anterograde/retrograde pyelography.Baseline creatinine,BUN and eGFR were(93.94±37.13)µmol/L,(5.91±1.99)mmol/L and(83.53±25.18)ml/min respectively,while in patients with solitary kidney,they were(104.83±69.14)mol/L,(7.33±2.90)mmol/L and(64.53±14.46)ml/min respectively.This study involved 138 cases,including 123 patients undergoing ileal ureter with mean stenosis length of(14.48±6.28)cm by intraoperative measurement.The mean(20.67±11.20)cm of ileal segment was taken to replace the mean(22.97±8.09)cm of ureteral defect.Yang-Monti ileal ureter was adopted in 7 patients with stenosis of mean(15.43±4.35)cm.Ileal segments of(16.83±3.97)cm were further divided into 2 to 4(mean 3.00±0.58)sub-segments,2.5 to 3cm each,and reconstructed ileal ureter of mean(11.50±5.65)cm.Eight patients undwewent Yang-Monti colonic ureter and the mean stenosis length was(6.00±0.93)cm.The mean(5.13±1.13)cm of colonic segment was taken and divided into 2 to 3 segments(mean 2.75±0.46 segments,1.5 to 2.0 cm each)and reconstructed mean(4.88±1.46)cm of colonic ureter.Drainage tube,ureter stent and foley catheter were used in all patients and nephrostomy tube inserted previously was preserved.There was no significant difference in intraoperatively measured stenosis length between Yang-Monti ileal ureter group[mean(15.43± 4.35)cm]and ileal ureter group[(14.48±6.28)cm](P=0.6900).Significant difference was observed in stenosis length measured intraoperatively between Yang-Monti colonic ureter group[(6.00±0.93)cm]and ileal ureter group(P=0.0002).There were significant differences in length of reconstructed ureter between Yang-Monti colonic ureter group,Yang-Monti ileal ureter group[(5.13±1.13)cm and(16.83± 3.97)cm]and ileal ureter group[(22.97±8.09)cm](P=0.0001,P=0.0003).Results All operations performed smoothly with no complications.There were significant differences in operation time among Yang-Monti ileal ureter group,Yang-Monti colonic ureter group[(376.40±202.80)min and(626.30±224.20)min]and ileal ureter group[(286.80±97.24)min](P=0.0294,P=0.0001).There were no difference in bleeding volume among three groups[(314.30±213.50)ml,(210.00±96.07)ml and(183.90± 199.70)ml respectively](P=0.0971,P=0.7157).Creatinine levels before discharge was significantly lower than preoperative levels in all patients[(84.45±28.51)µmol/L vs.(93.94±37.13)μmol/L(P=0.0239)],but BUN showed no significant change[(5.79±2.61)mmol/Lvs.(5.91±1.99)mmol/L](P=0.6684).There was no significant difference in eGFR between baseline and discharge level[(83.53± 25.18)ml/min vs.(89.11±25.17)ml/min](P=0.1506).In solitary kidney subunit,creatinine and BUN Levels measured before discharge showed no significant difference compared to preoperative levels(P＞0.05).Yang-Monti ileal ureter group had no significant difference compared to ileal ureter group in drainage time[(10.00±5.35)d vs.(9.24±6.45)d](P=0.7599),catheterization time[(13.17±4.79)d vs.(17.61±10.29)d](P=0.2973)and hospital stay after surgery[(19.86±9.34)d vs.(16.02±10.70)d](P=0.3553).Compared to ileal ureter group,Yang-Monti colonic ureter group had significant longer drainage time[(14.88±7.81)d vs.(9.24±6.45)d](P=0.0202),catheter time[(8.88±2.80)d vs.(17.61±10.29)d](P=0.0188)and hospital stay after surgery[(34.88±17.04)d vs.(16.02±10.70)d](P=0.0001).Hypokalemia was found 2 days after surgery in one case of Yang-Monti ileal ureter group and corrected by intravenous potassium chloride.Five cases of metabolic acidosis in ileal ureter group were found 2 days after surgery and were also corrected.Mucous secretion appeared in catheter in 7 patients(6 in ileal ureter group and 1 in Yang-Monti colonic ureter group).White flocculent emerged in catheter in 8 patients of Yang-Monti colonic ureter.Seven patients experienced urinary fistula(5 in ileal ureter group,1 in Yang-Monti ileal ureter group and 1 in Yang-Monti colonic ureter group).One fistula in ileal ureter group was successfully managed by replacing stent and the other 6 cases of fistula disappeared by conservative management and prolonged stenting.Thirteen patients had fever and healed after antibiotic therapy.Urinary tract infection were found in 33 patients,and there were 26 cases undergoing antibiotic therapy,including 10 patients undergoing sensitive antibiotics based on positive urinary culture,and 7 patients without antibiotic therapy.Six patients showed increased white blood cell count in urine with negative urinary cultures.Of the 138 patients,8 cases lost to follow up 2 to 36 months afterwards.Follow-up parameters included creatinine level,BUN,eGFR,serum electrolyte test,urinary routine,urinary culture,intravenous pyelography,CT and MRU.There was no significant difference between follow-up and baseline creatinine[(93.00±31.14)µmol/L vs.(93.94±37.13)μmol/L](P=0.8279).There was significant difference between follow-up and baseline BUN level[(6.82±2.46)mmol/L vs.(5.91±1.99)mmol/L](P=0.0022).eGFR at follow-up had no significant difference compared to baseline level[(83.10±24.32)ml/min vs.(83.53± 25.18)ml/min](P=0.9138).In solitary kidney subgroup,there was no significant difference between follow-up and baseline data in creatinine,BUN and eGFR.No electrolyte disturbance was found.A case of urinoma of 3 cm secondary to Foley catheter occlusion was found 7 days after discharge and was managed successfully by catheter replacment.One ureter stone and one kidney stone were found during follow-up and were managed by ureteroscopic lithotripsy.Thirteen patients showed hydronephrosis in ipsilateral side.Sixteen patients showed increased white blood cell count in routine urinary test,of which,8 had positive culture and 7 were administered sensitive antibiotics.Conclusions Ileum ureter is an excellent therapy for reconstructing upper urinary tract with fewer complications,and Yang-Monti ileum or Yang-Monti colon ureter are alternative methods.
万方数据
维普
