Ureteral replacement using segment of Ileum: an approach totally intracorporeal

• Autor(a) principal: Britto, Cesar Araujo
• Data de Publicação: 2013
• Outros Autores: Figueiredo, Fellipe Rodrigo Gomes, Carvalho, Pedro Sales Lima de, Medeiros, Filipe Correia Lima Rodrigues de, Nóbrega, Artur, Cavalcante, Vinicius Matias Monteiro, Cunha, Diego Rebouças, Marques, Andre Frederico Nogueira, Formiga, Cipriano Cruz, Medeiros, Paulo Jose
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Repositório Institucional da UFRN
• Texto Completo: https://repositorio.ufrn.br/handle/123456789/52581; https://doi.org/10.1089/vid.2012.0058
• topic: nephrostomy; replacement; procedure

Introduction: The ureteral avulsion during ureteroscopic procedures is a rare complication (incidence 0%–2%).1 Surgical options in this situation include ileal ureter replacement, autotransplantation, or nephrectomy.2 We present a video of a pure laparoscopic-assisted ileal ureter replacement for a scabbard avulsion ureter. Case Report: A 37-year-old man, allergic to iodine, body mass index (BMI) 31, referred to our clinic after a right ureteral avulsion, occurred one month ago, during a semirigid ureteroscopic management of 8 mm ureteral calculi, located at proximal ureter. An open nephrostomy was performed. MRI showed ureteral damage at the right ureteropyelic (UPJ) and nephrostomy tube. We performed on pure laparoscopic ileal ureter replacement, using five trocars. During dissection, severe fibrosis was observed at the renal hilum. The bladder was fixed at the psoas muscle. A segment of ileum (20 cm) was isolated, 20 cm proximal to the ileocecal valve. Intestinal reconstruction was made using the Godoy's technique (Eudes Paiva de Godoy, MD, personal communication). The ileal segment was placed in an isoperistaltic position and a proximal pyeloileal and a distal ileovesical anastomosis was performed, with continuous suture. No stapler was used. A Double-J catheter was introduced using a nephrostomy tube. The operative time was 347 minutes, blood loss was 200 mL, the drain was removed on the third postoperative day (PD), and the patient was discharged on the fifth PD. Double-J removed with 30 days. In the third month of follow-up, the patient was asymptomatic, with normal renal function and no obstruction was detected by ultrasound and renal scintigraphy. Discussion: A patient with a solitary kidney and urinary lithiasis has a risk to develop ureteral obstruction and acute renal failure, throughout the life. Therefore, as we faced a ureteral injury, we need to preserve the kidney, making nephrectomy, the last option of treatment. Autotransplantation is another option of treatment, performing the nephrectomy by the laparoscopic technique.3,4 In this case, severe fibrosis of the renal hilum, associated with a short renal vein, motivated us to avoid this procedure. The ileal ureter replacement has advantages, preserving the renal function, and facilitates the removal of calculi, which may be formed later. This procedure was first described by Shoemaker, in 1906 and popularized by Goodwin.5 Most recently, laparoscopy has advanced the field of reconstructive urology and urologists have reproduced the traditional procedures. Gill et al. described the first laparoscopic ileal ureter replacement, using a small open incision to intestinal reconstruction.6 The exposure of the bowel by small incision can lead tension and compression of the mesenteric vessels, especially in obese patients, with thick abdominal wall.7,8 Performing the procedure completely inside the body, this theoretical risk, and any complications related to the incision, can be avoided.9 The risk of neoplasia at the bowel's segment incorporated into the urinary tract is low, especially in patients without immunosuppression, and a strict follow-up will not be necessary.10,11 Conclusion: The ileal ureter replacement allows preservation of the kidney in complex ureteral injuries. When performed laparoscopically, reduces morbidity, avoiding large incision with associated protracted recovery. We describe a case of pure laparoscopic ileal ureter replacement duplicating the open technique, including intestinal reconstruction.