ILEAL URETER - 11/09/11
Résumé |
The search for an optimal method for reconstruction or replacement of the diseased ureter is a classic example of the way urologists seek solutions to complex genitourinary problems. Numerous types of grafts have failed, including those using blood vessels, fallopian tubes, peritoneal tubes, and metal and plastic. Ureteral replacement with ileal bowel segments has become part of the urologic surgeon's armamentarium more than 35 years after Goodwin et al10 first popularized the procedure.
Fenger7 is credited with the first written proposal for reconstructing the ureter with small bowel. In 1900, the operation was successfully performed on three dogs by d'Urso and de Fabii.6 In 1906, Shoemaker18 carried out the first repair in a human by replacing the ureter of an 18-year-old woman who was presumed to have genitourinary tuberculosis. Melnikoff15 published a classic treatise in 1912 on the history of the procedure but, by 1950, only three case reports were found in the literature. In 1959, the summary by Goodwin et al10 popularized the procedure.
In general, the indications for intestinal replacement of the ureter remain the same today:
• | Recurrent calculi |
• | Extensive ureteral injury |
• | Retroperitoneal fibrosis |
• | Ureteral stricture |
• | Fistula |
• | Tuberculosis |
• | Ureteral carcinoma in solitary kidney |
• | Undiversion |
• | Congenital obstruction |
• | Schistosomiasis |
This is because ileal ureter reconstruction should usually be considered when all other more conservative procedures, such as ureteroneocystostomy, ureterocalicostomy, Boari flap, transureteroureterostomy, and in some cases autotransplantation, are not applicable.
Contraindications to ileal ureter replacement include an inadequate length of usable bowel or inflammatory bowel disease:
• | Ileal disease (inflammatory bowel disease) |
• | Incontinence |
• | Bladder neck obstruction |
• | Neurogenic bladder |
• | Metastatic disease |
• | Renal failure |
• | Hepatic dysfunction |
Patients with hepatic dysfunction are at risk for the development of hepatic encephalopathy secondary to absorption of nitrogenous waste into the enteric circulation. This risk is particularly noteworthy in a patient with portacaval shunt.14 Furthermore, to avoid high-pressure reflux and subsequent renal deterioration, any difficulty with emptying the bladder should be evaluated and ruled out before operation.
Pre-existing azotemia has been a relative contraindication, particularly when the serum level of creatinine is greater than 2 mg/dL. Infrequently, however, we are faced with a patient with a level of creatinine greater than 2 mg/dL who wishes to risk metabolic complications to avoid a less palatable alternative. We recommend using a much smaller area of bowel as a segment or interposition graft. The safe use of small segments with caution to replace damaged ureters has been reported by Casale et al5 and Lytton and Schiff13 in humans and Waters et al24 in dogs.
Experience at the Lahey Hitchcock Medical Center now totals 61 ureteral replacements. In this group were 17 solitary kidneys and 11 segmental replacements, 3 of which are true interposition grafts.
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Address reprint requests to John J. Smith III, MD Department of Urology Lahey Hitchcock Medical Center 41 Mall Road Burlington, MA 01805 |
Vol 24 - N° 4
P. 813-825 - novembre 1997 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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