Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients

Abstract

ObjectivesTo evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. Patients and MethodsBetween August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. ResultsThe mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intraor peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. ConclusionsAppendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

Intestinal interposition for complex ureteral reconstruction: A comprehensive review

“…In addition, Duty et al . showed that appendiceal onlay ureteroplasty is a feasible option for managing patients with complex proximal and mid‐ureteral strictures of the right side . The onlay flap involved anastomosing the detubularized appendix to the posterior wall of the longitudinally opened ureter, which preserved the benefits of appendiceal interposition, but decreased the potential disadvantages.…”

Robotics and urologic reconstructive surgery

“…While distal ureteric strictures can be managed with reimplantation techniques, the bladder may not be able to reach mid or proximal ureteral strictures, and alternative reconstruction techniques are necessary ( 13 ). One such technique is the appendiceal interposition.…”

“…The tip of the appendix was transected and discarded, the lumen was flushed, and the appendix was detubularized along the antimesenteric border. The appendiceal flap was sutured to the opened ureteric segment as an onlay ( 13 ). The procedure was performed on 6 patients.…”

Use of a modifiedBoari flap for the treatment of a proximal ureteral obstruction in a cat

“…In human medicine, proximal ureteral obstructions may result from urolithiasis and after endoscopic treatment for urolithiasis, radiation therapy, trauma, thermal energy associated with laparoscopic therapy, retroperitoneal fibrosis, and iatrogenic injury . In addition, proximal ureteral obstructions can occur in children associated with congenital ureteropelvic junction obstructions .…”

“…When techniques for reconstruction of the proximal ureter in humans are being considered, there are several guiding surgical principles including techniques that allow for a wide, tension free and water tight anastomoses; the preservation of blood supply; and complete excision of the underlying pathology to prevent stricture recurrence . Surgical techniques currently performed in man include ureteroureterostomy, transureteroureterostomy, downward nephropexy, ureterocalicostomy, Boari bladder flap, psoas hitch, bowel interposition, pyeloplasty, renal autotransplantation, and nephrectomy . The technique chosen often depends on the location of the obstruction as well as its length.…”