Introduction: Long ureteral strictures not amenable to primary anastomosis pose a significant surgical challenge. First reported in 1912, several reports have suggested that an appendiceal flap may provide an excellent means of surgical reconstruction for some of these ureteral strictures. Likely limited by small patient cohorts, the use of appendix in ureteral reconstruction has not gained wide acceptance. We report a multi-institutional experience with the use of appendix in robotic ureteroplasty.
Methods: This is a multi-institutional retrospective chart review of patients who underwent right ureteral reconstruction with an appendix flap from 2016 to 2019. All surgeries were performed by a single surgeon from each of the two institutions. Surgical indication included all patients with right ureteral stricture not amenable to primary anastomosis due to extensive fibrosis or length. In patients whose stricture was obliterative, an appendiceal interposition was performed. Alternatively, if the stricture was nonobliterative, the surgeon had the option to detubularize the appendix and perform a ventral appendiceal onlay onto the opened ureteral plate. The primary endpoint was surgical success, which we defined as the absence of flank pain from ureteral obstruction without any hardware and ureteral patency on radiographic imaging.
Results: Mean age was 58 years (range 19-77). Of 12 total patients, 9 (75%) had narrowed ureters while 3 (25%) had lumenal obliteration. 8 (67%) underwent the appendiceal onlay and 4 (33%) underwent appendiceal interposition. Mean length of stricture was 6.7 cm (range 2-11 cm) ranging from the proximal to distal ureter with one panureteral defect due to avulsion. Mean operative time was 334 minutes (range 206-583), estimated blood loss was 124 mL (range 50-600), and length of stay was 3.8 days (range 1-9). One (8%) patient experienced a major postoperative complication (Clavien >2) within 30 days of surgery. At a mean follow up of 11.7 months (range 1-42), 100% of cases were successful.
Conclusions: Appendiceal onlay and interposition as a surgical management strategy for right-sided ureteral strictures may allow the patient to avoid the morbidity of buccal mucosa or ileal harvest while providing an excellent surgical cure. Source of
