Optimization of laparoscopic ureteral repair with a buccal graft in case of its extended strictures and obliterations

Purpose of the study. Currently, laparoscopic technique has become widely used in the treatment of extended strictures and obliterations of the ureter. The use of minimally invasive approaches will also be relevant for such a relatively new operation as buccal ureteroplasty. In the literature, there are isolated publications devoted to this technique. The aim of this study was to study the results of our own experience of laparoscopic ureteral reconstruction using a buccal graft.

Patients and methods. We observed 5 patients – 2 men and 3 women, at the age of 30–62 years. All patients have already been operated on the urinary tract, of these, in four patients, the urinary tract was drained with a nephrostomy or internal ureteral stent. Two patients underwent replacement ureteroplasty with tubularized buccal graft, and three patients underwent augmentation ureteroplasty with buccal graft using the onlay method.

Results. All operations in this group were carried out without conversions. The average length of the ureteral defect was 4.9 cm (4.0–6.0 cm). The patients did not have severe complications in the postoperative period according to the ClavienDindo classification. One patient underwent treatment for exacerbation of chronic pancreatitis; one man experienced ureteral stent migration, which required restentation. The follow-up period was 1–15 months; one woman developed unextended ureteral restenosis, which was eliminated by endoureterotomy and ureteral stenting. At the moment, all patients are spared from permanent urinary drains, they do not have upper urinary tract obstruction.

 Conclusion. All operations in this group were carried out without conversions. The average length of the ureteral defect was 4.9 cm (4.0–6.0 cm). The patients did not have severe complications in the postoperative period according to the Clavien-Dindo classification. One patient underwent treatment for exacerbation of chronic pancreatitis; one man experienced ureteral stent migration, which required restentation. The observation period for the patients was 1–15 months, one woman developed short ureteral restenosis, which was eliminated by endoureterotomy and ureteral stenting. At the moment, all patients do not have permanent urinary drains, violations of the urodynamics of the upper urinary tract were not revealed in them.

1. Zabrodina NB, Gallyamov EA, Kovalenko AV, Sysoev AM, Bekhteva ME. Ureteral laparoscopic surgery in cancer patients. Cancer Urology. 2020;16(2):118-125. (In Russian). https://doi.org/10.17650/1726-9776-2020-16-2-118-125

2. Ganpule AP, Singh AG, Islam MR, Sonawane P, Sabnis RB, Desai MR. Robotic buccal mucosa graft ureteroplasty (inlay and onlay) for upper ureteric stricture: Point of technique. J Minim Access Surg. 2018 Dec;14(4):357–361. https://doi.org/10.4103/jmas.JMAS_188_17

3. Seo IY, Oh TH, Jeon SH. Transperitoneal laparoscopic ureteroureterostomy with excision of the compressed ureter for retrocaval ureter and review of literature. Investig Clin Urol. 2019 Mar;60(2):108–113. https://doi.org/10.4111/icu.2019.60.2.108

4. Lee Z, Keehn AY, Sterling ME, Metro MJ, Eun DD. A Review of Buccal Mucosa Graft Ureteroplasty. Curr Urol Rep. 2018 Mar 1;19(4):23. https://doi.org/10.1007/s11934-018-0772-5

5. Kroepfl D, Loewen H, Klevecka V, Musch M. Treatment of long ureteric strictures with buccal mucosal grafts. BJU Int. 2010 May;105(10):1452–1455. https://doi.org/10.1111/j.1464-410X.2009.08994.x

6. Volkov AA, Budnik NV, Zuban ON, Abdulaev MA, Plotkin DV, Reshetnikov MN. Buccal ureteroplasty for recurrent extended strictures and obliterations of distal ureter. Bulletin of RSMU. 2020;(6):113–120. (In Russian). https://doi.org/10.24075/brsmu.2020.079

7. Heijkoop B, Kahokehr AA. Buccal mucosal ureteroplasty for the management of ureteric strictures: A systematic review of the literature. Int J Urol. 2021 Feb;28(2):189–195. https://doi.org/10.1111/iju.14426

8. Asghar AM, Lee Z, Lee RA, Slawin J, Cheng N, Koster H, et al. Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery. J Endourol. 2021 Feb;35(2):144–150. https://doi.org/10.1089/end.2020.0643

9. Hefermehl LJ, Tritschler S, Kretschmer A, Beck V, Stief CG, Schlenker B, et al. Open ureteroplasty with buccal mucosa graft for long proximal strictures: A good option for a rare problem. Investig Clin Urol. 2020 May;61(3):316–322. https://doi.org/10.4111/icu.2020.61.3.316

10. Li B, Xu Y, Hai B, Liu B, Xiang Y, Hua X, et al. Laparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stric ture: initial experience and 9-month follow-up. Int Urol Nephrol. 2016 Aug;48(8):1275–1279. https://doi.org/10.1007/s11255-016-1289-9

11. Menegola C, Tavares PM, Batezini NS, Gorgen ARH, Rosito TE. Laparoscopic ureteroplasty with buccal mucosa graft for long proximal ureteral stenosis: A step by step video. Int Braz J Urol. 2020 Feb;46(6):141–142. https://doi.org/10.1590/S1677-5538.IBJU.2018.0830

12. Volkov AA, Budnik NV, Zuban ON. Laparoscopic ureteroplasty with tubularized buccal graft for extended obliteration of the distal ureter. Experimental and Clinical Urology 2021;14(1):94–99. (In Russian). https://doi.org/10.29188/2222-8543-2021-14-1-94-99

13. Cheng S, Fan S, Wang J, Xiong S, Li X, Xu Y, et al. Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy. Int Urol Nephrol. 2021 Mar;53(3):479– 488. https://doi.org/10.1007/s11255-020-02679-5

14. Roth JD, Monn MF, Szymanski KM, Bihrle R, Mellon MJ. Ureteral Reconstruction With Ileum: Long-term Follow-up of Renal Function. Urology. 2017 Jun;104:225–229. https://doi.org/10.1016/j.urology.2017.02.026

15. Xiong S, Wang J, Zhu W, Yang K, Ding G, Li X, et al. Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review. Biomed Res Int. 2020;2020:6178286. https://doi.org/10.1155/2020/6178286

16. Kapogiannis F, Spartalis E, Fasoulakis K, Tsourouflis G, Dimitroulis D, Nikiteas NI. Laparoscopic and Robotic Management of Ureteral Stricture in Adults. In Vivo. 2020 Jun;34(3):965–972. https://doi.org/10.21873/invivo.11864

17. Katibov MI, Bogdanov AB, Dovlatov ZA. Buccal urethroplasty: 2020 literature review update. Experimental and clinical urology 2020;(3):118–123. (In Russian). https://doi.org/10.29188/2222-8543-2020-12-3-118-123

18. Volkov AA, Zuban ON, Budnik NV, Saenko GI. Surgical treatment of extended strictures and ureteral obliterations using oral mucosa graft. Our own experience. Experimental and clinical urology 2020;(3):124–131. (In Russian). https://doi.org/10.29188/2222-8543-2020-12-3-124-131

19. Simmons MN, Gill IS, Fergany AF, Kaouk JH, Desai MM. Laparoscopic ureteral reconstruction for benign stricture disease. Urology. 2007 Feb;69(2):280–284. https://doi.org/10.1016/j.urology.2006.09.067

20. De Cicco C, Ret Dávalos ML, Van Cleynenbreugel B, Verguts J, Koninckx PR. Iatrogenic ureteral lesions and repair: a review for gynecologists. J Minim Invasive Gynecol. 2007 Aug;14(4):428– 435. https://doi.org/10.1016/j.jmig.2007.01.003