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ROLE OF RENAL AUTOTRANSPLANTATIONIN COMPLEX URETERAL STRICTURE

Dharm Raj Singh*, S N Sagade**
*Resident; **Consultant; Dept. of Urology, PD Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai - 400 016, India.

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Majority of the ureteral strictures can be treated surgically by conventional techniques like ureteroneocystostomy, Boari flap and psoas hitch. Renal autotransplantation is a safe and effective surgical option in long segment ureteral stricture when conventional techniques are not suitable or have failed. We report 2 cases of long segment ureteral stricture managed by renal autotransplantation.

CASE REPORTS

Case 1

SAB, 53 year old male presented with 2 episodes of gross, total, painless haematuria in the last 10 months. Physical examination including per rectal examination was normal except for gynaecomastia and bilateral hypoplastic testis. Urinalysis showed large number of RBCs with occasional presence of WBC. The complete blood count, serum creatinine and BUN were normal. Intravenous urography (IVU) revealed right hydroureteronephrosis with hold up of contrast at S1-2 level with non visualisation of the ureter below this and filling defect at the dome of the bladder on the right side (Fig. 1). Cystoscopic examination showed presence of a bladder tumour around the right ureteric orifice. TUR of the bladder tumour was performed which on histology showed grade II transitional cell carcinoma. Retrograde ureterogram showed irregular narrowing of the ureter from the VU junction upto S2 level (Fig. 2).

Surgery was undertaken for the management of the stricture. Patient was explored via right modified Gibson incision. A long (approx. 4 inches) stricture of the ureter was seen. Wide excision of the strictured segment was done. Frozen section revealed no evidence of tumour hence the decision of autotransplantation was taken. The right kidney was mobilized through the 10th rib incision and auto transplanted in the right iliac fossa with renal artery anastomosed to the right internal iliac artery, renal vein to the right external iliac vein and the ureter was reimplanted by an extravesical technique. Patient tolerated the operation well with good function of the autotransplanted kidney (Fig. 3).

Case 2

NL, 18 year old male presented with history of low grade fever and weight loss of 1 year duration, urinary frequency since 5 months and pain in left loin radiating to left groin since 15 days. He was investigated and diagnosed as genitourinary tuberculosis. Antituberculous treatment (4 drugs for 2 months and 2 drugs for 7 months) was administered by family physician with resultant improvement in appetite and weight. Physical examination was normal. Mantoux test was positive. IVU showed left hydronephrosis with delayed function of the left kidney and narrowing of the whole ureter (Fig. 4). Cystoscopy revealed generalised cystitis with gaping of the left ureteric orifice and inflammation around it. DJ stent insertion and bladder biopsy was done which proved the diagnosis of tuberculous cystitis. A follow up IVU, 3 months after removal of DJ stent showed persistent left hydronephrosis, hence DJ stent was reinserted. Three months later DJ stent was removed and a retrograde ureterogram was performed which showed stenosis of the whole ureter, renal pelvis and major calyces (Fig. 5), hence a decision for replacement of the entire ureter and pelvicalyceal system in the form of bench surgery and autotransplantation was taken.

Fig. 1 : IVU showing right hydronephrosis with hold up of contrast at S1-2 level.	Fig. 2 : Retrograde ureterogram showing narrowing of right ureter from VU junction to S2 level.

 

Fig. 3 : Postop renogram showing good function of autotransplanted kidney.

 

During surgery the entire ureter was excised and the kidney was mobilized in preparation for autotransplantation. A segment of ileum was isolated, to be used to reconstruct the collecting system and ureter. Intestinal continuity was reestablished by ileoileostomy. At this time when the attention was turned towards the kidney for its removal it was found to be blue. However a decision to proceed for the surgery was taken. On perfusion, the kidney did change colour and was pale white. Onlay patch of the ileum onto the renal pelvis and major calyces was done after radial nephrotomy along the lower pole. The ureter was excised from the PUJ to the vesicoureteric junction and replaced by ileum. Follow up DTPA renogram showed poor function of the transplanted kidney.

Fig. 4 : IVU showing left hydronephrosis with narrowing of whole ureter.	Fig. 5 : Retrograde pyelogram demonstrating narrowing of whole ureter. Renal pelvis and major calyces.

 

DISCUSSION

Hardy (1963) has reported the first successful renal autotransplant for iatrogenic ureteral injury during aortic operation. [1] The common indications of renal autotransplantation are renovascular hypertension, extensive ureteral damage and in nephron sparing surgery for renal cell carcinoma. [2] It has also been reported successfully in a variety of other urological conditions like nephrolithiasis, [3] idiopathic retroperitoneal fibrosis, [4] localised amyloidosis of ureter, [5] severe loin pain/haematuria syndrome, [6] echinococcosis of the kidney. [7]

The conventional surgical techniques used in lower ureteral damage are : ureteroneocystostomy, Boari flap and psoas hitch. The last 2 techniques can be combined to replace a large segment ureteral defect provided bladder is of a large capacity and mobile. The kidney can also be displaced downward by either inferior reimplantation of right renal vein or left renal artery. [8] Ileal interposition may also be used for ureteric replacement, but the mucus discharge and urinary and infection are troublesome to the patient and may not be acceptable.

Renal autotransplantation has been used with great success in long segment benign ureteral defect where conventional surgical techniques can not be performed. Autotransplantation with ureteric reimplantation or with direct pyelovesicostomy gives excellent post operative results without deterioration in renal function due to vesicorenal reflux in later technique. Ranch T et al reported changes in renal function in long term (mean 5 1/2 years) follow up after autotransplantation with direct pyelocystostomy. Neither there was significant change in glomerular or tubular function nor increase in severity or frequency of urinary tract infection. [9] Bodie B et al reported excellent long term results of renal autotransplant for ureteral replacement. [10]

We have performed 2 renal autotransplant for benign ureteric stricture. In 1st case (case 1) a long segment lower ureteric stricture was present in addition to transitional cell carcinoma of urinary bladder. Benign nature of the ureteric stricture was proven on frozen section. In view of TCC of urinary bladder, Boari flap technique was not considered hence auto transplantation was performed in right iliac fossa. Our 2nd patient (case 2) was a case of genitourinary tuberculosis with extensive involvement of entire ureter, renal pelvis and major calyces. Bench surgery was essential in this case to rectify the stenosed renal pelvis and major calyces. The corrective surgery was performed by an onlay patch of the ileum on to the renal pelvis and major calyces. This was possible after radial nephrotomy along the lower pole. The ureter was excised from PUJ to vesicoureteric junction and replaced by ileum. The poor function of the autotransplanted kidney was probably due to renal artery spasm prior to its removal as mentioned earlier.

We conclude that renal autotransplantation can be considered as safe alternative method for the management of complex ureteric strictures (tubercular or infective origin) when conventional surgical techniques have failed or not suitable.

REFERENCES

1. Hardy JD. High ureteral injury. JAMA 1963; 184 : 91.
2. Andrew C Novick, Charles L Jackson, Ralph A Straffon. The role of renal autotransplantation in complex urological reconstruction. J Urol 1990; 143 : 452-7.
3. Flatmark A, Albrechtsen D, et al. Renal autotransplantation. World Journal of Surgery 1989; 13 (2) : 206-9.
4. Mikkelsen D, Lepor H. Innovative surgical management of idiopathic retroperitoneal fibrosis. J Urol 1989; 141 (5) : 1192-6.
5. Usami T, Sudoko H, et al. A case of localised amyloidosis of the ureter treated by renal autotransplantation. Japanese Journal of Urology 1988; 79 (12) : 2031-6.
6. Sheil AG, Ibels LS, et al.. Renal autotransplantation for severe loin pain/hematuria syndrome. Lancet 1985; 2 (8466) : 1216-7.
7. Tscholl R, Ausfeld R. Renal replantation (orthotopic autotransplantation) for echinococcosis of the kidney. J Urol 1985; 133 (3) : 456-7.
8. Gill Vernet JM. Lowering of the left renal artery. J Urol. 1982; 128 : 686.
9. Ranch T, Granerus G, et al. Renal function after autotransplantation with direct pyelocystostomy. Long term follow up. Br J Urol 1989; 63 (3) : 233-8.
10. Bodie B, Novick AC, et al. Long term results with renal autotransplantation for ureteral replacement. J Urol 1986; 136 (6) : 1187-9.

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