Clinical Essentials | Chinese expert consensus: key points of surgery and perioperative management of complex ureteral stricture repaired by autologous tissue mesh

Therefore, in order to establish a standardized process of autologous tissue mesh repair of complex ureteral stricture surgery and perioperative management, the Repair and Reconstruction Group of the Urology Branch of the Chinese Medical Doctor Association and the Urology Branch of the Chinese Research Hospital Association organized domestic experts to discuss the indications of autologous tissue mesh technology, the selection principles of mesh tissues (oral mucosa and appendix tissue), preoperative preparation and perioperative management. The key points of surgery and the postoperative follow-up plan reached this expert consensus. The main points of Yimaitong are as follows for the benefit of readers.

Preoperative evaluation and indications for surgery

Recommendation: preoperative evaluation of complex ureteral strictures includes a detailed history and thorough imaging, particularly anterograde and retrograde ureterography. Upper and middle ureteral strictures that cannot be reconstructed using end-to-end anastomosis can be reconstructed by autologous tissue mesh transplantation.

Preoperative management

1. Pipeline management

● For patients with indwelling double J (DJ) tubes, the DJ tubes should be removed before surgery.

● For patients with recurrent urinary tract infections and reoperation after failed reconstructive surgery, percutaneous nephrostomy is recommended for the affected kidney to fully drain urine, control infection, protect residual kidney function, and eliminate ureteral edema.

2. Infection control

● If the patient has a urinary tract infection before surgery, a nephrostomy should be performed to drain the urine sufficiently, and sensitive antibiotics should be used, and the urine culture should be negative before surgery.

● Antibiotics can be used prophylactically in the perioperative period according to the patient's infection status.

3. Timing of surgery

● It is recommended that patients undergo anterograde and retrograde ureterography 4~6 weeks after removing the DJ tube and undergoing nephrocentestomy, and then undergo ureteral stricture repair surgery after clarifying the location and length of ureteral stricture.

● Patients who have failed to undergo plastic surgery due to urine leakage from ureteral anastomosis in the past, or patients who have urinary leakage due to iatrogenic ureteral injury such as ureteral avulsion, gynecological or abdominal surgery injury, etc., are mostly accompanied by symptoms such as low back pain, peritoneal irritation, and fever on the affected side, and such patients should be extended to 1~2 months after nephrostomy before ureteral stricture repair surgery.

● Patients with ureteral stricture after tumor treatment should wait for 1~2 years after the completion of tumor treatment and consider ureteral repair and reconstruction when there is no tumor recurrence.

4. Patient communication

Due to the different causes of disease and surgical history, complex ureteral repair and reconstruction vary greatly among individuals, so the source of tissue mesh acquisition, preferred surgical options, alternate surgical options, including the possibility of choosing an intestinal ureteral or autologous kidney transplantation surgical regimen in the most difficult case, should be fully communicated with patients and their families before surgery to obtain the attention and support of patients and families.

Recommendation: Preoperative nephrostomy on the affected side can help control infection, preserve residual renal function, and eliminate ureteral edema. For patients with a history of urine leakage or failed ureteral stricture reconstruction, nephrostomy is recommended and wait for 1~2 months before reconstructive surgery.

Surgical points

1. Preoperative preparation

● Fasting for 8 hours and water for 4 hours before anesthesia.

● If an oral mucosal patch is taken, the state of the oral mucosa should be assessed before surgery, and a stomatology consultation should be requested if necessary. It is recommended to rinse the mouth with antibacterial mouthwash every day 2 days before surgery. Anesthesia can be administered by oral or nasal cannula, and transnasal cannula anesthesia is preferred to facilitate access to the oral mucosa. If oral intubation is used for anesthesia, the endotracheal tube should be fixed at the contralateral corner of the mouth when the tongue mucosa is taken, and the reverse is true for the buccal mucosa. After the anesthesia is completed, both eyes and ears are protected by a film to avoid being damaged by the disinfectant solution during facial disinfection.

2. Selection of surgical method and position

Autologous tissue mesh ureteroplasty can be done by open, laparoscopic, and robotic-assisted laparoscopy. Robot-assisted surgery can provide high-definition three-dimensional vision, making the cutting and suturing process more delicate and smooth, especially suitable for reconstructive surgery with a large amount of sutures such as autologous tissue mesh repair of ureteral stricture.

● If the patient has a single upper or middle ureteral stenosis, take the lateral decubitus position at 60° with the affected side facing up.

● If the patient has unilateral multi-segmental ureteral stricture, ureteral reconstruction can be performed with autologous tissue mesh combined with ureteral bladder replantation or bladder valve replacement ureterosurgery, which can be completed in an integrated position with head down and high lateral decubitus.

● If the patient has a long length of lower ureteral stricture (>4cm), or has a history of pelvic surgery and radiotherapy, and it is estimated that the ureters are difficult to dissociate, the patient does not need to force one-piece surgery, but can first complete the lower ureteral reconstruction in the head-down and high-toe supine position, and then manage the middle and upper ureteral stricture in the lateral decubitus position.

3. Surgical procedure

(1) Expose the ureters of the stricture segment: The ureteral stricture segment is mostly wrapped by scar tissue, which is difficult to locate and expose during surgery. The following methods are helpful in finding ureteral stricture segments

● Preoperative clipping of the nephrostomy tube or intraoperative slow perfusion of normal saline through nephrostomy causes hydronephrosis and proximal ureteral dilation. In patients without a nephrostomy, an intravenous diuretic can be given to dilate the ureter above the stricture, and the dilated ureter can be found, and then the stricture can be found distally.

● Retrograde injection of fluorescent agent indocyanine green (ICG) through nephrostomy and/or retrograde through a reserved ureteral catheter, which can be observed by laparoscopy or robotic fluorescence mode, and the stricture can be found and located according to the ureteral contour of fluorescence imaging. Intravenous ICG can help localize the stenosis (heavy scarring, low blood supply, weak fluorescence) and assess the blood supply to the ureter.

(2) Treatment of ureters in the stricture segment: different surgical methods are selected according to the degree of obstruction of the stricture segment and the presence or absence of atresia.

● If the ureteral lumen continues, the ventral wall of the ureteral stricture is cut longitudinally and extended to the proximal and distal ends until the urine can flow freely from the proximal ureter, the ureter texture is soft and the mucosa is normal, and the F10 ureteral cavity is explored up and down to confirm that the ureteral lumen is smooth and there is no resistance, and then ureteroplasty with simple mesh is performed.

● If the ureteral lumen of the lesion is completely closed and the scar is obvious or there is a ureteral polyp, the lesion should be excised (the length of the excision should not affect the tension-free suture of the posterior wall), and then the posterior wall reconstruction and ventral autologous tissue mesh ureteral enlargement plasty should be performed.

(3) Acquisition of oral mucosa (tongue mucosa/buccal mucosa/labial mucosa): accurately measure the length of the ventral wall of the ureter, and the length of the oral mucosa is generally 0.5~1.0cm longer than the length of the ventral defect of the ureter, and the width of the mucosa is controlled at 1.2~1.8cm.

(4) Acquisition of appendix and mesh production: For patients with right middle and upper ureteral stricture, if the blood supply to the appendix is good and there is no appendicitis, the appendix tissue mesh technique is recommended first, and if the appendix is not available, oral mucoureteroplasty is recommended.

● First, the appendix is severed at the base of the appendix to preserve the mesangium and blood supply. Then the appendix is appropriately pulled free from the cecum to the ureteral stricture, and then the appendix is dissected longitudinally on the opposite side of the mesangial margin to form a patch (because the peristalsis of the appendix itself is weak, it is not necessary to require the direction of the appendix to be consistent with the direction of ureteral peristalsis), and the excess length of the appendix is cut off.

● In the past, there have been reports of direct repair of ureteral stricture with tubular appendix replacement, but due to the predisposition of anastomotic stenosis and urinary tract infection after tubular replacement, appendiceal mesh technology is preferentially recommended.

● For patients with partial ureteral defects who are unable to undergo appendix mesh surgery, direct replacement of the ureteral defect with a tubular appendix may still be considered.

(5) Omentum or perirenal fat wrapping and covering technique: In order to establish blood supply as soon as possible with the oral mucosal patch, it is recommended to cover the reconstructed ureter with omentum (preferred) or perirenal fat wrap after suturing, and fix the omentum on the psoas major muscle.

4. Key points of autologous tissue mesh decision-making

(1) The first recommendation for right reconstruction is appendiceal tissue mesh: appendiceal tissue mesh is first recommended for right ureteral middle and upper ureteral stenosis. Appendiceal patches preserve the original blood supply and theoretically have a low risk of avascular necrosis.

(2) Application of combined technology in ureteral multi-segment stenosis: For patients with multiple ureteral stenosis in the middle and upper ureters and lower ureters at the same time, oral mucosal patches or appendiceal patches can be used to repair the middle and upper ureteral stenosis, and at the same time, ureteral bladder replantation, or bladder valve replacement ureteral repair of the middle and lower ureteral strictures, and the repair and reconstruction of ureteral multi-segment strictures can be completed in one stage. The decision-making flow chart of the surgical method of ureteral stricture repair with autologous tissue mesh is detailed in the original article.

Recommendation: For complex ureteral stricture repair and reconstruction, multiple sets of alternative surgical plans should be prepared before surgery, and the corresponding surgical method should be selected according to the results of ureteral stricture exploration during the operation. The intraoperative ureter-mesh anastomosis should meet the appropriate needle distance to ensure that there is no urine leakage at the reconstructed ureteral anastomosis. Attention should be paid to the protection of the mesoappendiceal membrane with appendiceal patches, and the oral mucosal patch should be enlarged and sutured with omentum or surrounding fat to wrap or cover. Due to the characteristics of the tongue mucosa, longer tissue patches are readily available for repair of long ureteral strictures.

Postoperative management and follow-up

1. Postoperative pipeline management

● For patients with nephrostomy before surgery and only autologous tissue mesh repair of ureteral stricture during surgery, it is recommended to recheck the abdominal ultrasound 3~4 days after surgery, and if there is no obvious effusion in the surgical area, the urethral tube can be removed.

● For patients with multiple ureteral strictures who undergo joint repair surgery during surgery or patients who refuse to undergo nephrostomy before surgery, it is recommended to extend the urethral catheter to 1~2 weeks after surgery to reduce the risk of urine leakage at the postoperative anastomosis. According to the intraoperative ureteral adhesion status, stenosis length, and mesh length, it is recommended to remove the DJ tube 4~8 weeks after surgery.

● Nephrostomy tube can generally be removed 2 weeks after surgery, if the scar adhesion is severe during the operation, the reconstruction operation is difficult, or there is a history of ureteral leakage, it is recommended that the nephrostomy tube be extended to 6~10 weeks after the operation, that is, 2 weeks after the DJ tube is removed, the ureteral antegrade angiography is performed, indicating that the ureteral patency is good, and then the nephrostomy tube is removed.

2 Postoperative follow-up

● Urine routine, renal function, B-ultrasound, CTU three-dimensional imaging (after 3 months) and other examinations should be performed 1, 3, 6 and 12 months after surgery, and the changes of hydronephrosis should be closely followed. After 3 months, if there is low back distention, low back pain, continuous increase in hydronephrosis, urinary tract infection, fever, etc., it should be revisited in time to determine whether there is a recurrence of stricture, and actively intervene and treat.

● It is recommended that all surgical patients be followed up for life, at least once a year.

3. Postoperative complication management

After ureteral reconstruction with autologous tissue mesh repair, most patients have effectively recovered ureteral function, significantly improved symptoms, and significantly improved their quality of life. However, some complications may occur, such as infection, bleeding, urine leakage, and recurrence of ureteral stricture, which need to be closely observed and treated in a timely manner after surgery. Antibiotics are recommended for all patients to prevent infection, and for patients undergoing appendix patches, special attention needs to be paid to the risk of infection in the surgical area.

Recommendation: Nephrostomy tube and DJ tube indwelling time should be appropriately prolonged after ureteral reconstruction with autologous tissue mesh for poor ureteral condition or multi-segmental ureteral stricture. Postoperative patients should be followed up with long-term imaging and functional tests.

Bibliography:

[1] Chai Shuaishuai, Li Bing, Xiao Xingyuan. Chinese expert consensus on surgical points and perioperative management of complex ureteral stricture repair with autologous tissue mesh (2024 edition)[J].Journal of Modern Urology,2024,29(05):388-393.)

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