In the past, the surgeons usually adopted ileal ureter plasty or ureter bladder flap plasty （Boari flap plasty） to restorelong-term ureteral mucosal avulsions and long or entire ureteral segment defects caused mostl...In the past, the surgeons usually adopted ileal ureter plasty or ureter bladder flap plasty （Boari flap plasty） to restorelong-term ureteral mucosal avulsions and long or entire ureteral segment defects caused mostly by ureteroscope operations. But there are still certain difficulties in the restoration of long segment ureteral defects （〉20 cm） using traditional methods. In order to overcome traditional surgical approaches, we designed a new ureteroplasty operation using spiral pedunculated bladder muscle flap to restore long segment ureteral defects. METHODS Six patients who presented long segment ureteral defects caused in the course of ureteroscopic lithotripsy due to ureteropelvic junction stenosis and stones （length of defects： 21-25 cm, mean length： 22.5 cm）, were given general anesthesia, and made to lay in the horizontal position while indwelling triple lumen catheters. These patients had Gibson incision in the hypogastrium of the injured sides, and we could prolong the surgical incision up to the epigastrium or the flank abdomen moderately if necessary. We exposed the retroperitoneal space, transected the umbilical ligaments, peritoneal adhesions, spermaducts or the round ligaments to dissociate the bladder to the maximum extent possible. We could increase the mobility of the bladder by dissociating the contralateral superior vesical arteries along the anterior trunk of the internal iliac artery. We could also identify the stump of the distal ureter along the path between the ureter and bladder below the iliac vessels, and then we had to ligate or transfix the ureteral stump. We dissociated the ureteropelvic junction carefully, trimmed the stump to the inclined plane in order to facilitate the anastomose between the bladder muscle flap and the trimmed ureteral stump while locating and tracting it by the suture. Filling the bladder with 400 ml of normal saline solution along the catheter, we located the anterior wall of the bladder with the suture. Before designing the spiral pedunculated bladder muscle flap, we had to identify the superior vesical arteries and their branches of the injured sides along the anterior trunk of the internal iliac artery. Then, we trimmed the shape S bladder muscle flap along the arteries＇ track while stretching the bladder by pulling the suture. The basal width of the designed flap had to be more than or equal to 2 cm, and the length should be equivalent to the injured ureter. We thenhad to wind the bladder muscle flap spirally upon the 12F catheter, followed by continuous stitching of the winding flap and interrupted embedded stitching of the serosal layer with 5-0 bioabsorbable sutures. If only we could keep the natural spiral conditions of the bladder muscle flap between the beginning of the forming ureter and the bladder, we would get a spontaneous anti-reflux structure just like the valve more than trim the base of flap to be traditional submucosal tunnel technique deliberately. We replaced the catheter with a 7F double J tube, and had to further anastomose the forming ureter to the ureteropelvic junction with bioabsorbable sutures while fixing the ureter upon the aponeurosis of the greater psoas muscle. After indwelling the three-cavity catheter and the retropubic drainage tube, we stitched the bladder incision with bioabsorbable sutures. Finally, we sutured the abdominal incision conventionally （Figure 1A and 1B）. RESULTS All six patients＇ operations were carried out smoothly and successfully. The duration of the six surgeries ranged from 60 to 120 minutes, with the average operation time being 90 minutes. During the operations, none of the patients accepted blood transfusion, and all of them recovered well after the operation. Among the six patients, the retropubic drainage tubes in four patients were removed successfully postoperation in 3 days, while the other two had theirs removed in 10 days because of mild leakage of urine. All six patients＇ surgical incisions healed well in the first attempt, and their indicators of serum creatinine and blood urea nitrogen were also normal after 2 weeks. The double J tubes were all successfully removed by a cystoscope in 3 months or so postoperation. Two patients were confirmed to have had mild uronephrosis and ureterectasia on the surgical side in the follow-up examination after 3 months, but their total renal functions were normal. 2-4 years postoperatively, the other four patients showed no obvious abnormalities in their follow-up examinations. Also,展开更多
文摘In the past, the surgeons usually adopted ileal ureter plasty or ureter bladder flap plasty （Boari flap plasty） to restorelong-term ureteral mucosal avulsions and long or entire ureteral segment defects caused mostly by ureteroscope operations. But there are still certain difficulties in the restoration of long segment ureteral defects （〉20 cm） using traditional methods. In order to overcome traditional surgical approaches, we designed a new ureteroplasty operation using spiral pedunculated bladder muscle flap to restore long segment ureteral defects. METHODS Six patients who presented long segment ureteral defects caused in the course of ureteroscopic lithotripsy due to ureteropelvic junction stenosis and stones （length of defects： 21-25 cm, mean length： 22.5 cm）, were given general anesthesia, and made to lay in the horizontal position while indwelling triple lumen catheters. These patients had Gibson incision in the hypogastrium of the injured sides, and we could prolong the surgical incision up to the epigastrium or the flank abdomen moderately if necessary. We exposed the retroperitoneal space, transected the umbilical ligaments, peritoneal adhesions, spermaducts or the round ligaments to dissociate the bladder to the maximum extent possible. We could increase the mobility of the bladder by dissociating the contralateral superior vesical arteries along the anterior trunk of the internal iliac artery. We could also identify the stump of the distal ureter along the path between the ureter and bladder below the iliac vessels, and then we had to ligate or transfix the ureteral stump. We dissociated the ureteropelvic junction carefully, trimmed the stump to the inclined plane in order to facilitate the anastomose between the bladder muscle flap and the trimmed ureteral stump while locating and tracting it by the suture. Filling the bladder with 400 ml of normal saline solution along the catheter, we located the anterior wall of the bladder with the suture. Before designing the spiral pedunculated bladder muscle flap, we had to identify the superior vesical arteries and their branches of the injured sides along the anterior trunk of the internal iliac artery. Then, we trimmed the shape S bladder muscle flap along the arteries＇ track while stretching the bladder by pulling the suture. The basal width of the designed flap had to be more than or equal to 2 cm, and the length should be equivalent to the injured ureter. We thenhad to wind the bladder muscle flap spirally upon the 12F catheter, followed by continuous stitching of the winding flap and interrupted embedded stitching of the serosal layer with 5-0 bioabsorbable sutures. If only we could keep the natural spiral conditions of the bladder muscle flap between the beginning of the forming ureter and the bladder, we would get a spontaneous anti-reflux structure just like the valve more than trim the base of flap to be traditional submucosal tunnel technique deliberately. We replaced the catheter with a 7F double J tube, and had to further anastomose the forming ureter to the ureteropelvic junction with bioabsorbable sutures while fixing the ureter upon the aponeurosis of the greater psoas muscle. After indwelling the three-cavity catheter and the retropubic drainage tube, we stitched the bladder incision with bioabsorbable sutures. Finally, we sutured the abdominal incision conventionally （Figure 1A and 1B）. RESULTS All six patients＇ operations were carried out smoothly and successfully. The duration of the six surgeries ranged from 60 to 120 minutes, with the average operation time being 90 minutes. During the operations, none of the patients accepted blood transfusion, and all of them recovered well after the operation. Among the six patients, the retropubic drainage tubes in four patients were removed successfully postoperation in 3 days, while the other two had theirs removed in 10 days because of mild leakage of urine. All six patients＇ surgical incisions healed well in the first attempt, and their indicators of serum creatinine and blood urea nitrogen were also normal after 2 weeks. The double J tubes were all successfully removed by a cystoscope in 3 months or so postoperation. Two patients were confirmed to have had mild uronephrosis and ureterectasia on the surgical side in the follow-up examination after 3 months, but their total renal functions were normal. 2-4 years postoperatively, the other four patients showed no obvious abnormalities in their follow-up examinations. Also,
