V04-08: Segmental Ureterectomy with Buccal Mucosa Graft Reconstruction in a Patient with Lynch Syndrome and Upper Tract Urothelial Carcinoma
Lifetime risk of upper tract urothelial carcinoma (UTUC) in patients with Lynch Syndrome is estimated at 8% and risk of bilateral disease reported as high as 46%. We present a 59 year-old female with Lynch Syndrome and a 3 cm low-grade UTUC in the right mid ureter on a CT scan for abdominal pain. Patient elected for segmental ureterectomy with a buccal mucosa graft reconstruction due to location of the tumor and risk of bilateral disease.
The case was performed in low lithotomy position to facilitate intra-operative ureteroscopy. A ureteroscopy was performed at the beginning of the case and was left at the location of the tumor while the ureter was dissected abdominally through a midline incision. The tumor-containing segment of ureter (7 cm in length) was then clipped and excised. A buccal mucosa graft was harvested and tubularized over a 12 French catheter. The proximal and distal ureteral anastamoses were made with two running 4-0 PDS sutures and an omental wrap was placed around the graft.
Patient was discharged on post-op day 5 after an uneventful hospital course. Estimated blood loss was 75 cc. Final pathology was a 2.6 cm, low grade, Ta, papillary UTUC with minute foci of high grade disease. Proximal and distal ureteral margins were both negative. Patient was stented for 6 months and had two surveillance ureteroscopies. Stent was permanently removed after second ureteroscopy. Renal scan with Lasix showed differential function of 46.8% on the right with a T1/2 of 10.4 minutes and 53.2% on the left with a T1/2 of 10.5 minutes. with no recurrences over 1 year of follow up.
Traditionally, UTUC is treated with nephroureterectomy. However, kidney-sparing surgery is preferred in Lynch Syndrome due to high risk of bilateral disease. While a buccal mucosa graft has been reported for ureteral strictures, it is rarely used for reconstruction with UTUC. We demonstrate that segmental ureterectomy with buccal mucosa graft reconstruction and omental wrap is a viable kidney-sparing option for large ureteral tumors.