V04-12: Laparoscopic left ureteral substitution using cecal appendix after en-bloc resection rectosigmoidectomy: a case report and video demonstration
On occasion, locally advanced pelvic tumors mandate en-bloc resection because they encroach on adjacent organs, such as the ureter 1. The treatment of ureteral division above the level of the iliac vessels carries a high degree of complexity and represents a challenge for the surgeon 2,3. Several options for ureteral reconstruction exist – such as reimplant, Boari flap, and the psoas hitch 4. A less commonly used option is the use of pedicled graft cecal appendix which can be used as a conduit interposed between bladder and ureter 5,6,7. The adoption of this technique on the right side is useful due to anatomic proximity, however the use on the left side is more challenging, particularly when performed laparoscopically. The aim of this video forum is to demonstrate the feasibility of laparoscopic reconstruction of the left urinary system utilizing an autografted native appendix during ureteral en bloc excision necessitated by extirpation of a locally advanced upper rectal adenocarcinoma.
A 69-year-old male patient with a sigmoid colon tumor diagnosed at 13 cm from the anal verge and occupying 90% of the colon lumen. The patient underwent en-bloc Laparoscopic rectosigmoidectomy of the tumor with invasion of the left ureter above the iliac vessels. The left bladder wall demonstrated direct tumor invasion as well. The operation was completed laparoscopically, and a primary, end-to-end coloproctostomy was performed utilizing a double stapled technique. The next steps are demonstrated in the supplemental video forum. Specifically, the urinary tract was reconstructed using transposition of the appendix used as a conduit to bridge the gap from the divided segment of left ureter to the bladder.
While technically challenging, a laparoscopic re-implantation was successfully performed. The surgery had no intraoperative complications. The operative time was 310 minutes, there was no adverse sequelae, and at 12 month follow up renal scans demonstrated preserved urinary function.
This video demonstrates that the laparoscopic use of the cecal appendix in the reconstruction of the left ureter is a possible option and longer follow-up with additional patients is necessary to validate the efficacy of this approach.
Funding: 1. R. Landmann, M. Weiser Surgical Management of Locally Advanced and Locally Recurrent Colon Cancer, Clin Colon Rectal Surg. Aug; 18(3): 182–189. doi: 10.1055/s-2005-916279 2. St. Lezin MA, Stoller ML. Surgical ureteral injuries. Urology 1991;38: 497–506 3. Frank N. Burks, Richard A. Santucci, Management of iatrogenic ureteral injury , Ther Adv Urol. 2014 Jun; 6(3): 115–124. doi: 10.1177/1756287214526767 4. Andersen, P., Andersen, L.M. & Iversen, L.H. Iatrogenic ureteral injury in colorectal cancer surgery: a nationwide study comparing laparoscopic and open approaches Surg Endosc (2015) 29: 1406. doi:10.1007/s00464-014-3814-1 5. Franke J, Smith J. Surgery of the ureter. En: Campbell’s Urology, 10th ed. Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. y A. J. Wein. Philadelphia: W. B. Saunders Co., 2010; Vol. 3, Cap. 98:3062-84 6. Reggio E, Richstone L, Okeke Z and Kavoussi LR. Laparoscopic Ureteroplasty Using On-lay Appendix Graft. Urology 2009 73: 928.e7 – 928.e10. 7. O. Castillo, G. Lopez, Ureteral replacement with cecal appendix Rev. Chilena de Cirugía. Vol 64 - N° 2, Abril 2012; pág. 185-188