V10-08: Total laparoscopic ureteral substitution using appendix
Complex ureteral injuries have challenging repair, involving renal autotransplantation or ureteral substitution, which was first described in 1911, using bowel segments (Shoemaker), and in 1912, using the appendix (Melkianof). We report a post-pyeloplasty complex ureteral injury that was laparoscopically repaired by an appendix interposition.
A 17 year-old boy with right ureteropelvic junction (UPJ) obstruction was scheduled for pyeloplasty. During surgery, an obstruction on the ureterovesical junction was discovered, making impossible the use of a double-J stent, causing local trauma. So, Anderson-Hynes pyeloplasty was performed and he was left only with a nephrostomy tube. Twenty days later, an anterograde pyelogram demonstrated a stricture on the UPJ level. A cystoscopy showed a scar on right ureteral meatus. It was impossible to identify the right ureteral meatus, during cystoscopy. Then an exploratory laparoscopy was scheduled on the fortieth postoperative day, and as the renal drainage was not possible by two points of obstruction, ureteral substitution was decided. Because of an intraoperative favorable anatomy, the appendix was chose and it was made laparoscopically.
The operation lasted about 350 minutes and the estimated blood loss was 200ml, so the patient received no blood transfusion. Postoperatively, the patient developed urinary tract infection and was discharged in the tenth postoperative day. Double-J stent was removed on the sixtieth postoperative day. Follow-up 6 months after surgery showed a satisfied patient, with no limitations on quality of life, asymptomatic, but with a residual hydronephrosis on image studies.
We support the use of the appendix for ureteral substitution (as a ureteral substitute) on selected cases, and we advice for the possibility of laparoscopic approach of complex injuries. We believe this is the first video of a total laparoscopic ureteral substitution using appendix.