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RESEARCH ARTICLE
Year : 2003  |  Volume : 20  |  Issue : 1  |  Page : 28-32
 

Use of buccal mucosa as onlay graft technique for benign ureteric strictures


Department of Urology and Kidney Transplantation, Institute of Kidney Diseases & Institute of Transplantation Sciences, BJ Medical College & Civil Hospital, Ahmedabad, India

Correspondence Address:
Shailesh A Shah
Kidneyline Healthcare, 1 st floor, Harikrupa Towers, Near Govt. Ladies Hostel, B/h Gujarat College, Ellisbridge, Ahmedabad - 380 006
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives: To cure long and multiple ureteric strictures by a simple procedure without the long term complications of bowel interposition or surgery of high magnitude like auto-transplantation.
Methods: Ureteric strictures in 5 patients were treated with buccal mucosa onlay grafts with an omental wrap. The underlying etiology was tuberculosis in 4 patients and amyloidosis in I patient. Mean age was 45 years. Three patients had strictures in upper ureter, 1 patient in mid­ureter and 1 patient had panureteric stricture. In all pa­tients length of stricture was greater than 5 cm.
Results: Ureteric patency was established in all patients. Four patients have persistent improvement in renal func­tion. In I patient, renal function improved initially (at 6 months follow-up) but subsequently (at 1-year follow-up) the unit was non functioning. Follow-up was in the range of 1.5 year to 3.5 years.
Conclusions: In selected patients with complicated be­nign ureteric strictures, buccal mucosal dorsal onlay graft was proved capable of maintaining patency and good uri­nary drainage. The procedure is technically simple and devoid of complications.


Keywords: Buccal mucosa, ureteric stricture.


How to cite this article:
Shah SA, Ranka P, Visnagara M, Dodia S, Jain R. Use of buccal mucosa as onlay graft technique for benign ureteric strictures. Indian J Urol 2003;20:28-32

How to cite this URL:
Shah SA, Ranka P, Visnagara M, Dodia S, Jain R. Use of buccal mucosa as onlay graft technique for benign ureteric strictures. Indian J Urol [serial online] 2003 [cited 2019 Jun 20];20:28-32. Available from: http://www.indianjurol.com/text.asp?2003/20/1/28/37120



   Introduction Top


A repertoire of procedures is needed when the ureter needs resection or reinsertion. Complicated ureteric stric­tures and segmental ureteric loss beyond the anticipated reach of a Boari flap might warrant bowel interposition or auto transplantation. Both procedures are of considerable surgical magnitude and entail long-term complications.

The success of buccal mucosal grafts in complicated hypospadias repair and urethroplasty, popularized by Duckett et al (1995) [1] is well known. Somerville & Naude (1984)[2] performed an animal study using a tubularized, free, buccal mucosal graft for segmental ureteric replace­ment and found excellent take-up of graft and upper-tract drainage.

Naude J. H. (1999)[3] reported successful use of buccal mucosal patch grafts in 5 patients having a variety of ureteric lesions, and a tubularized buccal mucosal graft in one patient with segmental ureteric loss.

We report our experience of ureteroplasty in 5 patients with long, benign ureteric strictures using buccal mucosal onlay grafts with omental wrap.


   Patients and Methods Top


From January 1999 to January 2001, 5 patients with ureteric strictures were treated. Patients were subjected to urinalysis and ultrasonography (USG). Serum creatinine was normal in all cases. Intravenous urogram (IVU) re­vealed non-visualized kidney on affected side and normal contralateral unit in all patients. Percutaneous nephrostomy (PCN), antegrade study, cystoscopy, retrograde uretero­pyelogram (RGP) and DTPA renal scan (3 to 4 weeks af­ter diversion) were done in all cases. Urine for AFB culture was positive in case numbers 1, 2, 3 and 4, and was nega­tive in case number five.

Case 1

A 36-year-old male presented with irritative voiding symptoms and right flank pain of 3 months duration with sterile pyuria, right-sided moderate hydronephrosis, nor­mal bladder and 8cm long stricture in upper ureter [Figure - 1]A. PCN output was about 1 litre / 24hours. Differential function of right kidney was 30% with obstructive pat­tern.

Case 2

A 32-year-old female presented with irritative voiding symptoms and left flank pain of 6 months duration with past history of pulmonary tuberculosis. Investigations re­vealed sterile pyuria with microscopic hematuria, gross hydronephrosis on left side, normal bladder and multiple strictures involving upper, middle and lower parts of ure­ter (panureteric stricture). PCN output was around 250m1 / 24hours. Differential function of left kidney was 15%.

Case 3

A 41-year-old male presented with right flank pain. In­vestigations revealed moderate hydronephrosis of right kidney, normal bladder and 5.5cm long stricture in upper ureter. Split function of right kidney was 18% [Figure - 2]A.

Case 4

A 30-year-old male presented with left flank pain of 4 months duration with gross hydronephrosis of left kidney, normal bladder and stricture involving 9cm of upper ure­ter with 15% split function of left kidney.

Case 5

A 60-year-old female presented with left flank pain and irritative voiding symptoms of 1-year duration with mod­erate hydronephrosis of left kidney. Cystoscopy revealed two irregular yellowish lesions over trigone and left lat­eral wall of bladder each measuring about 1.5 x 1 cm 2 . Left RGP showed narrowing of mid-ureter with a filling defect proximally. Ureterscopy showed a whitish exuberant le­sion arising from lateral wall of mid-ureter measuring about 2.0x1.5cm 2 . Biopsy was taken using forceps. Bladder le­sions were resected. Histopathology report of both tissues was amyloidosis [Figure - 3]. Cytology for malignant cells was negative. Differential function of left kidney was 22%. Investigations for systemic amyloidosis were negative.

Patients of tuberculosis were treated with three drug regi­men [Rifampicin 450mg, INH 300mg and Pyrazinamide 25mg/Kg body weight] for 3 months and then subjected to reconstructive surgery. Patient with amyloidosis was not given any medical treatment.

Operative technique:

Following exploration the length of strictured part of ureter was measured and buccal mucosa graft, 1 cm longer than stricture, was harvested from the inner aspect of cheek just below the Stenson's duct down upto the lower lip, under general anaesthesia in four patients and under local anaesthesia (from lip only) in one patient. The longest graft was 15cm. The mucosal margins of cheek were reapproxi­mated using 6/0 chromic catgut suture. The strictured por­tion was laid open, a double `J' stent was placed and graft was sutured to margins of ureter using 4-0 synthetic ab­sorbable polyglactin suture [Figure - 4],[Figure - 5] ABC. In one patient [Case number 5], 3cm obliterated segment of ureter with lesion was completely excised and laid open ureteral ends were spatulated and sutured dorsally follow­ing renal descensus. Then graft was placed ventrally to bridge the defect. Grafted portion was wrapped all around the omentum [Figure - 5]D. A periureteric drain was placed in each case.


   Results Top


The postoperative course was uneventful in all cases. Drain was removed 5 days after surgery. Double `J' stent was removed six weeks after surgery. In postoperative period two drugs were continued for 3 months [Rifampicin 450mg and INH 300mg daily]. Postoperative urine cul­ture was sterile in all patients. IVU was done at 3 months and RGP at 6 months after surgery. Nuclear scan was done at 6 months and then yearly.

Case 1

IVU showed delayed nephrogram and pyelogram with mild hydronephrosis and complete drainage. RGP revealed wide patency of ureter [Figure - 1]B. Split function of affected unit was 34% and 36% at 6 months & l year respectively.

Case 2

IVU revealed delayed function with residual hydrone­phrosis. RGP demonstrated wide patency of ureter. Split function was 16% at 6 months. However at 1-year uptake was 0%. Repeat RGP revealed normal calibre ureter but obstructed collecting - system. Ureteroscopy showed excel­lent "take up" of graft. Patient was advised urine for AFB culture and nephrectomy but she was reluctant and was then lost to follow-up.

Case 3

IVU showed improved renal function. RGP showed patent ureter. Split renal function was 22% and 26% at 6 months and 1 year respectively [Figure - 2]B.

Case 4

IVU and RGP revealed improved renal function and normal calibre ureter. Split renal function was 18% and 21% at 6 months and 1 year respectively.

Case 5

IVU revealed prompt excretion and drainage of con­trast. Cystoscopy, RGP and ureteroscopy done at 6 months and 1 year demonstrated, patent ureter with excellent "take up" of graft and no recurrent lesion of amyloidosis. Split renal function was 28% and 30% at 6 months and 1 year respectively.


   Discussion Top


Reconstructive surgery in tuberculosis is warranted for the preservation of renal function. The majority of recon­structive problems related to renal tuberculosis are obstruc­tive (Monchalova and Starikov, 1997). [4] If surgical therapy should become necessary, it is wise to precede the opera­tion with at least 3 weeks and preferably 3 months, of chemotherapy (Shin et al, 2002).[5] However, it has been suggested that tissue destruction may be accelerated greatly by obstructive strictures that can develop soon after initia­tion of medical therapy (Murphy et al 1982),[6] (Psirahims and Donahoe, 1986).[7] Therefore, it is essential to preserve existing renal function or to arrest the deterioration of re­nal function during medical therapy. Shin et al (2002)[5] stud­ied role of early endourologic management of tuberculous ureteral strictures. They concluded that early ureteral stenting or PCN might increase the opportunity for later reconstructive surgery and decrease the possibility of re­nal loss. In the present series, 4 patients with tubercular ureteral strictures were subjected to early PCN to mini­mize the risk of renal loss. In 3 patients renal unit could be salvaged but in 1 patient eventually the renal function was lost. Renal loss from parenchymal destruction may be in­evitable. In the series of Shin et al (2002)[5] nephrectomy rate in patients treated with medication only was 73% and in patients also undergoing ureteral stenting or PCN was 34%. Progressive renal damage in tuberculosis is due to initial inflammatory changes and subsequent fibrous changes that render the renal collecting system and ureter thickened, poorly contractile, and prone to obstruction by formation of thick-walled strictures. In the present series obstructed collecting system was demonstrable on RGP in case member two.

Ureteral reconstruction has been performed using au­tologous bladder mucosa graft (Hovnanian and Kingsley, 1966) and free flaps of parietal peritoneum (Eposti, 1956). [9] However, due to disruption, these materials did not come into vogue. Naude J. H. (1999)[3] reported use of buccal mucosal grafts in 6 patients for the treatment of variety of ureteric lesions viz. tubercular stricture. bilharzial stric­ture, severe fibrosis and stenosis of UPJ following pyelo­lithotomy in intrarenal pelvis, loss of a segment of ureter following gunshot injury and resection of peri-ureteric mass. In all patients ureteric patency was established and there were no complications.

Buccal mucosa can be used either as a patch graft or as a tubularized graft. In the present series tubularized graft was not used. Indeed, urothelium present even in part of circumference of the ureter, has inherent capacity to regene­rate. The classical Davis intubated ureterotomy (1943)[10] requires prolonged stenting and success depends only on damaged urothelium to regenerate. Buccal mucosal grafts demonstrate an abundant layer of vasculature in the outer layer of lamina propria. Added to this, the excellent vas­cular bed provided by omental wrap. grafts to the ureter would have an excellent take-up rate. The graft may be easily harvested from the cheek. Ureteral reconstruction by dorsal onlay graft technique is simple and devoid of complications. It ensures patency and good drainage. Hence procedures such as bowel interposition or autotrans­plantation, which are of considerable surgical magnitude with risk of significant complications, can be avoided in long ureteric strictures.

Albeit, the present initial experience may not claim uni­versal success of the technique, nonetheless, buccal mu­cosal dorsal onlay graft offers a viable option in long complicated ureteric strictures.


   Conclusions Top


Buccal mucosal onlay graft ureteroplasty is a suitable treatment option for long, complicated benign ureteric stric­tures. It is technically simple and capable of providing optimum patency of ureter with good urinary drainage. However, a larger number of patients and a longer follow­up is required to assess long-term results.

 
   References Top

1.Duckett JW, Coplen D, Ewalt D, Baskin LS. Buccal mucosal ure­thral replacement. J Urol 1995: 153, 1660-1663.  Back to cited text no. 1    
2.Somerville JJF, Naude JH. Segmental ureteric replacement and ani­mal study using a free non-pedicled graft. Urol Res 1984: 12: 115­-119.  Back to cited text no. 2    
3.Naude JH. Buccal mucosal grafts in the treatment of ureteric le­ sions. BJU International 1999, 83, 751-754.  Back to cited text no. 3    
4.Mochalova TP, Starikov IY. Reconstructive surgery for treatment of urogenital tuberculosis: 30 years of observation. World J Surg 1997: 21:511.  Back to cited text no. 4    
5.Shin KY, Park HJ, Lee JJ, Park HY, Woo YN, Lee TY. Role of early endourologic management of tuberculous ureteral strictures. J Endourol 2002, 16(10): 755-758.  Back to cited text no. 5    
6.Murphy DM, Fallon B, Lane V et al. Tuberculosis stricture of ure­ter. Urology 1982: 20:382.  Back to cited text no. 6    
7.Psirhamis KE, Donahoe PK. Primary genitourinary tuberculosis: Rapid progression and tissue destruction during treatment. J Urol 1986;135:1033.  Back to cited text no. 7    
8.Hovnanian AP, Kingsley IA. Reconstruction of the ureter by free autologous bladder mucosa graft. J Urol 1966: 96:167.  Back to cited text no. 8    
9.Eposti PL. Regeneration of smooth muscle fibers of the ureter fol­lowing plastic surgery with free flaps of the parietal peritoneum. Minerva Chir 1956: 11:1208.  Back to cited text no. 9    
10.Davis DM. Intubated ureterotomy: a new operation for ureteral and ureteropelvic stricture. Surg Gynaecol Obstet 1943: 76, 513.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
    Article Figures

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