AUA2017 V10-01: Reconstruction of Two Concurrent Ipsilateral Ureteral Strictures with Appendiceal Onlay and Non-Transecting Ureteral Reimplant

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INTRODUCTION
The management of concurrent ipsilateral ureteral strictures is challenging as the ureter cannot be transected in two places. The mainstays of reconstruction in this clinical scenario include renal autotransplant or ileal ureter, both of which are associated with morbid short and long-term complications. The concept of an onlay graft or flap to increase the size of the lumen is a well-established technique for urethral reconstruction. We demonstrate the feasibility of this concept to the ureter by placing an onlay of bladder and appendix to manage concurrent ureteral strictures.

METHODS
A 66-year-old man with bilateral proximal ureteral stones developed a 3cm right distal ureteral stricture and a 6cm right proximal ureteral after undergoing ureteroscopy and laser lithotripsy at an outside institution. These strictures were refractory to endoscopic management. The patient had an elevated creatinine. Robotic reconstruction was performed with simultaneous intraoperative ureteroscopy to delineate the stricture. As the ureteroscope was passed retrograde, the 3cm distal and 6cm proximal ureteral strictures were incised using the robot along the anterior aspect of the ureter. The patient’s appendix was mobilized, detubularized, and placed as an onlay flap onto the proximal stricture. The distal ureteral stricture was repaired by marsupializing a flap of bladder onto the ureter for a non-transecting reimplant.

RESULTS
The patient had an uneventful postoperative course and went home on postoperative day 4. Nephrostogram performed at 6 weeks post op demonstrated prompt drainage of contrast after stent removal. At 6 months post op, he had no urinary infections or flank pain. Ureteroscopy at this time demonstrated patency throughout the entire course of the right ureter.

CONCLUSION
For the appropriate patient, ureteral reconstruction using onlay of appendix and bladder is a feasible option for multiple ureteral strictures. Six-month outcomes are favorable, but long-term outcomes need to be elucidated.

Funding: none

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