Use of Ileum for Complex Ureteric Reconstruction:

Assessment of long term outcome, complications

and impact on renal function.

Presenter : Dr. Yash Pamecha

Guided by : Dr. Sujata Patwardhan
Seth G.S. Medical college and KEM Hospital,
Mumbai
• What is complex stricture?????
• simple or complex on the basis of length of
involved segment and associated nephropathy
• Why to classify????????
• Management changes as surgical options are
limited.
• Defect in ureteral continuity can be due to
stricture, obstruction due to malignancy,
traumatic avulsion or perforation.
• Causes of stricture: urinary tuberculosis,
radiation, bilharziasis, devascularization, etc.
• In 1909, Shoemaker reported the first ileal
ureter in a woman with tuberculous
involvement of the urinary tract2
 Indicated where length of the ureteric defect
or the pathophysiology of disease process
precludes the use of other options like psoas
hitch, Boari’s flap or trans-uretero-
ureterostomy.
 use of ileum is not free of complications.
 various metabolic derangements, like
metabolic acidosis and raised serum
creatinine.
 AIM..
• To study the various indications in which an
ileal segment can be used for ureteral
reconstruction and to assess the short term
and long term post-operative outcomes in
such patients.
• Also to understand its impact on renal
function.
 Materials and Methods

• It is an observational study conducted over a

period of 4 years from 2012 till 2016
• All patients where other reconstructive
procedures were not possible or failed.
• Detailed clinical, biochemical and radiological
work up
• In patients presenting with deranged renal
functions, preoperative optimization was
done using either D-J stent or percutaneous
nephrostomy
 Technique

• In case of unilateral ureteral reconstruction,

lumen of ileum was tailored over 12 French
Foleys catheter.
• Proximal end of ileum tube was anastomosed to
ureter or renal pelvis in an end- to end manner.
• Distal end was either anastomosed to bladder
using Lich-Gregoir extra-vesical non-refluxing
reimplantation technique or to ureter in end to
end fashion.
 Technique..

• In case of bilateral ureteric defect, bilateral

ureters were reimplanted into a common iso-
peristaltic ileum segment in end to side
manner.
• Proximal end of ileum was closed and the
distal end was subsequently anastomosed to
the dome of bladder using Lich-Gregoir
technique.
 Technique..

• Double J stents and percutaneous

nephrostomy (PCN) catheters were kept
during each reconstruction. Per urethral
catheter was kept for 10 days.
• Patients were put on Soda-bicarbonate tablets
as soon as bowel activity was regained and
also regular bicarbonate washes through PCN.
 Follow up
• Initially patients were asked to follow up every three
weeks. After six weeks, double J stents were removed
and PCN was blocked.
• If no complication occurred in a week and patient
remained asymptomatic, then PCN catheters were
removed after confirmation of normal drainage system
on imaging.
• Patients were asked to follow up with hematological
investigations and ultrasound after 3 months.
• Long-term follow up with every three monthly visits
were asked after that. In follow up visits, hematological,
biochemical and radiological investigations were done.
 Results

• Total 14 patients were included in the study.

Mean age was 41.2 years.
Sr. Clinical Site of lesion Previous Length of
No. History surgery stricture
done
1 Radiation post Left lower ureter UNC* 7cm
hysterectomy

2 Radiation post Left lower ureter Not Any 5cm

hysterectomy
3 Radiation B/L mid and lower Not Any 15cm
ureter
4 Radiation B/L Mid and lower Not Any 17cm
ureter
5 Radiation B/L Lower ureter Not Any 4 cm
6 Post URSL Right middle Boari’s 4cm
large mid- flap
ureteric stone
7 Post- B/L mid and lower Vaginal 10cm
hysterectomy ureteric stricture Vault
and vault repair repair with
reimplant
8 Post URSL Left Complete Not Any 20cm
Ureter avulsion
9 Post URSL Left Complete Not Any 15cm
Ureter avulsion
10 Pyelolithotomy Left Upper U-U** 8cm
11 GU TB Right mid and Not Any 20 cm
lower ureter and
small bladder
12 GU TB B/L mid and lower Not Any 12cm
ureter
13 GU TB Right mid and Not any 15 cm
lower ureter
14 Idiopathic Right upper ureter U-U** 5 cm
 Results…

• Most common indication : radiation induced

strictures and iatrogenic strictures.

• Most common site involved : mid- and lower

ureter

• Length of ileum used ranged from 4cm to

20cm, with a mean of 11.2cm
 Serial Monitoring of renal functions
(Sr. Creatinine in mg/dl)
No. Pre-intervention Nadir before Post-ileal interposition
surgery 1 month 6 months 12 months

01 2.1 1.8 1.8 1.2 1.3

02 3.5 1.7 1.9 1.9 1.4
03 2.9 1.0 1.5 1.4 0.9
04 1.1 1.1 1.6 1.0 1.2
05 0.8 0.8 0.9 0.7 0.8
06 2.4 2.1 2.2 1.9 2.1
07 2.2 2.2 2.4 2.0 2.0
08 2.7 1.9 2.1 1.8 1.7
09 1.4 1.4 1.3 1.1 1.1
10 1.8 1.8 1.8 1.7 1.9
11 2.8 2.2 2.4 1.1 1.1
12 2.0 1.8 1.7 1.8 1.8
13 1.8 1.3 1.5 1.1 1.1
14 1.1 1.1 1.9 1.5 1.0
 Results…

• Nine out of 14 patients required pre-operative

intervention
• Mean pre-operative nadir creatinine level
achieved after urinary diversion was 1.57mg%.
• Average post-operative creatinine level at
4weeks follow up was 1.75mg%.
• At 6 months and 12 months follow up, the
mean creatinine level reduced to 1.45mg% and
1.37mg%, respectively.
 Results..

At follow up, serum creatinine was stabilized in

8 out of 14 patients (57%) in 6 patients
decreasing trend of serum creatinine from
preoperative value was observed (43%).
 Complications

Short term complication No. of cases

Anastomotic leak 02
Anastomotic site bleed 00
Wound infection 04
Paralytic ileus 07
UTI 04
Sepsis/Pelvic abscess 02
Deep Vein Thrombosis 01
LRTI/Pneumonia 03
Urinary retention due to catheter block 01

Long term complications

Recurrent UTI 05
Hyper-chloremic metabolic acidosis 01
Anastomotic stricture 00
End stage renal disease 00
Short gut syndrome 00
Calculus in Ileal segment 01
 Discussion
• The motto behind the study is to describe the
change in spectrum of indications that has seen
a paradigm shift.

• To discuss various evolving techniques in

constructing long segments of ureter.

• (Pedicled ileum to artificial substitutes to Yang

Monti technique)
 Pre op renal function.. topic for debate
• Contraindications for use of ileum are impaired
renal function.

• Ileum as bladder substitute ---- Reservoir

• Ileum as ureteral substitute ---- Conduit

• Various studies in the literature have shown

that improvement or stabilization of renal
function is seen in approximately 74% of
patients, post-procedure3,4. Our study showed
better results as compared to other studies
 Use of bowel in irradiated patients

• Use of irradiated bowel segment is

contraindicated, due to problems in healing.
There is risk of fistula formation4,5,6 and
anastomotic leak1.

• Use of proximal healthy ileum with minimal

grossly visible radiation changes.
Metabolic complications.. not a problem for us!!

• Development of metabolic acidosis, excessive

mucous production, recurrent UTI and stone
formation owing to functional stasis were
common drawbacks of surgery reported in
various studies7,8

• This study had only 1 patient presenting with

metabolic acidosis during 1 year follow up.
• Metabolic complications like hyper-chloremic
metabolic acidosis, renal insufficiency, hepatic
dysfunction, etc. are noted commonly after
use of a long and wide caliber ileal segment.

• So the length of bowel used should preferably

be as short as possible to prevent these
complications9
 Importance of PCN
• Insertion of PCN in every patient and giving
washes through it has helped to resolve many
of the mucous associated complications like
infection, acidosis apart from preventing
worsening of renal functions.

• One case where PCN was not kept……

 Discussion on the point of technique.
• No common consensus on the use of distal implantation
technique and its effect on renal function.
• Some authors assumed that a distal anti reflux technique
of bowel implantation over bladder may decrease the
urinary flow with subsequent dilatation of ileal
segment10.
• Many authors1, 9 concluded that anti-reflux procedure is
not necessary at all as the natural iso-peristaltic waves of
ileal tube can prevent reflux from reaching the kidney11
• Others5 stressed role of anti-reflux procedure in
preventing further worsening of renal functions in
patients with already impaired renal function.
 Take on Yang-Monti’s technique
• Low incidence of graft dilatation, metabolic
acidosis, excessive mucous production and
recurrent UTI episodes.11,12.
• Attributed to use of reconfigured ileal segment
which provided a tube with markedly reduced
re-absorptive as well as secreting surface area.
• We obtained similar results by restricting the
length of ileal segment and tailoring its lumen
to 12 Fr thereby achieving the same goals as
that of Yang Monti technique.
 Conclusion
• It is found to be relatively easy and safe surgery
even in patients with borderline high creatinine.
• There was no worsening of renal function
attributable to the conduit in this study.
• A suitable alternative to permanent nephrostomy
catheters and regular stent change in patients with
limited surgical options.
• Metabolic acidosis and Mucous associated
complications like pain, infection and stone
formation can be minimized by adherence to strict
protocol.
 Conclusions

Key to successful outcome

• Adequate pre-operative optimization of renal

functions
• Keeping length of ileal segment as short as
possible and of adequate caliber
• Strict post-operative follow up
 References

1)Takeuchi M. et.al. Korean J Urol 2014;55:742-749.

2) Shoemaker GE. Removal of the ureter with a tuberculous kidney.Ann Surg 1911; 53:696-8.
3) Armatys et al. Use of Ileum as Ureteral Replacement in Urological Reconstruction. J Urol. 2009
January; 181(1): 177–181.
4) Boxer RJ et.al. Replacement of the ureter by small intestine: clinical application and results of the
ileal ureter in 89 patients. J Urol 1979;121:728.
5) Bazeed MA et.al. Ileal replacement of the bilharzial ureter: is it worthwhile? J Urol 1983;
130:245-8.
6) Waldner M et.al. Ileal ureteral substitution in reconstructive urological surgery: is an antireflux
procedure necessary? J Urol 1999;162:323-6.
7) Verduyckt FJ, Heesakkers JP, Debruyne FM. Long-term results of ileum interposition for ureteral
obstruction. Eur Urol 2002;42:181.
8) Bonfig R, Gerharz EW, Riedmiller H: Ileal ureteric replacement in complex reconstruction of the
urinary tract. BJU Int. 2004; 93: 575-80.
9) Ghoneim MA et.al. The use of ileum for correction of advanced or complicated bilharzial lesions
of the urinary tract. Int Urol Nephrol 1972; 4:25.
10)Kato H et.al. A case of ileal ureter with proximal antireflux system. Int J Urol 1999; 6:320-23.
11) Ali-el-Dein B, Ghoneim MA: Bridging long ureteral defects using the Yang-Monti principle. J
Urol. 2003; 169: 1074-7.
12) M.Esmat et.al. Application of Yang-Monti Principle in Ileal Ureter Substitution: Is It a beneficial
Modification? Int. braz j urol. vol.38 no.6 Rio de Janeiro Nov./Dec. 2012
 A N K
T H . .
O U …
Y