Long segment ureteral reconstruction using the prepuce: A case report

Abstract

Long segment ureteral reconstruction has always posed a challenge for surgeons. We report the case of a 49 years male patient with a right ureteral obstruction between the ileal orthotopic bladder and the ureter. The patient underwent a 12cm ureteral reconstruction with the prepuce. One month after the surgery, anterograde angiography through the nephrostomy tube showed ureteral patency. After one year of postoperative follow-up, the patient’s ureteral stricture did not recur. Using the prepuce as a free graft for ureteral reconstruction is one of the available options.

1 Introduction

Surgical repair of long-segment proximal ureteral strictures (LPUS) is challenging. Ureteroureterostomy alone is generally contraindicated in this setting given the difficulty in obtaining a tension-free anastomosis. . Usually, we have to select other materials to reconstruct the ureter, such as Boari flap, appendix, intestine, oral mucosa, etc., to achieve tension-free anastomosis. ^, . However, for some complex cases, where Boari flap, appendix, intestine, or oral mucosa are inaccessible, what other methods can replace and reconstruct the ureter? Therefore, it is highly necessary to develop safe, effective and new surgical techniques for ureteral reconstruction. Circumcision has been carried out for thousands of years, and it can be considered the most commonly performed surgical procedure in the world. . Usually, the removed prepuce is treated as medical waste. In this case we reported, because the patient needed materials for ureteral reconstruction, we performed circumcision on the patient and obtained the prepuce as a free graft to reconstruct the ureter.

2 Case presentation

The patient, male, 49 years old, underwent radical cystectomy and ileal orthotopic bladder for bladder cancer one year ago. Three months after the surgery, the patient developed right-sided hydronephrosis and was given nephrostomy. Through antegrade and retrograde angiography, we found that there was a distance of about 8cm between the dilated ureteral end and the new bladder ( Fig. 1 ). Because the patient had an ileal orthotopic bladder, it was not possible to reconstruct the ureter with a Boari flap. The patient had extensive adhesions in the intestine after radical cystectomy, and it was almost impossible to reconstruct the ureter with the intestine. The patient also did not agree to reconstruct the ureter with oral mucosa. Finally, we asked the patient whether he had undergone circumcision and whether the patient had a redundant prepuce. The patient answered that he had not undergone circumcision and had a redundant prepuce. So we designed this surgical procedure for him( Fig. 2 ). It seemed that reconstructing the ureter with the prepuce was the only choice.

Intraoperatively, the patient was found to have severe intra-abdominal adhesions. We completely disengaged the ureter and found that there was a distance of about 12cm between the ileal orthotopic bladder and the ureter to achieve tension-free anastomosis, rather than the 8cm evaluated by preoperative imaging. We took the end of the ureter out of the body, and then we performed a circumcision. We reconstructed about 12cm ureteral segment with a prepuce coil( Fig. 3 A). The ureter is then returned to the body, achieving a tension-free anastomosis with the ileal orthotopic bladder ( Fig. 3 BC). The ureteral part of the reconstruction with the prepuce was wrapped with omentum ( Fig. 3 D). The surgery time was about 3 hours, and blood loss was about 100ml. The abdominal drainage tube was removed 5 days after the surgery, and the renal fistula was kept. One month after the surgery, the patient returned to the hospital for antegrade angiography through the renal fistula, which showed that the ureteral reconstruction with free prepuce was unobstructed ( Fig. 1 ), and the renal fistula was removed. After one year of postoperative follow-up, the patient’s ureteral stricture did not recur.