Ureter-ileum-interposition: Combined experience from two high-volume centres

Abstract

The current study aimed to evaluate short- and long-term complication rates and functional outcomes in a substantial cohort of patients undergoing ileal ureter interposition at two high-volume medical centres.

Materials and methods: A retrospective single-arm analysis was conducted on patients who underwent ureter reconstruction using ileum between 2003 and 2022 at the University Clinic of Cologne and the National Cancer Institute of Ukraine. Data on aetiology, surgical techniques, pre- and postoperative kidney function changes, readmission rates and complication management were collected. Postoperative complications were classified according to Clavien-Dindo, and estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula.

Results: Results revealed 107 cases with consistent data. Within 90 days post-surgery, 53% experienced complications, mainly graded as I-II. Grade III complications were seen in 13%, with two cases of grade IV complications leading to extended hospitalisation and patient death. The 90-day mortality rate was 1.8%. Over a mean follow-up of 52 months, clinically significant vesico-renal refluxes occurred in 28%, with only 5.4% leading to persistent urinary tract infection. Antireflux techniques appeared to reduce urine upflow incidence compared with conventional interposition. Anastomosis stricture occurred in 15% of patients, with 63% requiring permanent re-stenting and 37% needing re-anastomosis. Metabolic acidosis was clinically significant in 7.5% of cases. A slight improvement in renal function was observed during the first year post-surgery (average postoperative eGFR = 76 ± 22 ml/min; Mann-Witney U test, p = 0,0198). Affected kidney function improved in 56 (52%), was stable in 41 (38%) and deteriorated in 10 (9.3%). Loss of kidney function on the surgery side was seen in 4 (3.7%) patients and resulted in nephrectomy in 3 (2.8%) cases.

Conclusion: Ileal ureter interposition demonstrated a favourable safety profile and functional outcomes. This surgical intervention provides an effective tension-free bypass, irrespective of healthy ureter length.

Keywords: complex kidney tumours; indications to partial nephrectomy; nephrometry; organ‐sparing management; renal‐cell carcinoma.

FIGURE 1

Flowchart of the ureteral stricture management approach. UUT, upper urinary tract; UT, urinary tract; DJ', double‐J stent; NS, nephrostomy; MDB, multidisciplinary board; GFR, glomerular filtration rate.

PICTURE 1

Types of ureteral‐ileal‐interposition depending on the length of reconstructed ureter. Description: from left to right—segmentary, subtotal, total, bilateral.

PICTURE 2

Intraileal plasty during ureteral‐Ileal‐interposition. The intestinal graft is mobilised according to the required length for ureter reconstruction. The distal end of the graft is everted with the mucosa outward for 3–4 cm. A longitudinal incision is made at the 12 o'clock and 6 o'clock positions of an imaginary clock face to incise the mucosa of the everted segment of the intestine. The next stage of the operation involves placing a continuous, uninterrupted suture at the ileal level—from the base of the everted segment of the ureter to its end. This manoeuvre creates 2 channels as shown on the picture. When placing the ileal suture, it is important to maintain symmetry in the suturing to prevent kinking of the ureter. This technique creates two channels in the distal part of the intestine, which increases resistance at the anastomosis to high intravesical pressure and does not compromise the blood supply of the distal part of the graft. The ureter is then invaginated into the posterior‐lateral wall of the bladder and anastomosed with it.

PICTURE 3

Ileum plication during ureteral interposition. The illustration shows the plication technique along the outer edge of the graft (3 sutures), which ensures its folding and alignment. The formed mucosal folds function as a valve, preventing urine reflux through the graft.

PICTURE 4

Clinical example of the positive result after combining ureteral‐ileal‐interposition with antireflux technique. Description: X‐ray films 1 and 2 illustrate urography and antegrade pyelography of a 35‐year‐old patient following iatrogenic injury to the left ureter during URS. The left ureter was entirely substituted with ileal interposition, and additional measures such as ileal nipple and ileum plication were employed. X‐ray films 3 and 4 depict radiographic results 11 months after surgery. The ileum is filled with contrast, and there is no evidence of urine retention in the left upper tract. Following the infusion of 300 ml of contrast‐containing fluid into the bladder, no vesico‐renal reflux is observed, and the ileal nipple is visible.

PICTURE 5

Clinical example of the stricture in the ileo‐vesical anastomoses. Description: 45‐year‐old patient with a stricture at the ileo‐vesical anastomosis, 15 years after undergoing bilateral ileal interposition. X‐ray films 1 and 2 show retention in the upper urinary tract. Film 3 displays contrasted ileum during antegrade pyeloureterography, revealing a block at the level of the anastomoses. The patient underwent surgical removal of the garft. Stricture level can be seen on Picture 4. Given the large and lengthy ureters, bilateral ureterocystostomy was performed. Intraureteral plasty was employed to modify the radius of the ureters. Six months after surgical correction, two channels are clearly visible on the left side.