Complete substitution of the left ureter with vermicular appendix during

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Progrèsenurologie(2020)30,547—549

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CLINICAL CASE

Complete substitution of the left ureter with vermicular appendix during

hemicolectomy for cancer in an adult patient

Substitution complète de l’uretère gauche par l’appendice vermiculaire lors d’une hémicolectomie pour un cancer chez un patient adulte

F. Dal Moro

^a^,^c^,∗

, G. Terrosu

^b

, D. Lorenzin

^b

,

V. Cherchi

^b

, F. Goffo

^c

, G. Lissandrello

^d

, G. Ferraioli

^c

, C. Zaborra

^c

, A. Risaliti

^b

aDepartmentofMedicalArea,Urology-UniversityofUdine,ViaPozzuolo330,33100Udine, Italy

bDepartmentofMedicalArea,Surgery-UniversityofUdine,Udine,Italy

cDepartmentofSurgery,OncologyandGastroenterology,Urology,UniversityofPadova, Padova,Italy

dDepartmentofImaging,AziendaSanitariaUniversitariaIntegrata,Udine,Italy

Received25January2020;accepted30March2020 Availableonline11May2020

KEYWORDS Ureter;

Ureteral replacement;

Appendix

Summary Wedemonstrated thatacomplete left ureteral substitutionwith appendixisa feasibleandsafetechnique.Toourknowledge,thisistheﬁrstcaseofasuccessfulcomplete substitution oftheleft ureterwithvermicularappendixinanadult patient reportedinthe literature.

∗Correspondingauthor.

E-mailaddress:[email protected](F.DalMoro).

https://doi.org/10.1016/j.purol.2020.03.010

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548 F.DalMoroetal.

MOTSCLÉS Uretère; Replacemente Urétéral; Appendice

Résumé Nousavonsdémontréqu’unesubstitutionurétéralegauchecomplèteavecappendice estunetechniquefaisableetsûre.Ànotreconnaissance,ils’agitdupremiercasdesubstitution complèteréussiedel’uretèregaucheparunappendicevermiculairechezunpatientadulte rapportédanslalittérature.

Introduction

Ureterallesionsoccur asaconsequence ofsurgicalproce- dures,tumours,radiation, orﬁbrosis. Themanagementof theselesionsisoftenachallenge.Thesurgicaloptionsfor themanagementofcomplexlong-segmenturetericdefects arelimited. Wereport a technique for complete ureteric replacementusingthe cecalappendix.This approachwas often proposed for the management of short right/left ureteral lesions or in pediatric patients; here we report a case of complete left ureteral substitution in an adult patient.

Case Report

Anintraoperativeconsultationwasrequestedbygeneralsur- geonsduringthelefthemicolectomyin a76-year-oldman withrecurrentrectaladenocarcinoma.Coloncancertotally surroundedtheleftureterandacompleteureteralresection wasperformedremoving thecolonmassenbloc.Classical surgerytechniquescouldnotbeperformedinthissituation forseveralreasons:bladderpsoashitchingwasnotsufﬁcient toreachtherenalpelvis;Boariﬂapureteroneocystostomy couldnotbeperformedduetothereducedvolumeofthe bladderandthethicknessofthebladderwall(highriskof ischemia);the ‘‘ileal ureter’’ or the use of a small ileal segmentaccording totheYang-Montiprinciplewereabso- lutelycontraindicated due toa prior removalof the long

Figure1. A.Schemeofthecompletesubstitutionoftheleftureterwithvermicularappendix.B.Intraoperativeimage.C.AngioCTscan after1monthdemonstratinganormalvascularizationoftheappendix(*).

intestinaltract(highriskofshortbowelsyndrome);kidney auto-transplantation wasnot indicateddue tohighrisk of bleeding(Jehovah’sWitnesspatient);asyntheticgraftwas non-available;leftgonadalveinwaspreviouslyremoved[1].

Technique

Weoptedfor acompleteleftureteralreconstructionwith appendicular transposition(Fig.1).Afterpartialmobiliza- tion and reconfiguration of the bladder (bladder psoas hitching), we mobilized the cecumand appendix (to pre- servetheappendicularvascularization):acrucialstepwas thefixationof thececum closetothebladderusingthree reabsorbable stitches.The appendix(7cm)wasdividedat itsbase;itsdistalendwasthenanastomosedtotherenal pelviswith4/0monofilament(singlestitches),anditsproxi- malportiontothebladderwithadirectrefluxingtechnique (4/0monofilamentinterruptedsuture),aftertheinsertion ofaureteralstentofdoubleJ(6Ch/24cm).

Results

The operative time for the ureteral replacement was 40minutes.Nointra-andpost-operativecomplicationwas recorded and the stent wasremoved after 2 months. An angioCT scan performed after 1 month demonstrated a

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Completesubstitutionoftheleftureter 549

Figure2. Uro-CTscanafter2monthsconﬁrmingaregularvas- cularizationoftheappendix(arrow)withanormalwashoutofthe urinefromthepelvis.

normalvascularization of the appendix.Acystogram con- trol conﬁrmed no urinary leakage. A uro-CT scanafter 2 monthsconﬁrmedaregularvascularizationoftheappendix withanormalwashoutoftheurinefromthepelvis(Fig.2).

Thefollow-up(1year)wasuneventful,withoutevidenceof strictures(norenaldilationatultrasonography)orstonesor renalimpairment.

Discussion

Inthepastwedescribedacaseofanextendedureteralstric- ture corrected withappendiceal replacement in a kidney transplantrecipient [2].Nevertheless, the substitution of theleftureterrepresentsachallengeduetotheanatomical, andaboveall,vascularriskscorrelatedtothetransposition oftheappendixfromtherighttotheleftside[3].

AlthoughintheLiteraturefewexperiencesreportedthe useofthececalappendixinreplacingtheleftureter,the majorityofproceduresarerelatedtopediatricpatientsorin caseoflongureteralstrictureafterkidneytransplantation [4].Thereisonlyonecasereportdescribingtheuseofthe appendixasa conduittobridge thegap fromthe divided segmentoflefturetertothebladdertheurinarytract:in thatcase theAuthorsusedtheappendixfromthe divided segmentoflefturetertothebladder[5].

Instead, inour case we wereforcedtoreplace all the ureterfrom the pelvistothe bladder. Only theextensive

mobilizationof both the bladder and the cecum allowed atension-freeanastomosisamongtheappendix,therenal pelvisandthebladder.

Moreover,we decidedtoorient the appendix withthe distalendtotherenalpelvisinordertoavoidanykindof traction/distortionofthemesoappendix:indeed,anisoperi- stalticanastomosis,whilewouldhelppropelurinedownthe segment,wouldtwistedthemesenteriolewithanischemic damageoftheappendix.

To our knowledge, this is the ﬁrst case of a success- fulcompletesubstitutionoftheleftureterwithvermicular appendixinanadultpatientreportedintheliterature.

We demonstratedthat a complete leftureteralsubsti- tution with appendix is a feasible and safe technique. A trickcouldbetheextensivemobilizationofthececumand itsﬁxationclosetothebladder(afterpsoas-hitching).Spe- cialattentionmustbegiventopreservingtheappendicular arteries,ensuringthatthemesoappendixwasnottwisted.

Acknowledgments

None

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

References

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replacementoftheureterwithgonadalvein.Acadavericstudy.

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[2]AdaniGL,Pravisani R, BaccaraniU, et al.Extended ureteral stricturecorrectedwithappendicealreplacementinakidney transplantrecipient.Urology2015;86:840—3.

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[5]Alcántara-QuispeC,Xavier JM,AtallahS,etal. Laparoscopic leftureteralsubstitutionusingthececalappendixafteren-bloc rectosigmoidectomy:a casereportand videodemonstration.

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