Buccal Mucosal Graft Ureteroplasty for Treatment of Proximal Ureteric Strictures, A Clinical Case Series.

Buccal Mucosal Graft Ureteroplasty for Treatment of Proximal Ureteric Strictures, A Clinical Case Series.

While short strictures and even long strictures in the distal or mid-section of the ureter can easily be repaired by end-to-end anastomosis or simple re-implantation as well as standard procedures, such as psoas bladder hitch and/or Boari-flap, reconstructions of long proximal ureter remain rare and challenging (1), Although long segment proximal ureteric stricture (LPUS) have traditionally been managed with ileal ureter replacement (IUR) or renal auto transplantation (RA), these procedures may be technically difficult to perform and associated with considerable morbidity.(2) While buccal mucosa grafts (BMG) in urethral reconstruction are well established, only few small series for BMG in ureteric stricture have been reported. While showing promising results, these studies were flawed by inhomogeneous cohorts of patients with different kinds of strictures like uretero-pelvic junction (UPJ) obstruction, proximal and mid-ureter strictures that were treated with different techniques such as onlay ureteroplasty or augmented end-to-endanastomosis. Even though buccal mucosa harvesting is well established and straightforward current guidelines still do not recommend BMG ureteroplasty as an equal alternative to more invasive alternatives such as ileum interposition or renal auto-transplantation. (3) In 1999, Naude (4) introduced an alternative and innovative technique for treating ureteric strictures by utilizing buccal mucosa grafts (BMG) in conjunction with omental wrapping. Implementing onlay BMG during ureteral reconstruction eliminates the necessity for extensive ureterolysis, reducing disruption to the peri-ureteral blood supply. Furthermore, the BMG can be customized to accommodate the dimensions of the ureteral defect, ensuring a tension-free anastomosis. (5)

Inclusion Criteria:

• Adult patients (age ≥ 18 years) of either sex.
• Confirmed diagnosis of long (>2 cm) upper and middle ureteric strictures, either fresh or recurrent with previous open or endoscopic intervention.

Exclusion Criteria:

• Malignant ureteric stricture or stricture secondary to active pelvic/retroperitoneal malignancy.
• Active urinary tract infection at the time of planned surgery.
• Uncorrected coagulopathy or other contraindication to anesthesia/surgery.
• Active oral mucosal disease, oral submucous fibrosis or previous bilateral grafting.
• Solitary non-functioning kidney on the affected side with differential renal function<15% on renogram (relative or absolute non-functioning renal unit) unless reconstruction is otherwise indicated.
• Pregnancy.
• Cases of ureteric avulsion where ileal ureter substitution will be used or cases with complete ureter obliteration no passing guidewire or ureteric catheter.