The ischaemia and fibrosis of the ureter and surrounding tissues caused by radiotherapy is a great challenge for surgeons. Long ureteral defects are treated surgically by constructing a nonrefluxing and nonobstructed urine outflow as quickly as feasible to restore or stabilize renal function [10].
In our case series, all patients had ureteral stents placed and replaced regularly for strictures. However, long-term indwelling ureteral stents may cause recurring urinary tract infections and renal function issues, putting patients under severe emotional, psychological, and financial stress.It is well known that the treatment of extensive long-segment ureteral strictures includes uretero-ureterostomy, renal autotransplantation, Boari bladder flap, and IUR. Historically, IUR was performed for ureteral strictures secondary to tuberculosis. However, among all available treatment options for radiation-induced extensive ureteral strictures, IUR is the last and only viable option at this time. Park JJ et al. [11]and Monn MF et al. [5] reported their experience with IUR in the treatment of radiation-induced ureteral stricture, but their procedures were performed open. Limited literature has reported completely intracorporeal laparoscopic IUR, and only a few case reports have concentrated on the treatment of long ureteral strictures after radiation therapy.
For example, Kochkin A et al. [12] reported the experience of 40 cases of total intracorporeal laparoscopic IUR for the treatment of long ureteral defects, which required a change in table position during the procedure. In addition, it has been reported that the current robot used to perform IUR must be undocked and redocked during the ileovesical anastomosis stage of the procedure [4]. Furthermore, ureteral strictures caused by radiation therapy after surgery for cervical cancer are often associated with severe scarring and fibrosis of the periureteral tissue, which poses a serious challenge for the surgeon when dissecting the ureter while preserving its blood supply. To optimize the problems faced above, we innovatively proposed a single-position TILIUR, and put the concept based on membrane anatomy that we reported earlier, that is, pay more attention to the plane between tissue and tissue when dissecting the ureter, and applied this technique to the dissection of ureteral strictures after radiotherapy.
The standard treatment for early-stage cervical cancer is radical hysterectomy with bilateral pelvic lymph node dissection. The important technical step in radical hysterectomy is to perform wide dissection of the periureteral tissue and bladder [13].Thus, we can consider that the ureters, bilateral iliac vessels, and peripheral tissues of the bladder in these patients after radical hysterectomy are mostly “naked” because of bilateral pelvic lymph node dissection, dissections of the ureters, and adjuvant radiation therapy and are replaced by a covering of fibrous scar tissue. It is difficult to free the fibrous scar tissue covering the surface of the ureter, and an alternative strategy was employed in our study series by looking for normal tissue with space as an entry point and by a combination of blunt and sharp methods if severe fibrous scar tissue was encountered.
Thereare limited TILIUR reports for treating postoperative cervical cancer radiotherapy-induced ureteral strictures. Gözen AS et al. [12] reported 40 cases of TILIUR in 2020, one of which was for ureteral strictures caused by cervical surgery followed by radiotherapy, and the mean operative time in this series was 335 (150–680) minutes, with a mean estimated blood loss of 221 (50–400) ml; Li B et al. [14]reported two cases in 2021, with operative times of 420 min and 410 min per patient and an estimated blood loss of 120 ml and 100 ml, respectively; Li X et al. [15] reported 15 cases of robotic-assisted total intracorporeal robot-assisted ileal ureter replacement (RA-IUR) in 2023, with 7 patients treated with unilateral RA-IUR and 8 patients treated with bilateral RA-IUR, with a mean operative time of 261.8 min (183–381 min) and an estimated blood loss of 64.7 ml (30–100 ml), including 7 patients who had surgery for cervical cancer plus radiotherapy. Our series were all in this category, with a mean operative time of 458 min (385–575 min) and an estimated blood loss of 158 ml (50–400 ml). Although the operation time was slightly longer and the estimated blood loss was slightly higher, in terms of postoperative outcome, the results were generally consistent with the above studies. One patient with postoperative incomplete ileus recovered following conservative therapy, one with abdominal wall stoma retraction due to obesity, and the others experienced no complications.
Next, in terms of indications for surgery, the main surgical indication for TILIUR is patients with bilateral long or multiple ureteral strictures, which is similar to the surgical indications reported in the current literature [15]. IUR combined with abdominal wall stoma is recommended for patients with bilateral long or multiple ureteral strictures accompanied by bladder dysfunction, such as urinary incontinence, or preoperative creatinine greater than 2 mg/dl. Because gynaecological cancer surgery and radiotherapy can cause complications of low-compliance bladder and vesicovaginal fistula, in this case, it can cause repeated urinary tract irritation or urinary incontinence. To maintain kidney function and improve lower urinary tract symptoms at the same time, urinary tract diversion is inevitable [16, 17].
Although the mid-urethral sling is the gold standard for treating urinary incontinence in women [18], for the loss of bladder capacity and urethral sphincter function that cannot be repaired, abdominal wall ostomy is an appropriate and feasible surgical method.
A previous study also supports the fact that half of the patients with serum creatinine over 2 mg/dl develop hyperchloremic metabolic acidosis, and the procedure needs to be changed to the conduit [19]. However, a study by Armatys SA et al. [20]showed that six patients had preoperative baseline creatinine greater than 2.0 mg/dl, and renal function stabilized or improved in five cases; therefore, we believe that IUR in patients with preoperative creatinine greater than 2.0 mg/dl still has a role in stabilizing renal function. Impaired renal function was not a contraindication to surgery, according to studies, and IUR may help preserve renal function in patients with high serum creatinine (> 2 mg/dl) [21, 22]. In our case, two patients with preoperative creatinine greater than 2.0 mg/dl had a decrease in creatinine at the last follow-up compared with the preoperative period.
Based on our encouraging initial experience, TILIUR in a single position based on membrane anatomy may be a promising option for the treatment of ureteral strictures induced by radiotherapy for cervical cancer. There are certain considerations in the management of RIEUS based on our experience. First, for patients with acute renal failure caused by RIEUS, preoperative percutaneous nephrostomy protects renal function and reduces the risk of urinary tract infection as well as effectively decreasing the incidence of postoperative urinary leakage and improving the healing of the ureter-ileum anastomosis; moreover, nephrostomy can be used intraoperatively to observe saline flow to assess the health of the ureter. Second, for patients with RIEUS accompanied by renal insufficiency and bladder dysfunction, TILIUR combined with abdominal wall ostomy may be considered because of the positive effect on the protection of renal function. All anastomoses adhered to the surgical principles of being tension free and waterproof and protecting the blood supply. Therefore, this requires proficiency in laparoscopic techniques as well as extensive experience in ureteral reconstruction for the urologist. Third, for dissection of the bilateral renal pelvis and upper ureter, we used a single caudal approach. This approach offers the advantages of avoiding procedures such as changing positions, resterilization, and draping during the surgery as well as simplifying the process and significantly reducing the operating time.
Although encouraging, the results of our report must be considered in the context of its limitations. First, all of the procedures were carried out by surgeons who were well trained and had much expertise with laparoscopic surgery. As a result, our findings could not be applied to all surgeons. Additionally, this was a pilot study, and the sample size was limited, which might impact the results. Therefore, to confirm our preliminary findings, more research with larger populations and longer follow-ups is needed.
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