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Renal Autotransplantation for Widespread Ureteral Lesions: Report of 4 Cases
THE JOURNAL OF UROLOGY
Vol. 113, January
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS: REPORT OF 4 CASES PAUL J. VAN CANGH, JEAN B. OTTE, CHARLES VAN YPERSELE DE STRIHOU, EDGARD COCHE AND GUY P. ALEXANDRE From the Departments of Transplantation and Nephrology, University of Louvain, Louvain, Belgium
right iliac fossa on August 25, 1967. The distal ureter and ureterovesical junction were resected, and ureteroneocystostomy was performed with the Leadbetter-Politano technique. Immediate and long-term results have been satisfactory. At a 5 ½-year followup the renal function was normal, urine was sterile and an IVP showed essentially normal images of both ureterorenal units (fig. 3). Retrograde cystography did not reveal vesicoureteral reflux. Case 2. R. M., a 37-year-old woman, was first seen in March 1971 for persistent urinary tract infection and recurrent hematuria following a Boari flap ureteroplasty. This procedure had been performed elsewhere in January 1970 to replace the right distal ureter injured during total hysterectomy. Urological evaluation revealed signs of chronic pyelonephritis and massive vesicoureteral reflux up to the renal cavities on the right side (fig. 4, A). On September 1, 1971 the right kidney was transplanted into the left iliac fossa. Ureteroneocystostomy was performed using the Gregoire technique. The distal right ureter and bladder tube were resected. Convalescence was uneventful. Two years later the patient was asymptomatic, the renal function was normal, the urine was sterile and the autografted kidney had regained a normal radiological aspect (fig. 4, B). Case 3. D. W. C., a 44-year-old man, was first seen in January 1973 for treatment of postoperative stenosis of the ureteropelvic junction. A congenital solitary left kidney had been fortuitously discovered in 1970. In October 1972 an Anderson-Kuss pyeloplasty was performed elsewhere for ureteropelvic junction obstruction. Convalescence was complicated by fistulization at the site of the anastomosis with secondary stenosis and rapidly progressing renal failure. Local reintervention failed to restore adequate urinary drainage. Renal failure was severe when the patient was hospitalized, as demonstrated by a serum creatinine level of 7.2 mg. per cent. Delayed films of a high dose perfusion urography showed only faint visualization of a hydronephrotic single kidney with little passage to the bladder (fig. 5, A). On February 1, 1973 the kidney was explored through a large flank incision. The proximal 10 cm. of the ureter were destroyed and there was a small fibrotic intrarenal pelvis. The kidney was transplanted into the ipsilateral iliac fossa. Vascular anastomoses were difficult because of severe inflammatory infiltration of the renal pedicle. The pelvis was anas-
Renal autotransplantation has gained a definite place in the urologic armamentarium. In most cases reported the operation has been performed for renovascular hypertension. 1 Other indications for renal autotransplantation include an extensive ureteral lesion 2 -• as well as an aid to workbench or ex vivo operations, such as microvascular repair, and excision of renal and pelvic tumors. 5- 7 We herein report 4 cases of renal autotransplantation for widespread ureteral lesions. CASE REPORTS
Case 1. C. G., a 19-year-old man, was first seen in August 1967 for ureteral stenosis. This patient had been hospitalized in November 1966 for treatment of pulmonary and renal tuberculosis. Urological evaluation at that time revealed moderate right hydronephrosis with cortical atrophy (fig. 1) secondary to a distal third ureteral stenosis typical of tuberculous ureteritis (fig. 2). The patient improved rapidly under intensive medical therapy, and sputum and urinary cultures became negative for tuberculous bacilli. Persistent lumbar pain and microhematuria motivated transfer of the patient to our department. Serum creatinine level was 1.1 mg. per cent and creatinine clearance was 97 ml. per minute. A urinary culture yielded 100,000 colonies of enterococci per ml. An excretory urogram (IVP) showed increasing hydronephrosis with a 10 cm. stenosis of the lower ureter. The right kidney was autotransplanted into the Accepted for publication May 17, 1974. 1 Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. J. Urol., 110: 20, 1973. 2 Hardy, J. D.: High ureteral injuries: management by autotransplantation of the kidney. J.A.M.A., 184: 97, 1963.
•Marshall, V. F., Whitsell, J., McGovern, J. H. and Miscall, B. G.: The practicality of renal autotransplantation in humans. J.A.M.A., 196: 1154, 1966. 'Rockstroh, H. and Schulze, R.: Autotransplantation der Niere bei ausgedehnter Harnleiteruerletzung. Z. Urol., 62: 331, 1969. 'Lim, R. C., Eastman, A. B. and Blaisdell, F. W.: Renal autotransplantation. Adjunct to repair of renal vascular lesions. Arch. Surg., 105: 847, 1972. 'Corman, J. L., Anderson, J. T., Taubman, J., Stables, D. P., Halgrimson, C. G., Popovtzer, M. and Starzl, T. E.: Ex vivo perfusion, arteriography, and autotransplantation procedures for kidney salvage. Surg., Gynec. & Obst., 137: 659, 1973. 7 Caine, R. Y.: Tumour in a single kidney: nephrectomy, excision, and autotransplantation. Lancet, 2: 761, 1971. 16
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS
with ensuing loss of the kidney. Three months later renal function returned to preoperative levels. DISCUSSION
FIG. 1
tomosed to the distal portion of the ureter. Hemodialysis was done 2 days postoperatively. Five days later leakage of the pyeloureterostomy required operative revision. Subsequently, convalescence was uneventful. Eight months later serum creatinine level was 1.7 mg. per cent and an IVP showed moderate residual dilatation of the renal cavities (fig. 5, B). Case 4. V. E. A., a 57-year-old woman, was first seen in January 1973 for evaluation of right ureterohydronephrosis and moderate renal insufficiency. A month previously she had undergone an operation elsewhere for midureteral stenosis of unknown origin. A postoperative urinary fistula closed spontaneously with simultaneous development of progressive hydronephrosis. When the patient was hospitalized moderate renal insufficiency was evident owing to a serum creatinine level of 2.5 mg. per cent. An IVP showed moderately severe hydronephrosis on the right side with amputation of the inferior renal pole and marked cortical atrophy (fig. 6). Retrograde pyelography revealed a 9 cm. ureteral stenosis with a blind fistula. The left kidney had signs of chronic pyelonephritis. In order to save as much renal parenchyma as possible, renal autotransplantation was planned. On March 3, 1973 a small kidney with marked cortical atrophy and inflammatory changes was transplanted into the right iliac fossa. The renal pelvis was anastomosed to the distal ipsilateral ureter. Initial function was satisfactory but the arterial anastomosis thrombosed 4 days later
Renal autotransplantation for ureteral complications has not been reported frequently. We found only 7 cases in the literature-ureteral lesions in 3 cases, 2 • 4 idiopathic retroperitoneal fibrosis in 2 cases 8 • 9 and ureteral tumors in 2 cases. 10 · 11 The optimal indication ofrenal autotransplantation for ureteral lesions is the correction of defects of benign origin, such as trauma or inflammation. In 3 of our cases autotransplantation was done to correct ureteral defects of surgical origin. Case 2 illustrates the complications of bladder flap ureteroplasty and their correction by autotransplantation. Failure of pyeloplasty with fistulization and sepsis had produced a wide proximal ureteral defect in case 3. Nephrostomy could have been only a temporary alternative and intestinoplasty would not have been possible without lower pole nephrectomy because of the thick cortex of the solitary kidney and the presence of a small scarred intrarenal pelvis. Case 4 exemplifies the problem of a post-surgical lumbar ureteral stenosis. It raises the question of the feasibility of transplanting a pyelonephritic kidney. The low blood flow increases the risk of vascular complications. To our knowledge case 1 is the first successful reported case of autotransplantation for tuberculous ureteritis. Sacrifice of a viable kidney is often accepted when confronted with an extensive ureteral stenosis of tuberculous origin. Our observation suggests that when the acute process has been brought under control, prompt and optimal restoration of urinary tract integrity by autotransplantation will salvage valuable functional renal tissue. Several reports have documented the usefulness of autotransplantation in the treatment of idiopathic retroperitoneal fibrosis when simple measures such as ureterolysis and intraperitonization of the ureter are inadequate. 8 • 9 The indication for autotransplantation in the treatment of a malignant lesion of the upper urinary tract is less well documented. The fact that transitional cell carcinoma may affect both upper tracts simultaneously or successively leads to a certain conservatism in the management of these tumors. 12 Autotransplantation is a logical procedure when resection of a large ureteral segment is necessary. 10 • 11 'Brisset, J. M.: Cited by Dufour, B.: Les obstructions de l'uretere lombo-iliaque. Rapport pour le 67eme Congres franrais d'Urologie, Paris, 1973. 'Linke, C. A. and May, A. G.: Autotransplantation in retroperitoneal fibrosis. J. Urol., 107: 196, 1972. 10 Murphy, G. P., Staubitz, W. J. and Kenny, G. M.: Renal autotransplantation for rehabilitation of a patient with multiple urinary tumors. J. Urol., 107: 199, 1972. 11 Rhame, R. C.: Application of renal autotransplantation to the treatment of simultaneous bilateral ureteral tumours. Brit. J. Urol., 45: 388, 1973. 12 Petkovic, S. D.: A plea for conservative operation for ureteral tumors. J. Urol., 107: 220, 1972.
18
VAN CANGH AND ASSOCIATES
FIG. 2
The technique of autotransplantation has been adequately described several times 13 and needs little elaboration. Nephrectomy should be atraumatic, preserving vascularization to the ureter when it is available. Inflammatory infiltration of the renal pedicle following a previous operation, urinary leakage or sepsis renders the operation much more difficult, as noted in our last 2 cases. The kidney is perfused with 500 ml. Collins' C3 solution at 4C and then kept at 4C in a bath of Collins' C2 solution while awaiting transplantation into the iliac fossa. Urinary continuity is restored by either ureteroneocystostomy, pyeloureterostomy or ureteroureterostomy as needed in the individual case. The major advantage of autotransplantation over the other reconstructive procedures is the restoration of a healthy autologous excretory system-urinary reflux and infection are remarkably absent. For that reason we believe that autotransplantation should be used more frequently for correction of widespread ureteral defects, especially in cases of a solitary kidney. Autotransplantation is also free of intestinal and intraperitoneal complications and can be adapted to almost any kind of situation. Even when the ureter is completely destroyed, vesicopyelostomy remains possible with a good probability of preserving satisfactory renal function. 1 • Experience 13 Whitsell, J. C.: Autotransplantation in the management of lower ureteral defects. In: Current Controversies in Urologic Management. Edited by R. Scott. Philadelphia: W. B. Saunders Co., 1972. 14 Herwig, K. R. and Konnak, J. W.: Vesicopyelostomy: a method for urinary drainage of the transplanted kidney. J. Urol., 109: 955, 1973.
FIG. 3
and technical competence in renal transplantation are prerequisites for the safe conduct of the procedure. It should not be improvised by the occasional
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS
FIG. 4
FIG. 5
19
20
VAN CANGH AND ASSOCIATES
failure caused by arterial thrombosis. That adequate vascular anastomoses are possible in cases of inflammatory lesions of the renal pedicle is shown in case 3, although the risk of thrombosis is admittedly increased. This fact might have contributed to ultimate vascular failure in case 4. Valuable alternatives to renal autotransplantation certainly exist but have several drawbacks. Transureteroureterostomy is only possible for the lower third ureteral defects and there must be a normal contralateral excretory tract. There is at least a theoretical possibility of injury to the normal ureter, stricture of the anastomosis compromising both kidneys and yo-yo peristalsis from one ureter to the other. Bladder flap ureteroplasty and bladder advancement techniques have obvious limitations as to the available bridging length and require intact noninflammatory bladder walls. The occurrence of stenosis or reflux is a distinct possibility as exemplified in case 2. A third alternative is the substitution of the ureter. Intestinoplasty has well known immediate and long-term complications, 15 and the use of an inert ureteral prosthesis remains experimental or confined at the present time to malignant obstruction. SUMMARY
Fm. 6
operator. However, autotransplantation should not be undertaken when equivalent results can be obtained by simpler measures or as a desperate means to salvage a greatly deteriorated kidney. Judging from the large number of successful kidney transplantations performed each year, the risk of vascular complications is low. In our series of more than 300 cases there has been only 1 early
Various approaches exist to widespread ureteral lesions. Renal autotransplantation has a privileged place in selected cases since it gives the patient the best chances for optimal long-term results. We believe that the procedure should be used more frequently. It does not compete with other procedures but extends the possibilities for the surgeon to save functional renal tissue. 16 Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversion. Ann. Surg., 167: 367, 1968.
Vol. 113, January
Copyright© 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS: REPORT OF 4 CASES PAUL J. VAN CANGH, JEAN B. OTTE, CHARLES VAN YPERSELE DE STRIHOU, EDGARD COCHE AND GUY P. ALEXANDRE From the Departments of Transplantation and Nephrology, University of Louvain, Louvain, Belgium
right iliac fossa on August 25, 1967. The distal ureter and ureterovesical junction were resected, and ureteroneocystostomy was performed with the Leadbetter-Politano technique. Immediate and long-term results have been satisfactory. At a 5 ½-year followup the renal function was normal, urine was sterile and an IVP showed essentially normal images of both ureterorenal units (fig. 3). Retrograde cystography did not reveal vesicoureteral reflux. Case 2. R. M., a 37-year-old woman, was first seen in March 1971 for persistent urinary tract infection and recurrent hematuria following a Boari flap ureteroplasty. This procedure had been performed elsewhere in January 1970 to replace the right distal ureter injured during total hysterectomy. Urological evaluation revealed signs of chronic pyelonephritis and massive vesicoureteral reflux up to the renal cavities on the right side (fig. 4, A). On September 1, 1971 the right kidney was transplanted into the left iliac fossa. Ureteroneocystostomy was performed using the Gregoire technique. The distal right ureter and bladder tube were resected. Convalescence was uneventful. Two years later the patient was asymptomatic, the renal function was normal, the urine was sterile and the autografted kidney had regained a normal radiological aspect (fig. 4, B). Case 3. D. W. C., a 44-year-old man, was first seen in January 1973 for treatment of postoperative stenosis of the ureteropelvic junction. A congenital solitary left kidney had been fortuitously discovered in 1970. In October 1972 an Anderson-Kuss pyeloplasty was performed elsewhere for ureteropelvic junction obstruction. Convalescence was complicated by fistulization at the site of the anastomosis with secondary stenosis and rapidly progressing renal failure. Local reintervention failed to restore adequate urinary drainage. Renal failure was severe when the patient was hospitalized, as demonstrated by a serum creatinine level of 7.2 mg. per cent. Delayed films of a high dose perfusion urography showed only faint visualization of a hydronephrotic single kidney with little passage to the bladder (fig. 5, A). On February 1, 1973 the kidney was explored through a large flank incision. The proximal 10 cm. of the ureter were destroyed and there was a small fibrotic intrarenal pelvis. The kidney was transplanted into the ipsilateral iliac fossa. Vascular anastomoses were difficult because of severe inflammatory infiltration of the renal pedicle. The pelvis was anas-
Renal autotransplantation has gained a definite place in the urologic armamentarium. In most cases reported the operation has been performed for renovascular hypertension. 1 Other indications for renal autotransplantation include an extensive ureteral lesion 2 -• as well as an aid to workbench or ex vivo operations, such as microvascular repair, and excision of renal and pelvic tumors. 5- 7 We herein report 4 cases of renal autotransplantation for widespread ureteral lesions. CASE REPORTS
Case 1. C. G., a 19-year-old man, was first seen in August 1967 for ureteral stenosis. This patient had been hospitalized in November 1966 for treatment of pulmonary and renal tuberculosis. Urological evaluation at that time revealed moderate right hydronephrosis with cortical atrophy (fig. 1) secondary to a distal third ureteral stenosis typical of tuberculous ureteritis (fig. 2). The patient improved rapidly under intensive medical therapy, and sputum and urinary cultures became negative for tuberculous bacilli. Persistent lumbar pain and microhematuria motivated transfer of the patient to our department. Serum creatinine level was 1.1 mg. per cent and creatinine clearance was 97 ml. per minute. A urinary culture yielded 100,000 colonies of enterococci per ml. An excretory urogram (IVP) showed increasing hydronephrosis with a 10 cm. stenosis of the lower ureter. The right kidney was autotransplanted into the Accepted for publication May 17, 1974. 1 Hodges, C. V., Lawson, R. K., Pearse, H. D. and Stranburg, C. 0.: Autotransplantation of the kidney. J. Urol., 110: 20, 1973. 2 Hardy, J. D.: High ureteral injuries: management by autotransplantation of the kidney. J.A.M.A., 184: 97, 1963.
•Marshall, V. F., Whitsell, J., McGovern, J. H. and Miscall, B. G.: The practicality of renal autotransplantation in humans. J.A.M.A., 196: 1154, 1966. 'Rockstroh, H. and Schulze, R.: Autotransplantation der Niere bei ausgedehnter Harnleiteruerletzung. Z. Urol., 62: 331, 1969. 'Lim, R. C., Eastman, A. B. and Blaisdell, F. W.: Renal autotransplantation. Adjunct to repair of renal vascular lesions. Arch. Surg., 105: 847, 1972. 'Corman, J. L., Anderson, J. T., Taubman, J., Stables, D. P., Halgrimson, C. G., Popovtzer, M. and Starzl, T. E.: Ex vivo perfusion, arteriography, and autotransplantation procedures for kidney salvage. Surg., Gynec. & Obst., 137: 659, 1973. 7 Caine, R. Y.: Tumour in a single kidney: nephrectomy, excision, and autotransplantation. Lancet, 2: 761, 1971. 16
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS
with ensuing loss of the kidney. Three months later renal function returned to preoperative levels. DISCUSSION
FIG. 1
tomosed to the distal portion of the ureter. Hemodialysis was done 2 days postoperatively. Five days later leakage of the pyeloureterostomy required operative revision. Subsequently, convalescence was uneventful. Eight months later serum creatinine level was 1.7 mg. per cent and an IVP showed moderate residual dilatation of the renal cavities (fig. 5, B). Case 4. V. E. A., a 57-year-old woman, was first seen in January 1973 for evaluation of right ureterohydronephrosis and moderate renal insufficiency. A month previously she had undergone an operation elsewhere for midureteral stenosis of unknown origin. A postoperative urinary fistula closed spontaneously with simultaneous development of progressive hydronephrosis. When the patient was hospitalized moderate renal insufficiency was evident owing to a serum creatinine level of 2.5 mg. per cent. An IVP showed moderately severe hydronephrosis on the right side with amputation of the inferior renal pole and marked cortical atrophy (fig. 6). Retrograde pyelography revealed a 9 cm. ureteral stenosis with a blind fistula. The left kidney had signs of chronic pyelonephritis. In order to save as much renal parenchyma as possible, renal autotransplantation was planned. On March 3, 1973 a small kidney with marked cortical atrophy and inflammatory changes was transplanted into the right iliac fossa. The renal pelvis was anastomosed to the distal ipsilateral ureter. Initial function was satisfactory but the arterial anastomosis thrombosed 4 days later
Renal autotransplantation for ureteral complications has not been reported frequently. We found only 7 cases in the literature-ureteral lesions in 3 cases, 2 • 4 idiopathic retroperitoneal fibrosis in 2 cases 8 • 9 and ureteral tumors in 2 cases. 10 · 11 The optimal indication ofrenal autotransplantation for ureteral lesions is the correction of defects of benign origin, such as trauma or inflammation. In 3 of our cases autotransplantation was done to correct ureteral defects of surgical origin. Case 2 illustrates the complications of bladder flap ureteroplasty and their correction by autotransplantation. Failure of pyeloplasty with fistulization and sepsis had produced a wide proximal ureteral defect in case 3. Nephrostomy could have been only a temporary alternative and intestinoplasty would not have been possible without lower pole nephrectomy because of the thick cortex of the solitary kidney and the presence of a small scarred intrarenal pelvis. Case 4 exemplifies the problem of a post-surgical lumbar ureteral stenosis. It raises the question of the feasibility of transplanting a pyelonephritic kidney. The low blood flow increases the risk of vascular complications. To our knowledge case 1 is the first successful reported case of autotransplantation for tuberculous ureteritis. Sacrifice of a viable kidney is often accepted when confronted with an extensive ureteral stenosis of tuberculous origin. Our observation suggests that when the acute process has been brought under control, prompt and optimal restoration of urinary tract integrity by autotransplantation will salvage valuable functional renal tissue. Several reports have documented the usefulness of autotransplantation in the treatment of idiopathic retroperitoneal fibrosis when simple measures such as ureterolysis and intraperitonization of the ureter are inadequate. 8 • 9 The indication for autotransplantation in the treatment of a malignant lesion of the upper urinary tract is less well documented. The fact that transitional cell carcinoma may affect both upper tracts simultaneously or successively leads to a certain conservatism in the management of these tumors. 12 Autotransplantation is a logical procedure when resection of a large ureteral segment is necessary. 10 • 11 'Brisset, J. M.: Cited by Dufour, B.: Les obstructions de l'uretere lombo-iliaque. Rapport pour le 67eme Congres franrais d'Urologie, Paris, 1973. 'Linke, C. A. and May, A. G.: Autotransplantation in retroperitoneal fibrosis. J. Urol., 107: 196, 1972. 10 Murphy, G. P., Staubitz, W. J. and Kenny, G. M.: Renal autotransplantation for rehabilitation of a patient with multiple urinary tumors. J. Urol., 107: 199, 1972. 11 Rhame, R. C.: Application of renal autotransplantation to the treatment of simultaneous bilateral ureteral tumours. Brit. J. Urol., 45: 388, 1973. 12 Petkovic, S. D.: A plea for conservative operation for ureteral tumors. J. Urol., 107: 220, 1972.
18
VAN CANGH AND ASSOCIATES
FIG. 2
The technique of autotransplantation has been adequately described several times 13 and needs little elaboration. Nephrectomy should be atraumatic, preserving vascularization to the ureter when it is available. Inflammatory infiltration of the renal pedicle following a previous operation, urinary leakage or sepsis renders the operation much more difficult, as noted in our last 2 cases. The kidney is perfused with 500 ml. Collins' C3 solution at 4C and then kept at 4C in a bath of Collins' C2 solution while awaiting transplantation into the iliac fossa. Urinary continuity is restored by either ureteroneocystostomy, pyeloureterostomy or ureteroureterostomy as needed in the individual case. The major advantage of autotransplantation over the other reconstructive procedures is the restoration of a healthy autologous excretory system-urinary reflux and infection are remarkably absent. For that reason we believe that autotransplantation should be used more frequently for correction of widespread ureteral defects, especially in cases of a solitary kidney. Autotransplantation is also free of intestinal and intraperitoneal complications and can be adapted to almost any kind of situation. Even when the ureter is completely destroyed, vesicopyelostomy remains possible with a good probability of preserving satisfactory renal function. 1 • Experience 13 Whitsell, J. C.: Autotransplantation in the management of lower ureteral defects. In: Current Controversies in Urologic Management. Edited by R. Scott. Philadelphia: W. B. Saunders Co., 1972. 14 Herwig, K. R. and Konnak, J. W.: Vesicopyelostomy: a method for urinary drainage of the transplanted kidney. J. Urol., 109: 955, 1973.
FIG. 3
and technical competence in renal transplantation are prerequisites for the safe conduct of the procedure. It should not be improvised by the occasional
RENAL AUTOTRANSPLANTATION FOR WIDESPREAD URETERAL LESIONS
FIG. 4
FIG. 5
19
20
VAN CANGH AND ASSOCIATES
failure caused by arterial thrombosis. That adequate vascular anastomoses are possible in cases of inflammatory lesions of the renal pedicle is shown in case 3, although the risk of thrombosis is admittedly increased. This fact might have contributed to ultimate vascular failure in case 4. Valuable alternatives to renal autotransplantation certainly exist but have several drawbacks. Transureteroureterostomy is only possible for the lower third ureteral defects and there must be a normal contralateral excretory tract. There is at least a theoretical possibility of injury to the normal ureter, stricture of the anastomosis compromising both kidneys and yo-yo peristalsis from one ureter to the other. Bladder flap ureteroplasty and bladder advancement techniques have obvious limitations as to the available bridging length and require intact noninflammatory bladder walls. The occurrence of stenosis or reflux is a distinct possibility as exemplified in case 2. A third alternative is the substitution of the ureter. Intestinoplasty has well known immediate and long-term complications, 15 and the use of an inert ureteral prosthesis remains experimental or confined at the present time to malignant obstruction. SUMMARY
Fm. 6
operator. However, autotransplantation should not be undertaken when equivalent results can be obtained by simpler measures or as a desperate means to salvage a greatly deteriorated kidney. Judging from the large number of successful kidney transplantations performed each year, the risk of vascular complications is low. In our series of more than 300 cases there has been only 1 early
Various approaches exist to widespread ureteral lesions. Renal autotransplantation has a privileged place in selected cases since it gives the patient the best chances for optimal long-term results. We believe that the procedure should be used more frequently. It does not compete with other procedures but extends the possibilities for the surgeon to save functional renal tissue. 16 Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversion. Ann. Surg., 167: 367, 1968.