Lingual Mucosal Graft Treatment for Recurrent Renal Bleeding after Ureteral Stricture Surgery: A Case Report

Lingual Mucosal Graft Treatment for Recurrent Renal Bleeding after Ureteral Stricture Surgery: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Lingual Mucosal Graft Treatment for Recurrent Renal Bleeding after Ureteral Stricture Surgery: A Case Report Longyuhe Yang, Yueqiang Wang, Jianbing Yang, Yunliang Zhao, Zhen Ma, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5628566/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Ureteral stricture is a prevalent and complex condition within the urinary system, often leading to significant complications. In severe instances can result in renal insufficiency and damage. Although various treatment options exist for ureteral strictures,but effectively managing specific cases remains a challenge. Autologous grafts have emerged as a novel surgical approach for ureteral repair and reconstruction. However, due to the specific surgical conditions required, reports of complications associated with these techniques are relatively limited. Case Presentation This article presents a case of a long-segment ureteral stricture treated with lingual mucosal graft. The patient experienced postoperative severe renal hemorrhage, prompting a thorough analysis of the factors contributing to this complication. This case highlights the complexities involved in the surgical management of ureteral strictures and underscores the need for careful patient selection. Conclusion The use of lingual mucosal grafts in the treatment of ureteral strictures demonstrates potential benefits, but the risk of postoperative complications, such as renal hemorrhage, necessitates further investigation. By refining the selection criteria for patients undergoing surgical intervention and addressing associated complications, this study aims to enhance clinical practice and improve patient outcomes. Lingual mucosal graft ureteral stricture renal hemorrhage repair and reconstruction Figures Figure 1 Figure 2 Figure 3 Introduction Ureteral stricture (US) is a common urological condition characterized by narrowing of the ureteral lumen due to various causes, which subsequently affects urine drainage and significantly affects the patient's quality of life and renal function. Clinically, the causes of US are diverse, with common factors including congenital malformations, trauma, postoperative scar tissue, infections, and tumors. This condition typically presents as hydronephrosis, impaired renal function, or even renal failure, making timely and effective treatment particularly crucial[1]. Currently, the treatment methods for US can be divided into two main categories: endoscopic and non-endoscopic. Endoscopic treatments typically include stent placement, stricture incision, and balloon dilation, which can achieve better results in patients with mild strictures[2]. However, the efficacy of these methods is often limited by the degree and location of the stricture and maintaining long-term patency can be challenging. Non-endoscopic surgical treatment is an important option for more severe or complex cases. Traditional surgical methods include end-to-end anastomosis after resection of the narrowed segment of the ureter, and ureteral reimplantation into the bladder. Although these surgeries can restore urinary flow to some extent, in patients with longer segments or multiple narrowed segments, tension after complete resection of the narrowed segment may be relatively high, potentially leading to the development of new strictures and resulting in surgical failure. In recent years, autologous tissue patches haves emerged as a new therapeutic strategy. This approach offers promising results for US treatment. Autologous lingual mucosa patches have been increasingly applied in the repair of ureteral strictures owing to their rich blood supply and good biocompatibility. This approach not only effectively avoids rejection reactions that may arise from allogeneic grafts but also exhibits favorable healing characteristics[3]. Case Report/Case Presentation Basic Information This case involved a 59-year-old male patient who was admitted on May 25, 2023, because of left ureteral stones and severe hydronephrosis of the left kidney. His medical history included "bilateral kidney stones and chronic renal failure" for over two years, during which he underwent multiple treatments at other hospitals, including "bilateral PCNL and URSL procedures." In February 2021, the patient underwent L-URSL and B-URSL in March 2022, L-URSL in June 2022, and L-PCNL in January 2023. He had a history of hypertension and chronic renal failure and had undergone regular dialysis. The patient also had a history of blood transfusions. CT upon admission revealed stones in the upper segment of the left ureter, accompanied by significant hydronephrosis, with a serum creatinine level of 541.4 µmol/L. After comprehensive examination, the patient underwent L-PCNL at our hospital. During the procedure, a stricture was noted in the upper segment of the left ureter, and two double-J stents(F5) were placed for dilation. Three months later, the stents were removed, and dialysis treatment was continued locally. One week after stent removal, the patient reported discomfort and mild pain in the left flank accompanied by fever. This raised the suspicion of a left renal abscess infection, prompting a return to the hospital for left renal puncture and drainage, yielding 400–600 mL of drainage fluid daily. Postoperatively, left renal stent imaging and retrograde pyelography revealed a stricture in the upper segment of the ureter. Surgical Method After fully explaining the condition to the patient and their family, consent was obtained for laparoscopic ureteral stricture resection with end-to-end anastomosis (oral mucosa grafting). Two days prior to surgery,a chlorhexidine mouthwash was used for oral care. After anesthesia was administered, the patient was placed in a lithotomy position. Under guidewire assistance, the left ureter was accessed, and upon entering the ureteroscope 20 cm, the lumen was pinhole-sized with stiff tissue, preventing the passage of the ureteroscope. A ureteral catheter was inserted and the scope was withdrawn, leaving an F18 three-lumen catheter in place. The patient was then positioned in the left lateral decubitus position, and a veress needle was inserted at the umbilicus to establish pneumoperitoneum. The skin was incised 1.5 cm along the left rectus abdominis at the umbilicus, and a 10 mm trocar was used to create an access port. A laparoscope was introduced into the abdominal cavity, and no abnormalities were observed. A 1.0 cm skin incision was made 2 cm below the left clavicle along the midclavicular line, and an 8 mm trocar was inserted into the left hand. A 1.5 cm skin incision was made along the anterior axillary line at the level of the umbilicus, and a 12 mm trocar was inserted into the right hand. An ultrasonic scalpel was used to dissect the peritoneum adjacent to the ascending colon, exposing the US site. Significant adhesions were noted around the stricture, which were released using an ultrasonic scalpel approximately 5 cm from the ureteropelvic junction (UPJ). The stricture segment of the ureter was cut with scissors, measuring approximately 2 cm in length.However, the ureteral tissue above and below the stricture was stiff, resulting in a longer defect after resection.Therefore,we decided to perform ureteroplasty using an oral mucosal graft. The catheter was removed, and the ureter was reinforced with 4 − 0 absorbable sutures on the posterior wall (Fig. 1 A). A double-J stent(F6) was inserted to measure the ureteral defect to be 4 cm long. The oral cavity was disinfected, and 3 − 0 absorbable sutures were used to suture the outer two stitches of the left lingual mucosa. A segment of the left lingual mucosa measuring 4.5 cm in length and 1.0 cm in width was marked. Saline was injected submucosally, and the marked mucosa was excised. After trimming, the graft was soaked in saline at 4°C, and the mucosal wound was continuously sutured with 5 − 0 absorbable sutures (Fig. 1 B). The lingual mucosa was then placed into the abdominal cavity and continuously sutured to the ureteral defect using 4 − 0 absorbable sutures(Fig. 1 C). The omentum was wrapped around the ureteroplasty site, and 3 − 0 barbed sutures were used to secure it (Fig. 1 D). No significant active bleeding was observed, and a drainage tube was placed in the abdominal cavity at the ureteroplasty site. All trocars were removed, and the drainage tube was secured with sutures, followed by closure of all incisions. Approximately 200 mL of blood was lost and the surgery was successfully completed. First Kidney Hemorrhage On postoperative day post-surgery, the drainage fluid was red. A follow-up CT scan indicated hematoma in the left renal pelvis (Fig. 2 B). During surgery, the injection of saline through the stoma to locate the narrowed ureter caused mucosal bleeding in the left renal pelvis. Hemostatic medications were administered, and anti-infection treatment was intensified. The patient's creatinine level increased postoperatively. Due to regular dialysis prior to surgery, heparinized dialysis was performed on the fourth postoperative day. After dialysis, the color of the stoma and ureter drainage deepened, but the was no significant decrease in the hemoglobin level. Hemostatic treatment was continued, and urine color gradually decreased. On the eighth postoperative day, heparinized dialysis was performed, and the drainage fluid from the stoma and ureter turned bright red. A follow-up CT scan revealed a large blood clot in the left renal pelvis (Fig. 2 C), and two units of suspended red blood cells were transfused the following day. On the fifteenth postoperative day, no significant bleeding was observed, and a follow-up CT scan indicated that the blood clot in the left renal pelvis had dissolved on its own (Fig. 2 D).The infection markers were normal, vital signs were stable, and the patient was discharged after the removal of the urinary catheter. Second renal hemorrhage One week after discharge,drainage fluid from the left kidney stoma was clear. The patient visited a local hospital for hemodialysis once, and on the same day, the stoma tube turned bright red, with an inability to urinate, leading to an emergency transfer to our hospital. A CT scan upon admission indicated hematoma in the left renal pelvis (Fig. 3 A). Examination results revealed a creatinine level of 1023.4 µmol/L, and a potassium level of 6.9 mmol/L, suggesting reduced blood volume and inadequate perfusion. An emergency blood transfusion was performed, followed by hemodialysis, anti-infection treatment, urinary catheter placement, and continuous bladder irrigation. Blood transfusion therapy was continued the following day. Subsequently, two sessions of heparin-free dialysis were maintained, with no significant bleeding observed,and the stoma and urinary catheter remained clear. However, after the fourth heparin-free dialysis session, the stoma and urinary catheter turned bright red again, with a progressive decline in hemoglobin levels.Arteriovenous fistula or pseudoaneurysm formation was suspected, and CT angiography did not reveal any clear vascular bleeding points (Fig. 3 B). Hemorrhage from the renal mucosa was still considered, and the medication for hemostasis was continued. An investigation of the coagulation factors revealed no abnormalities. After multidisciplinary discussion, it is recommended to discontinue hemodialysis and switch to oral uremic-clearing granules, sodium bicarbonate, sodium zirconium silicate, rosuvastatin, or compound α-keto acid treatment. Subsequent CT re-examination showed that the left renal pelvis hematoma had resolved (Fig. 3 C), and the left nephrostomy tube was removed. Results After three weeks of hospitalization, the patient was successfully discharged. Following discharge, no further hemodialysis treatment was administered. Three months later, follow-up CT showed that the left ureter was unobstructed, hydronephrosis had resolved, and the symptoms had completely resolved. The left ureteral stent was removed. At the one-month post-removal follow-up, there was no worsening of the left hydronephrosis (Fig. 3 D), and the left flank pain had completely resolved. Daily urine output was maintained at 1000–1500 mL, and creatinine levels were stable at 530–600 µmol/L. The patient was advised to resume hemodialysis; however, due to concerns about potential rebleeding, he declined treatment and will continue with regular outpatient follow-ups every three months. Discussion Selection of Indications The oral mucosa is smooth and flat, often exposed to moist conditions for extended periods, and is characterized by thick epithelial tissue, good elasticity, a thin lamina propria, and abundant capillaries. These features facilitate the revascularization of the transplanted tissue, making it an ideal graft material. After repairing the narrowed areas of the ureter with tissue grafting, the survival rate of the transplanted tissue was high, with no complications such as retraction, necrosis, or urinary leakage. Histological results indicated a significant trend toward urothelialization in the epithelium post-transplant, accompanied by a substantial presence of newly formed capillaries in the mucosa following the grafting procedure. Therefore, oral mucosal graft techniques haves promising applications in urological surgeries[4]. However, oral mucosal grafts for ureteral stricture still have certain limitations, such as donor site trauma and postoperative wound healing, which should attract the attention of physicians[5]. Currently, the indications for the use of autologous lingual mucosal grafts are not clearly defined and should be assessed comprehensively based on the specific circumstances of the patient. When selecting indications, several aspects need to be considered: ① The location, length, and nature of the stricture. For longer or more complex ureteral strictures, performing traditional end-to-end anastomosis after resecting the stricture segment can result in excessive tension, leading to a potential risk of postoperative restenosis. Autologous lingual mucosa grafts effectively address this issue by providing better repair outcomes without tension on the ureter[6,7]. ② The overall health status of the patient and any comorbidities must also be considered. In this case, we learned during the preoperative evaluation that the patient had a history of hemodialysis. Renal function of the affected side due to ureteral stricture was evaluated solely based on the daily drainage volume after nephrostomy, without considering the function of the unilateral kidney. The appropriateness of renogram as a routine preoperative assessment standard for ureteral stricture surgery warrants further investigation. The patient's symptoms were completely relieved postoperatively, and complications associated with long-term nephrostomy tube use were avoided.However, repeated treatments for bleeding introduced a certain economic burden and damage to the patient. This also serves as a reminder that surgical options should be chosen with caution in patients with severe underlying diseases or poor postoperative recovery. ③ Patients ' willingness and understanding of surgical risks should be prioritized. Adequate preoperative communication can help patients make informed decisions. In this case, the patient demonstrated a strong desire to undergo surgery and insisted on proceeding,even after being informed of potential complications. After experiencing related complications postoperatively, the patient was cooperative in treatment, and mutual trust and communication between the medical staff and the patient were crucial factors for the successful execution of such surgeries. Analysis of Causes of Renal Hemorrhage In this case, the patient experienced recurrent renal hemorrhage after autologous lingual mucosal patch repair surgery. The cause of renal hemorrhage may involve multiple factors. Intraoperative injury was a significant contributing factor.While searching for a proximal ureteral stricture, it is common to confirm its location by infusing saline into the renal nephrostomy tube to identify the dilated segment. However, we used a method of pushing saline through the nephrostomy tube, which resulted in an excessively high pressure within the renal pelvis in a short period. Coupled with the kidney's poor contraction function and increased vascular fragility, this led to rupture of the surrounding blood vessels in the renal pelvis, causing postoperative bleeding. Currently, for the localization of ureteral stricture segments, indocyanine green near-infrared fluorescence imaging can accurately highlight the location of the ureteral stricture[8]. This technique has been effectively applied in laparoscopic ureteral stricture repair and reconstruction surgery. In future ureteral stricture reconstruction surgeries, it is essential to remind surgeons to consider using fluorescent agents to locate ureteral strictures, thereby avoiding similar injuries. Second, postoperative infections are potential causes of bleeding. Based on the results of the infection indicators reviewed after each bleeding episode, procalcitonin levels showed a significant increase. Urinary tract infections may trigger local inflammatory responses, leading to congestion, edema, and even erosion of the renal pelvis mucosa, which in turn affects the healing process and increases the risk of bleeding. Additionally, increased vascular permeability allows red blood cells to leak, resulting in recurrent bleeding. Therefore,in patients undergoing ureteral stricture repair with autologous patch grafts, it is essential to ensure infection control before surgery when carrying a nephrostomy tube for an extended period. Postoperatively, routine follow-up should include blood counts, infection indicators, and urine cultures, with antibiotic use adjusted according to drug sensitivity to ensure graft viability and prevent local infections that could lead to restenosis, thereby improving the success rate of surgery[9]. Finally, the patient's underlying conditions, anticoagulation therapy, and postoperative activity levels may also influence the occurrence of bleeding. In the present case, the patient had a long history of hemodialysis. Although coagulation function and coagulation factors appear normal, the possibility of intrinsic coagulation abnormalities causing renal bleeding cannot be ruled out. Discussion on the Timing of Postoperative Dialysis In the present case, the patient experienced renal hemorrhage after surgery, leading to hypovolemia and a sharp increase in renal function. However, varying degrees of renal hemorrhage occurred after each dialysis session, further increasing renal function. Therefore, the timing of dialysis is crucial. Considering the causes of bleeding in other areas of hemodialysis patients[10], we believe that recurrent renal bleeding post-dialysis may involve the following mechanisms: (1) frequent use of anticoagulants increases the risk of bleeding; (2) chronic kidney disease may cause hemodynamic instability in renal blood supply, hindering the healing of the renal pelvis mucosa;and (3) platelet dysfunction, interactions between platelets and the vascular wall, and coagulation abnormalities. Generally,indications for dialysis include severe electrolyte disturbances, uremic symptoms, and acute renal failure. When assessing the timing of dialysis, it is essential to closely monitor the patient's renal function indicators, such as blood urea nitrogen, creatinine levels, and electrolyte status. If there are clear signs of renal failure, dialysis should be promptly performed to avoid further complications. Early postoperative recovery of renal function should also be considered.If the patient's renal function improves shortly after surgery, dialysis can be delayed. Additionally, using Nafamostat for anticoagulation treatment in patients with a high risk of bleeding during hemodialysis can effectively improve the patient's dialysis situation, regulate electrolyte levels and coagulation function, enhance dialysis adequacy, and have a minimal impact on nutritional status, demonstrating favorable application effects. Follow-up Considerations For patients undergoing autologous oral mucosa graft repair surgery, postoperative follow-up is a key component to ensure long-term effectiveness and safety. Follow-up should include regular monitoring of renal function, imaging examinations, and assessment of clinical symptoms. Specifically, renal function evaluations should be conducted at 1, 3, and 6 months post-surgery, with ultrasound or CT scans performed as necessary to assess the patency of the ureters. Additionally, it is important to monitor for signs of complications such as infection and bleeding, and to promptly address these issues. Furthermore, the patient's psychological state and quality of life should be included in the follow-up scope, with psychological support and rehabilitation guidance provided as needed. Declarations Statements Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Acknowledgement (optional) Statement of Ethics Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources Grants from the research project at Qingdao University (YLJT20231002).The funders had no role in this study. Author Contributions LY,YZ and YW analyzed and interpreted the patient data and drafted the paper. LY and YW contributed equally to this work.ZS,ZM,and JY conceptualized the study and design, analysis, and interpretation of data. All authors contributed to the article and approved the submitted version. Data Availability Statement All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author. Consent for publication Written informed consent for publication of their clinical details and clinical images was obtained from the patients. A copy of the consent form is available to the Editor of this journal. References De Coninck V, Keller EX, Somani B, et al. Complications of ureteroscopy: a complete overview. World J Urol. 2020 Sep;38(9):2147-2166. doi: 10.1007/s00345-019-03012-1. Epub 2019 Nov 20. Moretto S, Saita A, Scoffone CM, et al. Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis. World J Urol. 2024 Apr 13;42(1):234. doi: 10.1007/s00345-024-04933-2. Xu MY, Song ZY, Liang CZ. Robot-assisted repair of ureteral stricture. J Robot Surg. 2024 Sep 28;18(1):354. doi: 10.1007/s11701-024-01993-9. Filipas D , Fisch M , Fichtner J , et al. The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine[J]. Bju International, 2015, 84(1):108-111. Li B, Zhou Y, Chai S, et al. Robotic lingual mucosal graft ureteroplasty combined with Boari flap ureteroneocystostomy for one-stage repair of complex ureteral strictures: initial experience. Int Urol Nephrol. 2023 Apr;55(4):893-895. doi: 10.1007/s11255-022-03460-6. Liang C, Wang J, Hai B, et al. Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases. Eur Urol. 2022 Aug;82(2):193-200. doi: 10.1016/j.eururo.2022.05.006. Kapogiannis F, Spartalis E, Fasoulakis K, et al. Laparoscopic and Robotic Management of Ureteral Stricture in Adults. In Vivo. 2020 May-Jun;34(3):965-972. doi: 10.21873/invivo. Petrut B, Bujoreanu CE, Porav Hodade D,et al. Indocyanine green use in Urology. J BUON. 2021 Jan-Feb;26(1):266-274. Chai S, Xiao X, Chen J, et al. Treating Multifocal Ureteral Strictures with Combined Techniques: 14 Cases of Initial Experience. J Endourol. 2024 Mar;38(3):283-289. doi: 10.1089/end.2023.0454. Epub 2024 Feb 20. Solanki S, Haq KF, Khan MA, et al. Gastrointestinal Hemorrhage in Acute Kidney Injury Patients on Hemodialysis. Cureus. 2019 Sep 13;11(9):e5652. doi: 10.7759/cureus.5652. Zhang W, Bai M, Yu Y, et al. Continuous renal replacement therapy without anticoagulation in critically ill patients at high risk of bleeding: A systematic review and meta-analysis. Semin Dial. 2021 May;34(3):196-208. doi: 10.1111/sdi.12946. Lang Y, Zheng Y, Qi B, et al. Anticoagulation with nafamostat mesilate during extracorporeal life support. Int J Cardiol. 2022 Nov 1;366:71-79. doi: 10.1016/j.ijcard.2022.07.022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5628566","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":392437040,"identity":"ad6a4d88-1ada-4e7d-bd0c-18123b3dc5d4","order_by":0,"name":"Longyuhe Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACefaG9N9/eCTkGNsbiNRi2HPggQSPjI0xc88BYq25kQjUYpOW2D4jgUgdjDOSEwwkcg4b8858vPEGQ41NNEEt7DzPEhIMzhyWk5ydVmzBcCwtt4GgLe05CQcSew4bG87OMZNgbDhMWAvDgfyPDQf/HU7cf/MMsVpOJCQzNvCkJTbO4CFSCzCQ05gZeGyMGXuAfkkgxi/AqARpAUXl4Y03PtTYEOEwJGAgkUCKcogWUnWMglEwCkbByAAA61xCwVThR14AAAAASUVORK5CYII=","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":true,"prefix":"","firstName":"Longyuhe","middleName":"","lastName":"Yang","suffix":""},{"id":392437042,"identity":"e4dbe6ed-0d70-4a51-8f27-524dd07cdc60","order_by":1,"name":"Yueqiang Wang","email":"","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Yueqiang","middleName":"","lastName":"Wang","suffix":""},{"id":392437044,"identity":"7bab228a-508b-4fb1-97b0-6d04f72fc137","order_by":2,"name":"Jianbing Yang","email":"","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Jianbing","middleName":"","lastName":"Yang","suffix":""},{"id":392437045,"identity":"78933865-37e4-41a8-966f-5aadeaa5199f","order_by":3,"name":"Yunliang Zhao","email":"","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Yunliang","middleName":"","lastName":"Zhao","suffix":""},{"id":392437046,"identity":"c908341e-b231-4e7a-81b2-9ada185e8b4a","order_by":4,"name":"Zhen Ma","email":"","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Ma","suffix":""},{"id":392437047,"identity":"2be34740-51e9-4b62-842d-a32e4f5b691f","order_by":5,"name":"Zhixuan Su","email":"","orcid":"","institution":"Yunnan Central Hospital (Honghe First People's Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Zhixuan","middleName":"","lastName":"Su","suffix":""}],"badges":[],"createdAt":"2024-12-12 05:58:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5628566/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5628566/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72376488,"identity":"82a86113-135c-41f8-9ad1-99c2fa086ce8","added_by":"auto","created_at":"2024-12-26 08:24:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":585869,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure of laparoscopic tongue mucosa patch formation. A: Freeing the narrowed segment of the ureter and resection, followed by posterior wall reinforcement suturing and measurement of the defect length. B: Measuring an appropriate length of oral mucosa, cutting it, and placing it in ice water for later use. C: Continuously suturing the tongue mucosa patch to the ureter. D: Wrapping the ureter with omentum to provide protection and a certain degree of blood supply to the tongue mucosa.\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5628566/v1/c9eb1a906dd14db0a5c1a5bd.png"},{"id":72374694,"identity":"d3b19b1b-8ad3-40f0-94a4-1719ed5da154","added_by":"auto","created_at":"2024-12-26 08:16:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":476589,"visible":true,"origin":"","legend":"\u003cp\u003eCT changes before and after surgery. A: Preoperative moderate to severe hydronephrosis of the left kidney. B: Hemorrhage in the left renal pelvis postoperatively. C: Significant hematoma in the left renal pelvis after heparinized dialysis. D: Hematoma in the left renal pelvis has resolved spontaneously before discharge.\u003c/p\u003e","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5628566/v1/276ba6b9fe9993b2cad2fceb.png"},{"id":72374700,"identity":"db61e3d6-b274-4add-b1ce-4faf4a5925b5","added_by":"auto","created_at":"2024-12-26 08:16:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":426098,"visible":true,"origin":"","legend":"\u003cp\u003eCT changes after the second renal hemorrhage. A: Significant hematoma in the left renal pelvis after heparinized dialysis at an external hospital. B: After non-heparinized dialysis, the left kidney showed no arteriovenous fistula or pseudoaneurysm formation on CT enhancement. C: Hematoma in the left renal pelvis resolved spontaneously after dialysis was stopped. D: Four months post-surgery, removal of the double J stent showed no significant worsening of left renal hydronephrosis.\u003c/p\u003e","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5628566/v1/18adcd2e991990318a37b93f.png"},{"id":72378658,"identity":"dc744f2f-b0be-4bf0-9f36-494575f3647d","added_by":"auto","created_at":"2024-12-26 08:48:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1710207,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5628566/v1/36e5c8b8-1fd6-4e39-81f0-35db0bd908bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lingual Mucosal Graft Treatment for Recurrent Renal Bleeding after Ureteral Stricture Surgery: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUreteral stricture (US) is a common urological condition characterized by narrowing of the ureteral lumen due to various causes, which subsequently affects urine drainage and significantly affects the patient's quality of life and renal function. Clinically, the causes of US are diverse, with common factors including congenital malformations, trauma, postoperative scar tissue, infections, and tumors. This condition typically presents as hydronephrosis, impaired renal function, or even renal failure, making timely and effective treatment particularly crucial[1].\u003c/p\u003e \u003cp\u003eCurrently, the treatment methods for US can be divided into two main categories: endoscopic and non-endoscopic. Endoscopic treatments typically include stent placement, stricture incision, and balloon dilation, which can achieve better results in patients with mild strictures[2]. However, the efficacy of these methods is often limited by the degree and location of the stricture and maintaining long-term patency can be challenging.\u003c/p\u003e \u003cp\u003eNon-endoscopic surgical treatment is an important option for more severe or complex cases. Traditional surgical methods include end-to-end anastomosis after resection of the narrowed segment of the ureter, and ureteral reimplantation into the bladder. Although these surgeries can restore urinary flow to some extent, in patients with longer segments or multiple narrowed segments, tension after complete resection of the narrowed segment may be relatively high, potentially leading to the development of new strictures and resulting in surgical failure.\u003c/p\u003e \u003cp\u003eIn recent years, autologous tissue patches haves emerged as a new therapeutic strategy. This approach offers promising results for US treatment. Autologous lingual mucosa patches have been increasingly applied in the repair of ureteral strictures owing to their rich blood supply and good biocompatibility. This approach not only effectively avoids rejection reactions that may arise from allogeneic grafts but also exhibits favorable healing characteristics[3].\u003c/p\u003e"},{"header":"Case Report/Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eBasic Information\u003c/h2\u003e \u003cp\u003eThis case involved a 59-year-old male patient who was admitted on May 25, 2023, because of left ureteral stones and severe hydronephrosis of the left kidney. His medical history included \"bilateral kidney stones and chronic renal failure\" for over two years, during which he underwent multiple treatments at other hospitals, including \"bilateral PCNL and URSL procedures.\" In February 2021, the patient underwent L-URSL and B-URSL in March 2022, L-URSL in June 2022, and L-PCNL in January 2023. He had a history of hypertension and chronic renal failure and had undergone regular dialysis. The patient also had a history of blood transfusions. CT upon admission revealed stones in the upper segment of the left ureter, accompanied by significant hydronephrosis, with a serum creatinine level of 541.4 \u0026micro;mol/L. After comprehensive examination, the patient underwent L-PCNL at our hospital. During the procedure, a stricture was noted in the upper segment of the left ureter, and two double-J stents(F5) were placed for dilation. Three months later, the stents were removed, and dialysis treatment was continued locally. One week after stent removal, the patient reported discomfort and mild pain in the left flank accompanied by fever. This raised the suspicion of a left renal abscess infection, prompting a return to the hospital for left renal puncture and drainage, yielding 400\u0026ndash;600 mL of drainage fluid daily. Postoperatively, left renal stent imaging and retrograde pyelography revealed a stricture in the upper segment of the ureter.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Method\u003c/h3\u003e\n\u003cp\u003eAfter fully explaining the condition to the patient and their family, consent was obtained for laparoscopic ureteral stricture resection with end-to-end anastomosis (oral mucosa grafting). Two days prior to surgery,a chlorhexidine mouthwash was used for oral care. After anesthesia was administered, the patient was placed in a lithotomy position. Under guidewire assistance, the left ureter was accessed, and upon entering the ureteroscope 20 cm, the lumen was pinhole-sized with stiff tissue, preventing the passage of the ureteroscope. A ureteral catheter was inserted and the scope was withdrawn, leaving an F18 three-lumen catheter in place. The patient was then positioned in the left lateral decubitus position, and a veress needle was inserted at the umbilicus to establish pneumoperitoneum. The skin was incised 1.5 cm along the left rectus abdominis at the umbilicus, and a 10 mm trocar was used to create an access port. A laparoscope was introduced into the abdominal cavity, and no abnormalities were observed. A 1.0 cm skin incision was made 2 cm below the left clavicle along the midclavicular line, and an 8 mm trocar was inserted into the left hand. A 1.5 cm skin incision was made along the anterior axillary line at the level of the umbilicus, and a 12 mm trocar was inserted into the right hand. An ultrasonic scalpel was used to dissect the peritoneum adjacent to the ascending colon, exposing the US site. Significant adhesions were noted around the stricture, which were released using an ultrasonic scalpel approximately 5 cm from the ureteropelvic junction (UPJ). The stricture segment of the ureter was cut with scissors, measuring approximately 2 cm in length.However, the ureteral tissue above and below the stricture was stiff, resulting in a longer defect after resection.Therefore,we decided to perform ureteroplasty using an oral mucosal graft. The catheter was removed, and the ureter was reinforced with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures on the posterior wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). A double-J stent(F6) was inserted to measure the ureteral defect to be 4 cm long. The oral cavity was disinfected, and 3\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures were used to suture the outer two stitches of the left lingual mucosa. A segment of the left lingual mucosa measuring 4.5 cm in length and 1.0 cm in width was marked. Saline was injected submucosally, and the marked mucosa was excised. After trimming, the graft was soaked in saline at 4\u0026deg;C, and the mucosal wound was continuously sutured with 5\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The lingual mucosa was then placed into the abdominal cavity and continuously sutured to the ureteral defect using 4\u0026thinsp;\u0026minus;\u0026thinsp;0 absorbable sutures(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). The omentum was wrapped around the ureteroplasty site, and 3\u0026thinsp;\u0026minus;\u0026thinsp;0 barbed sutures were used to secure it (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). No significant active bleeding was observed, and a drainage tube was placed in the abdominal cavity at the ureteroplasty site. All trocars were removed, and the drainage tube was secured with sutures, followed by closure of all incisions. Approximately 200 mL of blood was lost and the surgery was successfully completed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eFirst Kidney Hemorrhage\u003c/h3\u003e\n\u003cp\u003eOn postoperative day post-surgery, the drainage fluid was red. A follow-up CT scan indicated hematoma in the left renal pelvis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). During surgery, the injection of saline through the stoma to locate the narrowed ureter caused mucosal bleeding in the left renal pelvis. Hemostatic medications were administered, and anti-infection treatment was intensified. The patient's creatinine level increased postoperatively. Due to regular dialysis prior to surgery, heparinized dialysis was performed on the fourth postoperative day. After dialysis, the color of the stoma and ureter drainage deepened, but the was no significant decrease in the hemoglobin level. Hemostatic treatment was continued, and urine color gradually decreased. On the eighth postoperative day, heparinized dialysis was performed, and the drainage fluid from the stoma and ureter turned bright red. A follow-up CT scan revealed a large blood clot in the left renal pelvis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), and two units of suspended red blood cells were transfused the following day. On the fifteenth postoperative day, no significant bleeding was observed, and a follow-up CT scan indicated that the blood clot in the left renal pelvis had dissolved on its own (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD).The infection markers were normal, vital signs were stable, and the patient was discharged after the removal of the urinary catheter.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSecond renal hemorrhage\u003c/h3\u003e\n\u003cp\u003eOne week after discharge,drainage fluid from the left kidney stoma was clear. The patient visited a local hospital for hemodialysis once, and on the same day, the stoma tube turned bright red, with an inability to urinate, leading to an emergency transfer to our hospital. A CT scan upon admission indicated hematoma in the left renal pelvis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Examination results revealed a creatinine level of 1023.4 \u0026micro;mol/L, and a potassium level of 6.9 mmol/L, suggesting reduced blood volume and inadequate perfusion. An emergency blood transfusion was performed, followed by hemodialysis, anti-infection treatment, urinary catheter placement, and continuous bladder irrigation. Blood transfusion therapy was continued the following day. Subsequently, two sessions of heparin-free dialysis were maintained, with no significant bleeding observed,and the stoma and urinary catheter remained clear. However, after the fourth heparin-free dialysis session, the stoma and urinary catheter turned bright red again, with a progressive decline in hemoglobin levels.Arteriovenous fistula or pseudoaneurysm formation was suspected, and CT angiography did not reveal any clear vascular bleeding points (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Hemorrhage from the renal mucosa was still considered, and the medication for hemostasis was continued. An investigation of the coagulation factors revealed no abnormalities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter multidisciplinary discussion, it is recommended to discontinue hemodialysis and switch to oral uremic-clearing granules, sodium bicarbonate, sodium zirconium silicate, rosuvastatin, or compound α-keto acid treatment. Subsequent CT re-examination showed that the left renal pelvis hematoma had resolved (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC), and the left nephrostomy tube was removed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter three weeks of hospitalization, the patient was successfully discharged. Following discharge, no further hemodialysis treatment was administered. Three months later, follow-up CT showed that the left ureter was unobstructed, hydronephrosis had resolved, and the symptoms had completely resolved. The left ureteral stent was removed. At the one-month post-removal follow-up, there was no worsening of the left hydronephrosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD), and the left flank pain had completely resolved. Daily urine output was maintained at 1000\u0026ndash;1500 mL, and creatinine levels were stable at 530\u0026ndash;600 \u0026micro;mol/L. The patient was advised to resume hemodialysis; however, due to concerns about potential rebleeding, he declined treatment and will continue with regular outpatient follow-ups every three months.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSelection of Indications\u003c/h2\u003e \u003cp\u003eThe oral mucosa is smooth and flat, often exposed to moist conditions for extended periods, and is characterized by thick epithelial tissue, good elasticity, a thin lamina propria, and abundant capillaries. These features facilitate the revascularization of the transplanted tissue, making it an ideal graft material. After repairing the narrowed areas of the ureter with tissue grafting, the survival rate of the transplanted tissue was high, with no complications such as retraction, necrosis, or urinary leakage.\u003c/p\u003e \u003cp\u003eHistological results indicated a significant trend toward urothelialization in the epithelium post-transplant, accompanied by a substantial presence of newly formed capillaries in the mucosa following the grafting procedure. Therefore, oral mucosal graft techniques haves promising applications in urological surgeries[4].\u003c/p\u003e \u003cp\u003eHowever, oral mucosal grafts for ureteral stricture still have certain limitations, such as donor site trauma and postoperative wound healing, which should attract the attention of physicians[5].\u003c/p\u003e \u003cp\u003eCurrently, the indications for the use of autologous lingual mucosal grafts are not clearly defined and should be assessed comprehensively based on the specific circumstances of the patient. When selecting indications, several aspects need to be considered: ① The location, length, and nature of the stricture. For longer or more complex ureteral strictures, performing traditional end-to-end anastomosis after resecting the stricture segment can result in excessive tension, leading to a potential risk of postoperative restenosis. Autologous lingual mucosa grafts effectively address this issue by providing better repair outcomes without tension on the ureter[6,7]. ② The overall health status of the patient and any comorbidities must also be considered. In this case, we learned during the preoperative evaluation that the patient had a history of hemodialysis. Renal function of the affected side due to ureteral stricture was evaluated solely based on the daily drainage volume after nephrostomy, without considering the function of the unilateral kidney. The appropriateness of renogram as a routine preoperative assessment standard for ureteral stricture surgery warrants further investigation. The patient's symptoms were completely relieved postoperatively, and complications associated with long-term nephrostomy tube use were avoided.However, repeated treatments for bleeding introduced a certain economic burden and damage to the patient. This also serves as a reminder that surgical options should be chosen with caution in patients with severe underlying diseases or poor postoperative recovery. ③ Patients ' willingness and understanding of surgical risks should be prioritized. Adequate preoperative communication can help patients make informed decisions. In this case, the patient demonstrated a strong desire to undergo surgery and insisted on proceeding,even after being informed of potential complications. After experiencing related complications postoperatively, the patient was cooperative in treatment, and mutual trust and communication between the medical staff and the patient were crucial factors for the successful execution of such surgeries.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis of Causes of Renal Hemorrhage\u003c/h3\u003e\n\u003cp\u003eIn this case, the patient experienced recurrent renal hemorrhage after autologous lingual mucosal patch repair surgery. The cause of renal hemorrhage may involve multiple factors. Intraoperative injury was a significant contributing factor.While searching for a proximal ureteral stricture, it is common to confirm its location by infusing saline into the renal nephrostomy tube to identify the dilated segment. However, we used a method of pushing saline through the nephrostomy tube, which resulted in an excessively high pressure within the renal pelvis in a short period. Coupled with the kidney's poor contraction function and increased vascular fragility, this led to rupture of the surrounding blood vessels in the renal pelvis, causing postoperative bleeding. Currently, for the localization of ureteral stricture segments, indocyanine green near-infrared fluorescence imaging can accurately highlight the location of the ureteral stricture[8]. This technique has been effectively applied in laparoscopic ureteral stricture repair and reconstruction surgery. In future ureteral stricture reconstruction surgeries, it is essential to remind surgeons to consider using fluorescent agents to locate ureteral strictures, thereby avoiding similar injuries.\u003c/p\u003e \u003cp\u003eSecond, postoperative infections are potential causes of bleeding. Based on the results of the infection indicators reviewed after each bleeding episode, procalcitonin levels showed a significant increase. Urinary tract infections may trigger local inflammatory responses, leading to congestion, edema, and even erosion of the renal pelvis mucosa, which in turn affects the healing process and increases the risk of bleeding. Additionally, increased vascular permeability allows red blood cells to leak, resulting in recurrent bleeding. Therefore,in patients undergoing ureteral stricture repair with autologous patch grafts, it is essential to ensure infection control before surgery when carrying a nephrostomy tube for an extended period.\u003c/p\u003e \u003cp\u003ePostoperatively, routine follow-up should include blood counts, infection indicators, and urine cultures, with antibiotic use adjusted according to drug sensitivity to ensure graft viability and prevent local infections that could lead to restenosis, thereby improving the success rate of surgery[9].\u003c/p\u003e \u003cp\u003eFinally, the patient's underlying conditions, anticoagulation therapy, and postoperative activity levels may also influence the occurrence of bleeding. In the present case, the patient had a long history of hemodialysis. Although coagulation function and coagulation factors appear normal, the possibility of intrinsic coagulation abnormalities causing renal bleeding cannot be ruled out.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDiscussion on the Timing of Postoperative Dialysis\u003c/h2\u003e \u003cp\u003eIn the present case, the patient experienced renal hemorrhage after surgery, leading to hypovolemia and a sharp increase in renal function. However, varying degrees of renal hemorrhage occurred after each dialysis session, further increasing renal function. Therefore, the timing of dialysis is crucial. Considering the causes of bleeding in other areas of hemodialysis patients[10], we believe that recurrent renal bleeding post-dialysis may involve the following mechanisms: (1) frequent use of anticoagulants increases the risk of bleeding; (2) chronic kidney disease may cause hemodynamic instability in renal blood supply, hindering the healing of the renal pelvis mucosa;and (3) platelet dysfunction, interactions between platelets and the vascular wall, and coagulation abnormalities.\u003c/p\u003e \u003cp\u003eGenerally,indications for dialysis include severe electrolyte disturbances, uremic symptoms, and acute renal failure. When assessing the timing of dialysis, it is essential to closely monitor the patient's renal function indicators, such as blood urea nitrogen, creatinine levels, and electrolyte status. If there are clear signs of renal failure, dialysis should be promptly performed to avoid further complications. Early postoperative recovery of renal function should also be considered.If the patient's renal function improves shortly after surgery, dialysis can be delayed. Additionally, using Nafamostat for anticoagulation treatment in patients with a high risk of bleeding during hemodialysis can effectively improve the patient's dialysis situation, regulate electrolyte levels and coagulation function, enhance dialysis adequacy, and have a minimal impact on nutritional status, demonstrating favorable application effects.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up Considerations\u003c/h2\u003e \u003cp\u003eFor patients undergoing autologous oral mucosa graft repair surgery, postoperative follow-up is a key component to ensure long-term effectiveness and safety. Follow-up should include regular monitoring of renal function, imaging examinations, and assessment of clinical symptoms. Specifically, renal function evaluations should be conducted at 1, 3, and 6 months post-surgery, with ultrasound or CT scans performed as necessary to assess the patency of the ureters.\u003c/p\u003e \u003cp\u003eAdditionally, it is important to monitor for signs of complications such as infection and bleeding, and to promptly address these issues. Furthermore, the patient's psychological state and quality of life should be included in the follow-up scope, with psychological support and rehabilitation guidance provided as needed.\u003c/p\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrants from the research project at Qingdao University (YLJT20231002).The funders had no role in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLY,YZ and YW analyzed and interpreted the patient data and drafted the paper. LY and YW contributed equally to this work.ZS,ZM,and JY conceptualized the study and design, analysis, and interpretation of data. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details and clinical images was obtained from the patients. A copy of the consent form is available to the Editor of this journal.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDe Coninck V, Keller EX, Somani B, et al. Complications of ureteroscopy: a complete overview. World J Urol. 2020 Sep;38(9):2147-2166. doi: 10.1007/s00345-019-03012-1. Epub 2019 Nov 20. \u003c/li\u003e\n\u003cli\u003eMoretto S, Saita A, Scoffone CM, et al. Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis. World J Urol. 2024 Apr 13;42(1):234. doi: 10.1007/s00345-024-04933-2. \u003c/li\u003e\n\u003cli\u003eXu MY, Song ZY, Liang CZ. Robot-assisted repair of ureteral stricture. J Robot Surg. 2024 Sep 28;18(1):354. doi: 10.1007/s11701-024-01993-9.\u003c/li\u003e\n\u003cli\u003eFilipas D , Fisch M , Fichtner J , et al. The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine[J]. Bju International, 2015, 84(1):108-111. \u003c/li\u003e\n\u003cli\u003eLi B, Zhou Y, Chai S, et al. Robotic lingual mucosal graft ureteroplasty combined with Boari flap ureteroneocystostomy for one-stage repair of complex ureteral strictures: initial experience. Int Urol Nephrol. 2023 Apr;55(4):893-895. doi: 10.1007/s11255-022-03460-6.\u003c/li\u003e\n\u003cli\u003eLiang C, Wang J, Hai B, et al. Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases. Eur Urol. 2022 Aug;82(2):193-200. doi: 10.1016/j.eururo.2022.05.006.\u003c/li\u003e\n\u003cli\u003eKapogiannis F, Spartalis E, Fasoulakis K, et al. Laparoscopic and Robotic Management of Ureteral Stricture in Adults. In Vivo. 2020 May-Jun;34(3):965-972. doi: 10.21873/invivo.\u003c/li\u003e\n\u003cli\u003ePetrut B, Bujoreanu CE, Porav Hodade D,et al. Indocyanine green use in Urology. J BUON. 2021 Jan-Feb;26(1):266-274.\u003c/li\u003e\n\u003cli\u003eChai S, Xiao X, Chen J, et al. Treating Multifocal Ureteral Strictures with Combined Techniques: 14 Cases of Initial Experience. J Endourol. 2024 Mar;38(3):283-289. doi: 10.1089/end.2023.0454. Epub 2024 Feb 20.\u003c/li\u003e\n\u003cli\u003eSolanki S, Haq KF, Khan MA, et al. Gastrointestinal Hemorrhage in Acute Kidney Injury Patients on Hemodialysis. Cureus. 2019 Sep 13;11(9):e5652. doi: 10.7759/cureus.5652.\u003c/li\u003e\n\u003cli\u003eZhang W, Bai M, Yu Y, et al. Continuous renal replacement therapy without anticoagulation in critically ill patients at high risk of bleeding: A systematic review and meta-analysis. Semin Dial. 2021 May;34(3):196-208. doi: 10.1111/sdi.12946. \u003c/li\u003e\n\u003cli\u003eLang Y, Zheng Y, Qi B, et al. Anticoagulation with nafamostat mesilate during extracorporeal life support. Int J Cardiol. 2022 Nov 1;366:71-79. doi: 10.1016/j.ijcard.2022.07.022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lingual mucosal graft, ureteral stricture, renal hemorrhage, repair and reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-5628566/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5628566/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUreteral stricture is a prevalent and complex condition within the urinary system, often leading to significant complications. In severe instances can result in renal insufficiency and damage. Although various treatment options exist for ureteral strictures,but effectively managing specific cases remains a challenge. Autologous grafts have emerged as a novel surgical approach for ureteral repair and reconstruction. However, due to the specific surgical conditions required, reports of complications associated with these techniques are relatively limited.\u003c/p\u003e\u003ch2\u003eCase Presentation\u003c/h2\u003e \u003cp\u003eThis article presents a case of a long-segment ureteral stricture treated with lingual mucosal graft. The patient experienced postoperative severe renal hemorrhage, prompting a thorough analysis of the factors contributing to this complication. This case highlights the complexities involved in the surgical management of ureteral strictures and underscores the need for careful patient selection.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe use of lingual mucosal grafts in the treatment of ureteral strictures demonstrates potential benefits, but the risk of postoperative complications, such as renal hemorrhage, necessitates further investigation. By refining the selection criteria for patients undergoing surgical intervention and addressing associated complications, this study aims to enhance clinical practice and improve patient outcomes.\u003c/p\u003e","manuscriptTitle":"Lingual Mucosal Graft Treatment for Recurrent Renal Bleeding after Ureteral Stricture Surgery: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-26 08:16:01","doi":"10.21203/rs.3.rs-5628566/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b7cd74e-d848-4139-852e-b7d7f2403827","owner":[],"postedDate":"December 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-26T08:16:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-26 08:16:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5628566","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5628566","identity":"rs-5628566","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}