Long-term follow-up of ureteroplasty with different methods for long ureteral stenosis: A Single Institution Study

Long-term follow-up of ureteroplasty with different methods for long ureteral stenosis: A Single Institution Study | 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 Research Article Long-term follow-up of ureteroplasty with different methods for long ureteral stenosis: A Single Institution Study Junhai Ma, Xiaoran Li, Gongjin Wu, Ze Qin, Hong Chang, Xuewu Wu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1986531/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 Surgical management of long ureteral stenosis is challenging. We describethe different modalities used in our center to treat long ureteral stenosis and report ourlong-term results. Methods This is a 17-year retrospective study to evaluate the efficacy of ureteroplasty with different surgical procedures in 12 patients with long ureteral stenosis. This study has passed ethical approval. Data were collected between May 2005 and September 2021. The mean age was 41 years. Recurrent stenosis was treated with long-term ureteral stent placement. The main observation index was the success rate of surgery. The secondary index was the rate of surgical complications and recurrent stenosis. The mean is used to describe parametric continuity variables, and the median and quartile range (IQR) are used to describe nonparametric continuity variables. Results Twelve patients were included. There were iatrogenic injuries in nine patients (75%), bilateral polyps in one (8.3%), ureteral occupation in one (8.3%), and unknown origins in one (8.3%). Ileal replacement was performed in three (25%) patients, lingual mucosa grafts in four(33.3%) patients, and boari bladder flaps in five (41.7%) patients. One of the surgeries was performed laparoscopically. The median follow-up was 49 months (range 8-204), and three patients (25%) had major postoperative complications. One patient’s treatment failed, requiring special reintervention, and two patients (16.7%) underwent ureteral stent placement. We accept the limitations of this small retrospective single-surgeon series, where the surgeon had a certain surgical selection preference. Conclusion Iatrogenic injury is the most common cause of long ureteral stenosis.There are many surgical methods for ureteral reconstruction, and the boari bladder flap is a preferred method for repairing long ureteral stenosis due to fewer postoperative complications and a low treatment failure rate. Ureteral stenosis ileal substitution lingual mucosa graft Boari bladder flap ureteroplasty Figures Figure 1 Figure 2 Figure 3 Introduction The etiology of ureteral stenosis is complex, and includes congenital dysplasia, iatrogenic injury, radiotherapy, retroperitoneal fibrosis, trauma, infection and tumors[ 1 , 2 ]. Short ureteral stenosis can be treated with balloon dilation, end-to-end ureteral anastomosis, pyeloplasty and reimplantation, while the ureteral reconstruction techniques for long ureteral stenosis are complicated[ 3 ]. At present, techniques such as ileal replacement, autotransplantation, boari bladder flap and lingual mucosal grafting have been reported for the ureteral reconstruction of long ureteral stenosis. Reconstruction of long ureteral stenosis is challenging for urologists. Ileal replacement, autotransplantation, boari flap and lingual mucosa graft ureteroplasty are all options to solve this problem. Few studies have compared the available surgical techniques for long ureteral stenosis to determine the best option for different clinical situations, and surgeon selection is often based on experience and preference.The ideal ureteral reconstruction should have smooth urine drainage, should have less metabolic waste absorption, allow for the repair of different ureteral lengths and positions, and should maximize the protection of renal function.Therefore, this study analyzed and compared the clinical and functional outcomes of patients with long ureteral stenosis treated with different surgical techniques in the department of Urology of our hospital in the past 17 years, to provide help for optimizing the surgical selection of long ureteral stenosis. Patients And Methods We retrospectively analyzed the clinical records of all patients who underwent ureteral reconstruction for long ureteral stenosis at our hospital between May 2005 and September 2021. The study was approved by the ethics committee. The inclusion criteria included: patients with ureteral stenosis greater than 5 cm in length who underwent reconstructive surgery. The surgical indications include persistent clinical symptoms, deterioration of renal function, and radiographic evidence of long obstruction. All procedures were performed by the same urologist, and the surgical approach was selected according to the different clinical conditions and the preferences of the surgeon. For each patient, we described age, sex, body mass index, age-adjusted Charlson Comorbidity Index, cause of injury, and lateral and segmental ureters involved at diagnosis. Preoperative CTU and anterograde or retrograde pyelography were used to assess the stenosis and length. Preoperative routine examination were performed of blood renal function and electrolytes. For patients who underwent a boari bladder flap, the bladder capacity was required to be greater than 300 ml. The severity of the ureteral injuries was classified according to a modified version of the ureteral injury scale proposed by the American Association for the Surgery of Trauma[ 4 ]. Our patients were grade V. The following intraoperative parameters were collected: reconstructive surgery method, operative time, blood loss, intraoperative and postoperative complications, and length of hospital stay. All patients were followed up for at least 6 months. KUB was performed 1 week after surgery to evaluate the stent position, and follow-up was performed every 3 months. All patients underwent abdominal ultrasound or CTU every 3 months postoperatively. The postoperative complications were classified into mild (grades 1 and 2) and severe (grades 3 and 4) according to the modified Clavien system [ 5 ]. In the patients treated with boari bladder flaps and lingual mucosa grafts, lower urinary tract storage symptoms (LUTS) and oral symptoms (oral pain or discomfort) were assessed by nonstructured interviews. The criteria for complete success during follow-up were no clinical symptoms and no obstruction on imaging. CTU and ultrasound were performed during follow-up. In some complex cases, we also performed ureteroscopy to determine the final status of the ureteral lumen after obtaining the patient's consent. However, ureteroscopy is not a routine or necessary procedure. Treatment failure was defined as upper urinary tract obstruction requiring permanent ureteral stents or nephrostomy. The statistical methods include descriptive statistics. The mean is used to describe parametric continuity variables, and the median and quartile range (IQR) are used to describe nonparametric continuity variables. Results Table 1 details the general characteristics of the 12 patients. Ureteral reconstruction was performed in nine (75%) men and three (25%) women. There were six patients (50%) with surgery on the right side, five patients (42%) with surgery on the left side, and one patient (8%) had surgery bilaterally. The stenosis was located proximal to the ureter in five patients (42%) and distal in seven patients (58%). Eleven patients (92%) had pain symptoms, and two (17%) had impaired contralateral renal function. Table 1 –Patients’ characteristics and preoperative findings of the 12patients. Variables Values Age (yr), median (IQR) 41 (22–75) Gender, n (%) Male 9 (75) Female 3 (25) Body mass index (kg/m 2 ), median (IQR) 22 (19–25) Age-adjusted Charlson Comorbidity Index, n (%) 0 9 (75) > 0 3 (25) Ureteral segment, n (%) Proximal 5 (42) Distal 7 (58) Side, n (%) Right 6 (50) Left 5 (42) Bilateral 1 (8) Presenting symptoms, n (%) Flank pain 11 (92) Asymptomatic 1 (8) Contralateral kidney, n (%) Normal 10 (83) Functional impairment 2 (17) Table 2 details the etiology, severity and level of ureteral injury, and the corresponding surgical procedures. There were iatrogenic injurys in nine patients (75%), bilateral polyps in one (8.3%), ureteral occupation in one (8.3%), and unknown origins in one (8.3%). Ileal substitution was performed in three (25%) patients, lingual mucosa graft in four (33.3%), and boari bladder flap in five (41.7%). One of the surgeries was performed laparoscopically. Our patients were grade V. Table 2 –Ureteral stenosis location, etiology, severity and surgical options. Location Etiology Severity Surgical options Lumbar (n = 5) Ureteroplasty Grade V Boari bladder flap Unknown origin Grade V Lingual mucosa graft Bilateral ureteral polyps Grade V Lingual mucosa graft Endourology Grade V Lingual mucosa graft Endourology Grade V Lingual mucosa graft Cross with the iliac vessels (n = 7) Endourology Grade V Ileal replacement Occupying lesion Grade V Ileal replacement Endourology Grade V Ileal replacement Endourology Grade V Boari bladder flap Endourology Grade V Boari bladder flap Ureteroplasty Grade V Boari bladder flap Endourology Grade V Boari bladder flap The main perioperative outcomes stratified by the type of surgical procedure are reported in Tables 3 and 4 . There were no intraoperative complications or blood transfusions. The average length of receiving lingual mucosa was 6.6 cm and the width was 1.5 cm. The length of the Boari bladder flap was 16 cm and the width was 3cm. The Ileal replacement length was 15 cm. Postoperative complications occurred in the boari bladder flap group in one patient (25%), ileal replacement group in two patients (67%) and lingual mucosa graft group in two patients (50%). Major postoperative complications occurred in two patients (50%) in the lingual mucosa graft group, and one patient required permanent ureteral stents. Table 3 – Intraoperative details and follow-up results Results Lingual mucosa graft, n (%) 4 (33) Length of LMG (cm), mean (range) 6.6(5–10) Width of LMG (cm), mean (range) 1.5 (1–2) Boari bladder flap, n (%) 5 (42) Length of BBF (cm), mean (range) 16(14–17) Width of BBF (cm), mean (range) 3(2–5) Ileal replacement, n (%) 3 (25) Length of Ileal (cm), mean (range) 15(11–19) Follow-up time (mo), median (range) 58(8–204) Overall success rate (%) 92 (11/12) LMG = lingual mucosal graft. BBF = Boari bladder flap Table 4 –Perioperative outcomes stratified by the type of surgical repair procedure. Surgical method Perioperative outcomes Median operative time (min) Median blood loss (ml) length of hospital stay (d) Postoperative complications, n (%) Major postoperative complications, n (%) Boari bladder flap 167 ± 12 230 ± 57 8.2 ± 1.3 1(25) - Ileal replacement 162 ± 20 213 ± 12 14 ± 1.5 2(67) 1 (33) Lingual mucosa graft 183 ± 25 158 ± 49 10.6 ± 3.5 2(50) 2 (50) At a median follow-up of 58 months, one patient (lingual mucosa graft) underwent a secondary repair. Two patients (one with lingual mucosa grafts and the other with ileal replacement) developed pain symptoms one month after stent removal, and CTU examination showed progressive hydronephrosis. An indwelling ureteral stent was placed in these patients for 3 months, and follow-up showed no recurrence of pain symptoms after removal. None of the 5 patients who underwent Boari bladder flap surgery had LUTS. There was a reconstructed ureter with a long stenosis of approximately 10 cm in length. Laparoscopic boari bladder flap ureteroplasty was performed with a boari flap of approximately 17 cm in length (Fig. 1 ). The case was a patient with bilateral ureteral polyps, who underwent bilateral lingual mucosa graft mucosa ureteroplasty. After the ureteral stent was removed on the left side, pain symptoms appeared, and a ureteral stent was placed for 3 months (Fig. 2 ). The patient underwent ileal replacement ureteroplasty after iatrogenic injury and had good renal function(Fig. 3 ). Discussion Our study shows that iatrogenic injury is the most important cause of long ureteral stenosis. There are a variety of surgical options, given the surgeons’ varied experience and preferences. Our clinical results showed that due to the homology of the tissue in boari bladder flap ureteroplasty, intraoperative and postoperative major complications infrequently developed and the operation success rate was high. Intestinal replacement techniques are options for the reconstruction of long ureteral stenosis, and these replacement techniques including the use of the ileum, appendix, or colon[ 6 ]. Sandra A et al reported 105 patients who underwent ileum ureteral replacement and finally included 91 patients (99 nephrons) to form the study cohort. The mean age of the patients was 46.8 years, and the mean follow-up was 36.0 months. Ureteral reconstruction using the ileum may result in hyperchloremic metabolic acidosis, short bowel syndrome, vitamin B12 deficiency, cholelithiasis, anastomotic stenosis, and enterocutaneous fistulas[ 7 ]. Benjamin I et al reported 56 patients who underwent intestinal replacement for ureteral reconstruction, including 52 ileal ureteral replacements and 2 colonic replacements. During a mean follow-up of 6.04 years, there was no worsening of renal function. Mild postoperative complications occurred in 17.9% of patients, and the complications included pyelonephritis, unexplained fever, neuroma, hernia, recurrent urolithiasis, and deep vein thrombosis. Severe complications, including anastomotic stricture, ileal graft obstruction, wound dehiscence, and chronic renal failure, occurred in 10.5% of the patients. There have also been reports of using the appendix instead of ileal interposition to avoid the need for intestinal anastomosis[ 8 ]. The failure rate of open ileal replacements ranges from 4–25% depending on the anatomical condition and extent of injury. Notably, ureteral replacement can be performed using the Yang-Monti principle, according to which the bowel segment opens longitudinally along the bowel margin and then closes laterally. Bedeir et al. (2003) reported 10 patients who underwent the Yang-Monti procedure. The median postoperative follow-up was 9.6 months. The mean serum creatinine of all patients remained stable, and imaging angiography showed no obstruction and no tendency for the dilation to worsen. This procedure allows for the construction of ileal ureteral replacement with an appropriate cross-sectional diameter, without the need for tailoring, and this procedure enables the use of antireflux techniques [ 9 ]. Autologous kidney transplantation can be selected when orthotopic reconstruction is not suitable for long ureteral stenosis and renal vascular abnormalities. Laparoscopic or robotic-assisted autologous kidney transplantation is a novel, safe and effective modality [ 10 – 12 ]. Nick G et al reported 51 patients who received autologous kidney transplantation in 2 centers. The most common complications were renal pain and hematuria syndrome/chronic renal pain, ureteral stenosis, and vascular abnormalities. Early, high-grade complications (grade IIIa or higher) occurred in 14.8 percent of the patients, late complications occurred in 12.9 percent of the patients, and 2 patients underwent transplant nephrectomy[ 13 ]. Vascular abnormalities are a serious problem after autologous kidney transplantation, and these abnormalities include renovascular hypertension, arterial thrombosis, and advanced pseudoaneurysm. Autologous transplantation seems to have a higher incidence of vascular complications than allogeneic transplantation [ 11 , 14 ] . In adults with long ureteral stenosis, the Boari flap is feasible after the excision of the diseased segment. Boari, an Italian, performed the experiment on dogs in 1894, and in 1926, German surgeon Baiden replaced the lower two-thirds of the ureter in a woman who had lost her ureter to a fistula and stricture after pelvic surgery[ 15 ]. With the development of minimally invasive techniques, laparoscopic and robotic techniques are increasingly used for boari flap ureteroplasty [ 16 , 17 ], although a potential disadvantage of robotic-assisted reconstruction is the use of a transperitoneal approach, with the risks of postoperative bowel obstruction and peritoneal urine leakage[ 16 ] [ 16 ]. Boari flap ureteroplasty is relatively simple, with few major complications and a low failure rate. It is the most commonly used surgical method for the treatment of iatrogenic intermediate and distal ureteral injuries [ 18 ]. Boari flaps can repair ureteral injuries up to 15 cm in length [ 16 ]. Shchukin et al reported 70 patients with boari flap reconstruction of the ureter; the average bladder flap length was 9.8 ± 1.4 cm; and 8.2% of the patients successfully underwent reconstruction of the upper third of the ureter. The total incidence of intraoperative complications did not exceed 12.9%, the total incidence of early postoperative complications was high but not serious, and only 1 patient required surgical correction. The long-term satisfaction was 91.5%, and only 2 patients (2.3%) required nephrectomy [ 19 ]. The Boari flap is an acceptable technique for the reconstruction of long ureteral strictures, even proximal ureteral stenosis, but depending on the patient's bladder capacity, the Boari flap may not be able to reach the stenotic proximal ureter. Somerville and Naude first studied buccal mucosal grafts for ureteral reconstruction in an animal model in 1984 [ 20 ] because buccal mucosal grafts have rich vascular plexus and akeratinized thick epithelium suitable for transplantation. Over the years, buccal mucosal grafts have been used extensively in urethroplasty. Naude first reported buccal mucosal grafts for human ureteral reconstruction [ 21 ], followed by multiple studies reporting favorable clinical and functional outcomes of buccal mucosal grafts for ureteral injury repair [ 22 , 23 ]. The incidence of serious complications with buccal mucosal graft ureteroplasty is very low. The robotic approach for buccal mucosal graft ureteral reconstruction has complications similar to robotic pyeloplasty, with the exception of additional oral discomfort when obtaining buccal grafts[ 23 ]. Buccal mucosal graft ureteroplasty is suitable for proximal or middle ureteral stenosis. This technique can be used in patients where the lumen has enough stenosis to cause obstruction and cannot be directly anastomosed. However, there should be enough viable ureter, and the buccal mucosal graft with rich blood vessels should cover enough to restore the normal ureter cavity. In buccal mucosal graft ureteroplasty, placing the graft in an anterior position is technically easier to maneuver, so ventral (anterior) buccal mucosal graft ureteroplasties were performed in all of our patients. Animal experiments have also verified the safety and efficacy of buccal mucosal graft ureteroplasty[ 24 ]. Buccal mucosal graft ureteroplasty is a safe and feasible technique that offers an option for the reconstruction of long-distance proximal and mid-ureteral stenosis[ 1 ]. A unique feature of ureteral flap reconstruction is the removal of the graft from one part of the body and transferring it to the recipient site to create a new blood supply. The flap is a capillary-rich tissue that transfers to the recipient site, and it should maintain its own blood supply. The tissue selection for ureteral flap-plasty should be based on the characteristics of the ureteral stenosis and the patient's overall condition, as well as related complications at the donor site and the functional outcomes at the reconstruction site [ 25 ]. In recent years, with the rise of laparoscopy and robotics, an increasing number of urological centers are using minimally invasive techniques for ureteral reconstruction [ 8 , 26 – 30 ]. This was a retrospective study that enrolled patients who were highly screened. The sample size of our study is small and has limitations. Our study was based on years of experience at a single center, with most patients undergoing open surgery. We still need large sample sizes and multicenter and long-term studies. Conclusions Iatrogenic injury is the most common cause of long ureteral stenosis.There are many surgical methods for ureteral reconstruction, and the boari bladder flap is a preferred method for repairing long ureteral stenosis due to fewer postoperative complications and a low treatment failure rate. Abbreviations CTU Multi-slice CT urography KUB kidney ureter bladder LUTS lower urinary tract storage symptoms IQR Inter Quartile Range BMI Body mass index LMG Lingual mucosa graft BBF Boari bladder flap. Declarations Acknowledgements Not applicable. Author Contributions J.M. and Z.Y. contributed to the idea and formed the study design. G.W. , Q.Z., H.C., X.W., W.S. and J.B. undertook to maintain research data. S.Z. and X.L. analyzed the data. X.L., J.M. and P.S. contributed to the drafting. P.S. and Z.Y. critically reviewed the article. All authors contributed to drafting the article and approved the final version. All theauthors agree to be responsible for all aspects of the study,and they all have read and approved the final article. Funding This work was supported by the Cuiying Scientific and Technological Innovation Program of Lanzhou University Second Hospital [Grant number 2020QN-09] and National Natural Science Foundation of China [No. 82160146]. Data Availability Statement All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author. Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of Lanzhou University Second Hospital (approval no. 2022A-394) . Written Informed consent was obtained from all the participants prior for the publication. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. 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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-1986531","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":131591576,"identity":"106afe44-5e96-4672-9005-2a58ce78b897","order_by":0,"name":"Junhai Ma","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Junhai","middleName":"","lastName":"Ma","suffix":""},{"id":131591579,"identity":"6a2628ea-1f70-4d4c-8f70-3d552d478918","order_by":1,"name":"Xiaoran Li","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou 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University","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Chang","suffix":""},{"id":131591585,"identity":"dba4c3ea-9553-4571-8f94-21c1f30fd400","order_by":5,"name":"Xuewu Wu","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Xuewu","middleName":"","lastName":"Wu","suffix":""},{"id":131591586,"identity":"56075e0b-196e-40f5-855e-c4448f29e8c6","order_by":6,"name":"Su Zhang","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Su","middleName":"","lastName":"Zhang","suffix":""},{"id":131591589,"identity":"3a7b380a-2fcc-4773-9b2d-2e4af7612fc0","order_by":7,"name":"Wei Shi","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Shi","suffix":""},{"id":131591594,"identity":"8e8b9d03-0015-441e-af6e-fe9b2056ae36","order_by":8,"name":"Junsheng Bao","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Junsheng","middleName":"","lastName":"Bao","suffix":""},{"id":131591595,"identity":"96a97b7b-9ed5-4dfd-a144-d9040438df31","order_by":9,"name":"Panfeng Shang","email":"","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":false,"prefix":"","firstName":"Panfeng","middleName":"","lastName":"Shang","suffix":""},{"id":131591597,"identity":"67012617-004e-49ad-8d75-4f35e8ba10e6","order_by":10,"name":"Zhongjin Yue","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYJACZhDB2MzA+IDBgEQtzAakaQECNgmilBvcSD78uaDijl1zO++xyh8Fd+QZ2M8eIKAlLcF4xplnyY3NfGm3eQyeGTbw5CUQ0JJjkMzbdjiZsZnH7DaDwWHGBgke/D4yuJH/4TBMS+EPg8P2RGjJYWwGarEDaWHgMTicSFCL5Jlnxsw8Zw4nALUYSwO1JLfx5ODXwnc8+fFnnorD9ob9Zww//vhz2Laf/Qx+LQoHIHTixgaoCBte9UAgD1VpL09I5SgYBaNgFIxcAAAP5kUwuaWkfwAAAABJRU5ErkJggg==","orcid":"","institution":"Lanzhou University Second Hospital, Lanzhou University","correspondingAuthor":true,"prefix":"","firstName":"Zhongjin","middleName":"","lastName":"Yue","suffix":""}],"badges":[],"createdAt":"2022-08-22 13:29:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1986531/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1986531/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":26779615,"identity":"00ec872d-93f7-4dc5-8e7b-33a88709a315","added_by":"auto","created_at":"2022-09-21 18:02:40","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130577,"visible":true,"origin":"","legend":"\u003cp\u003eCase of a 36-yr-old man who had undergone ureteroscopic lithotripsy at a county-level city hospital and had long segment ureter stenosis.(a) Antegrade pyelography showing left ureter stenosis below the third lumbar vertebra. (b) MR showing that the left ureter was interrupted and dilated and that the length of the left ureteral stenosis was approximately 10 cm. (c) Enhanced CTU 3 months postoperatively showed good patency and no leakage of the left ureter.\u003c/p\u003e","description":"","filename":"floatimage1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1986531/v1/56889e04603ee6c53fd5633a.jpg"},{"id":26779613,"identity":"1a40bc91-aa2a-436b-8234-bbd05d215369","added_by":"auto","created_at":"2022-09-21 18:02:40","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171175,"visible":true,"origin":"","legend":"\u003cp\u003eCase of a 22-yr woman with bilateral ureteral polyps. (a) Preoperative enhanced CTU examination. Bilateral proximal ureteral long segment stenosis, 7 cm (right) and 5 cm (left). (b) Surgical methods and procedures of lingual mucosa graft ureteroplasty. (c) Three-dimensional reconstruction imaging of an abdominal CT scan performed 3 mo after the surgical repair, showing patency of the right reconstructed upper urinary tract.\u003c/p\u003e","description":"","filename":"floatimage2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1986531/v1/0d2d7700c34c4acfddc09134.jpg"},{"id":26779944,"identity":"61752781-3267-4ab4-83ad-3b46a7f3edfb","added_by":"auto","created_at":"2022-09-21 18:07:40","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":172791,"visible":true,"origin":"","legend":"\u003cp\u003eCase of a 40-yr-old man who had undergone left ileal ureterectomy after iatrogenic injury. (a-c) Three-dimensional reconstruction imaging of an abdominal CT scan performed 17 yr after the surgical repair, showing patency of the reconstructed upper urinary tract.\u003c/p\u003e","description":"","filename":"floatimage3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1986531/v1/e6a4bea7cc9027fa82c97963.jpg"},{"id":28495932,"identity":"85583b8a-64c5-425d-b1b0-fb3f97bd4c61","added_by":"auto","created_at":"2022-11-01 07:59:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1161958,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1986531/v1/58c7a4e8-7ebf-495d-a598-3d61500756a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term follow-up of ureteroplasty with different methods for long ureteral stenosis: A Single Institution Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe etiology of ureteral stenosis is complex, and includes congenital dysplasia, iatrogenic injury, radiotherapy, retroperitoneal fibrosis, trauma, infection and tumors[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Short ureteral stenosis can be treated with balloon dilation, end-to-end ureteral anastomosis, pyeloplasty and reimplantation, while the ureteral reconstruction techniques for long ureteral stenosis are complicated[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. At present, techniques such as ileal replacement, autotransplantation, boari bladder flap and lingual mucosal grafting have been reported for the ureteral reconstruction of long ureteral stenosis.\u003c/p\u003e \u003cp\u003eReconstruction of long ureteral stenosis is challenging for urologists. Ileal replacement, autotransplantation, boari flap and lingual mucosa graft ureteroplasty are all options to solve this problem. Few studies have compared the available surgical techniques for long ureteral stenosis to determine the best option for different clinical situations, and surgeon selection is often based on experience and preference.The ideal ureteral reconstruction should have smooth urine drainage, should have less metabolic waste absorption, allow for the repair of different ureteral lengths and positions, and should maximize the protection of renal function.Therefore, this study analyzed and compared the clinical and functional outcomes of patients with long ureteral stenosis treated with different surgical techniques in the department of Urology of our hospital in the past 17 years, to provide help for optimizing the surgical selection of long ureteral stenosis.\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003eWe retrospectively analyzed the clinical records of all patients who underwent ureteral reconstruction for long ureteral stenosis at our hospital between May 2005 and September 2021. The study was approved by the ethics committee. The inclusion criteria included: patients with ureteral stenosis greater than 5 cm in length who underwent reconstructive surgery. The surgical indications include persistent clinical symptoms, deterioration of renal function, and radiographic evidence of long obstruction. All procedures were performed by the same urologist, and the surgical approach was selected according to the different clinical conditions and the preferences of the surgeon.\u003c/p\u003e \u003cp\u003eFor each patient, we described age, sex, body mass index, age-adjusted Charlson Comorbidity Index, cause of injury, and lateral and segmental ureters involved at diagnosis. Preoperative CTU and anterograde or retrograde pyelography were used to assess the stenosis and length. Preoperative routine examination were performed of blood renal function and electrolytes. For patients who underwent a boari bladder flap, the bladder capacity was required to be greater than 300 ml. The severity of the ureteral injuries was classified according to a modified version of the ureteral injury scale proposed by the American Association for the Surgery of Trauma[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our patients were grade V.\u003c/p\u003e \u003cp\u003eThe following intraoperative parameters were collected: reconstructive surgery method, operative time, blood loss, intraoperative and postoperative complications, and length of hospital stay. All patients were followed up for at least 6 months. KUB was performed 1 week after surgery to evaluate the stent position, and follow-up was performed every 3 months. All patients underwent abdominal ultrasound or CTU every 3 months postoperatively. The postoperative complications were classified into mild (grades 1 and 2) and severe (grades 3 and 4) according to the modified Clavien system [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the patients treated with boari bladder flaps and lingual mucosa grafts, lower urinary tract storage symptoms (LUTS) and oral symptoms (oral pain or discomfort) were assessed by nonstructured interviews. The criteria for complete success during follow-up were no clinical symptoms and no obstruction on imaging. CTU and ultrasound were performed during follow-up. In some complex cases, we also performed ureteroscopy to determine the final status of the ureteral lumen after obtaining the patient's consent. However, ureteroscopy is not a routine or necessary procedure. Treatment failure was defined as upper urinary tract obstruction requiring permanent ureteral stents or nephrostomy. The statistical methods include descriptive statistics. The mean is used to describe parametric continuity variables, and the median and quartile range (IQR) are used to describe nonparametric continuity variables.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e details the general characteristics of the 12 patients. Ureteral reconstruction was performed in nine (75%) men and three (25%) women. There were six patients (50%) with surgery on the right side, five patients (42%) with surgery on the left side, and one patient (8%) had surgery bilaterally. The stenosis was located proximal to the ureter in five patients (42%) and distal in seven patients (58%). Eleven patients (92%) had pain symptoms, and two (17%) had impaired contralateral renal function.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash;Patients\u0026rsquo; characteristics and preoperative findings of the 12patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValues\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (yr), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (22\u0026ndash;75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody mass index (kg/m 2 ), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (19\u0026ndash;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge-adjusted Charlson Comorbidity Index, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUreteral segment, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProximal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSide, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresenting symptoms, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFlank pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsymptomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContralateral kidney, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFunctional impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e details the etiology, severity and level of ureteral injury, and the corresponding surgical procedures. There were iatrogenic injurys in nine patients (75%), bilateral polyps in one (8.3%), ureteral occupation in one (8.3%), and unknown origins in one (8.3%). Ileal substitution was performed in three (25%) patients, lingual mucosa graft in four (33.3%), and boari bladder flap in five (41.7%). One of the surgeries was performed laparoscopically. Our patients were grade V.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash;Ureteral stenosis location, etiology, severity and surgical options.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEtiology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSeverity\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgical\u0026nbsp;options\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumbar (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUreteroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown origin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral ureteral polyps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCross with the\u003c/p\u003e\n \u003cp\u003eiliac vessels (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleal replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOccupying lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleal replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleal replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUreteroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndourology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe main perioperative outcomes stratified by the type of surgical procedure are reported in Tables \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. There were no intraoperative complications or blood transfusions. The average length of receiving lingual mucosa was 6.6 cm and the width was 1.5 cm. The length of the Boari bladder flap was 16 cm and the width was 3cm. The Ileal replacement length was 15 cm. Postoperative complications occurred in the boari bladder flap group in one patient (25%), ileal replacement group in two patients (67%) and lingual mucosa graft group in two patients (50%). Major postoperative complications occurred in two patients (50%) in the lingual mucosa graft group, and one patient required permanent ureteral stents.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; Intraoperative details and follow-up results\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResults\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of LMG (cm), mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6(5\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidth of LMG (cm), mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 (1\u0026ndash;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of BBF (cm), mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16(14\u0026ndash;17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidth of BBF (cm), mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(2\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleal replacement, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of Ileal (cm), mean (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(11\u0026ndash;19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFollow-up time (mo), median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58(8\u0026ndash;204)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverall success rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92 (11/12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLMG\u0026thinsp;=\u0026thinsp;lingual mucosal graft. BBF\u0026thinsp;=\u0026thinsp;Boari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash;Perioperative outcomes stratified by the type of surgical repair procedure.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eSurgical method Perioperative outcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian operative time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian blood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003elength of hospital stay (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003cp\u003ecomplications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajor postoperative\u003c/p\u003e\n \u003cp\u003ecomplications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoari bladder flap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e167\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e230\u0026thinsp;\u0026plusmn;\u0026thinsp;57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleal replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e162\u0026thinsp;\u0026plusmn;\u0026thinsp;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e213\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLingual mucosa graft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e158\u0026thinsp;\u0026plusmn;\u0026thinsp;49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eAt a median follow-up of 58 months, one patient (lingual mucosa graft) underwent a secondary repair. Two patients (one with lingual mucosa grafts and the other with ileal replacement) developed pain symptoms one month after stent removal, and CTU examination showed progressive hydronephrosis. An indwelling ureteral stent was placed in these patients for 3 months, and follow-up showed no recurrence of pain symptoms after removal. None of the 5 patients who underwent Boari bladder flap surgery had LUTS.\u003c/p\u003e\n\u003cp\u003eThere was a reconstructed ureter with a long stenosis of approximately 10 cm in length. Laparoscopic boari bladder flap ureteroplasty was performed with a boari flap of approximately 17 cm in length (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The case was a patient with bilateral ureteral polyps, who underwent bilateral lingual mucosa graft mucosa ureteroplasty. After the ureteral stent was removed on the left side, pain symptoms appeared, and a ureteral stent was placed for 3 months (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The patient underwent ileal replacement ureteroplasty after iatrogenic injury and had good renal function(Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study shows that iatrogenic injury is the most important cause of long ureteral stenosis. There are a variety of surgical options, given the surgeons\u0026rsquo; varied experience and preferences. Our clinical results showed that due to the homology of the tissue in boari bladder flap ureteroplasty, intraoperative and postoperative major complications infrequently developed and the operation success rate was high.\u003c/p\u003e \u003cp\u003eIntestinal replacement techniques are options for the reconstruction of long ureteral stenosis, and these replacement techniques including the use of the ileum, appendix, or colon[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Sandra A et al reported 105 patients who underwent ileum ureteral replacement and finally included 91 patients (99 nephrons) to form the study cohort. The mean age of the patients was 46.8 years, and the mean follow-up was 36.0 months. Ureteral reconstruction using the ileum may result in hyperchloremic metabolic acidosis, short bowel syndrome, vitamin B12 deficiency, cholelithiasis, anastomotic stenosis, and enterocutaneous fistulas[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Benjamin I et al reported 56 patients who underwent intestinal replacement for ureteral reconstruction, including 52 ileal ureteral replacements and 2 colonic replacements. During a mean follow-up of 6.04 years, there was no worsening of renal function. Mild postoperative complications occurred in 17.9% of patients, and the complications included pyelonephritis, unexplained fever, neuroma, hernia, recurrent urolithiasis, and deep vein thrombosis. Severe complications, including anastomotic stricture, ileal graft obstruction, wound dehiscence, and chronic renal failure, occurred in 10.5% of the patients. There have also been reports of using the appendix instead of ileal interposition to avoid the need for intestinal anastomosis[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The failure rate of open ileal replacements ranges from 4\u0026ndash;25% depending on the anatomical condition and extent of injury.\u003c/p\u003e \u003cp\u003eNotably, ureteral replacement can be performed using the Yang-Monti principle, according to which the bowel segment opens longitudinally along the bowel margin and then closes laterally. Bedeir et al. (2003) reported 10 patients who underwent the Yang-Monti procedure. The median postoperative follow-up was 9.6 months. The mean serum creatinine of all patients remained stable, and imaging angiography showed no obstruction and no tendency for the dilation to worsen. This procedure allows for the construction of ileal ureteral replacement with an appropriate cross-sectional diameter, without the need for tailoring, and this procedure enables the use of antireflux techniques [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAutologous kidney transplantation can be selected when orthotopic reconstruction is not suitable for long ureteral stenosis and renal vascular abnormalities. Laparoscopic or robotic-assisted autologous kidney transplantation is a novel, safe and effective modality [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Nick G et al reported 51 patients who received autologous kidney transplantation in 2 centers. The most common complications were renal pain and hematuria syndrome/chronic renal pain, ureteral stenosis, and vascular abnormalities. Early, high-grade complications (grade IIIa or higher) occurred in 14.8 percent of the patients, late complications occurred in 12.9 percent of the patients, and 2 patients underwent transplant nephrectomy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Vascular abnormalities are a serious problem after autologous kidney transplantation, and these abnormalities include renovascular hypertension, arterial thrombosis, and advanced pseudoaneurysm. Autologous transplantation seems to have a higher incidence of vascular complications than allogeneic transplantation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eIn adults with long ureteral stenosis, the Boari flap is feasible after the excision of the diseased segment. Boari, an Italian, performed the experiment on dogs in 1894, and in 1926, German surgeon Baiden replaced the lower two-thirds of the ureter in a woman who had lost her ureter to a fistula and stricture after pelvic surgery[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. With the development of minimally invasive techniques, laparoscopic and robotic techniques are increasingly used for boari flap ureteroplasty [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], although a potential disadvantage of robotic-assisted reconstruction is the use of a transperitoneal approach, with the risks of postoperative bowel obstruction and peritoneal urine leakage[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Boari flap ureteroplasty is relatively simple, with few major complications and a low failure rate. It is the most commonly used surgical method for the treatment of iatrogenic intermediate and distal ureteral injuries [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Boari flaps can repair ureteral injuries up to 15 cm in length [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Shchukin et al reported 70 patients with boari flap reconstruction of the ureter; the average bladder flap length was 9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 cm; and 8.2% of the patients successfully underwent reconstruction of the upper third of the ureter. The total incidence of intraoperative complications did not exceed 12.9%, the total incidence of early postoperative complications was high but not serious, and only 1 patient required surgical correction. The long-term satisfaction was 91.5%, and only 2 patients (2.3%) required nephrectomy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Boari flap is an acceptable technique for the reconstruction of long ureteral strictures, even proximal ureteral stenosis, but depending on the patient's bladder capacity, the Boari flap may not be able to reach the stenotic proximal ureter. Somerville and Naude first studied buccal mucosal grafts for ureteral reconstruction in an animal model in 1984 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] because buccal mucosal grafts have rich vascular plexus and akeratinized thick epithelium suitable for transplantation. Over the years, buccal mucosal grafts have been used extensively in urethroplasty. Naude first reported buccal mucosal grafts for human ureteral reconstruction [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], followed by multiple studies reporting favorable clinical and functional outcomes of buccal mucosal grafts for ureteral injury repair [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The incidence of serious complications with buccal mucosal graft ureteroplasty is very low. The robotic approach for buccal mucosal graft ureteral reconstruction has complications similar to robotic pyeloplasty, with the exception of additional oral discomfort when obtaining buccal grafts[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBuccal mucosal graft ureteroplasty is suitable for proximal or middle ureteral stenosis. This technique can be used in patients where the lumen has enough stenosis to cause obstruction and cannot be directly anastomosed. However, there should be enough viable ureter, and the buccal mucosal graft with rich blood vessels should cover enough to restore the normal ureter cavity. In buccal mucosal graft ureteroplasty, placing the graft in an anterior position is technically easier to maneuver, so ventral (anterior) buccal mucosal graft ureteroplasties were performed in all of our patients. Animal experiments have also verified the safety and efficacy of buccal mucosal graft ureteroplasty[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Buccal mucosal graft ureteroplasty is a safe and feasible technique that offers an option for the reconstruction of long-distance proximal and mid-ureteral stenosis[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA unique feature of ureteral flap reconstruction is the removal of the graft from one part of the body and transferring it to the recipient site to create a new blood supply. The flap is a capillary-rich tissue that transfers to the recipient site, and it should maintain its own blood supply. The tissue selection for ureteral flap-plasty should be based on the characteristics of the ureteral stenosis and the patient's overall condition, as well as related complications at the donor site and the functional outcomes at the reconstruction site [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In recent years, with the rise of laparoscopy and robotics, an increasing number of urological centers are using minimally invasive techniques for ureteral reconstruction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis was a retrospective study that enrolled patients who were highly screened. The sample size of our study is small and has limitations. Our study was based on years of experience at a single center, with most patients undergoing open surgery. We still need large sample sizes and multicenter and long-term studies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIatrogenic injury is the most common cause of long ureteral stenosis.There are many surgical methods for ureteral reconstruction, and the boari bladder flap is a preferred method for repairing long ureteral stenosis due to fewer postoperative complications and a low treatment failure rate.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMulti-slice CT urography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKUB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ekidney ureter bladder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLUTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elower urinary tract storage symptoms\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInter Quartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLingual mucosa graft\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBBF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBoari bladder flap.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.M. and Z.Y. contributed to the idea and formed the study design. G.W. , Q.Z., H.C., X.W., W.S. and J.B. undertook to maintain research data. S.Z. and X.L. analyzed the data. X.L., J.M. and P.S. contributed to the drafting. P.S. and Z.Y. critically reviewed the article. All authors contributed to drafting the article and approved the final version. All theauthors agree to be responsible for all aspects of the study,and they all have read and approved the final article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the\u0026nbsp;Cuiying Scientific and Technological Innovation Program of Lanzhou University Second Hospital\u0026nbsp;[Grant number 2020QN-09] and National Natural Science Foundation of China [No. 82160146].\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 enquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of Lanzhou University Second Hospital (approval no. 2022A-394) . Written Informed consent was obtained from all the participants prior for the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYang K, Fan S, Li Z, Guan H, Zhang P, Li X, Zhou L: \u003cb\u003eLingual mucosa graft ureteroplasty for ureteral stricture: a narrative review of the current literature\u003c/b\u003e. Ann Palliat Med. 2021;\u003cb\u003e10\u003c/b\u003e(4):4840\u0026ndash;4845.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiran A, Hilton P, Cromwell DA: \u003cb\u003eThe risk of ureteric injury associated with hysterectomy: a 10-year retrospective cohort study\u003c/b\u003e. 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J Urol. 1955;\u003cb\u003e74\u003c/b\u003e(4):485\u0026ndash;491.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMusch M, Hohenhorst L, Pailliart A, Loewen H, Davoudi Y, Kroepfl D: \u003cb\u003eRobot-assisted reconstructive surgery of the distal ureter: single institution experience in 16 patients\u003c/b\u003e. BJU Int. 2013; \u003cb\u003e111\u003c/b\u003e(5):773\u0026ndash;783.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStolzenburg JU, Rai BP, Do M, Dietel A, Liatsikos E, Ganzer R, Qazi H, Meneses AD, Kallidonis P: \u003cb\u003eRobot-assisted technique for Boari flap ureteric reimplantation: replicating the techniques of open surgery in robotics\u003c/b\u003e. BJU Int. 2016; \u003cb\u003e118\u003c/b\u003e(3):482\u0026ndash;484.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFicarra V, Rossanese M, Crestani A, Caloggero S, Alario G, Novara G, Giannarini G, Valotto C: \u003cb\u003eA Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter\u003c/b\u003e. Eur Urol Focus.2020; 7(6):1476\u0026ndash;1484.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShchukin DV, Demchenko VM, Lisova GV, Bielievtsova IS: \u003cb\u003eOrganization of urological care for patients with iatrogenic ureteral injury\u003c/b\u003e. Wiad Lek. 2019;\u003cb\u003e72\u003c/b\u003e(1):22\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSomerville JJ, Naude JH: \u003cb\u003eSegmental ureteric replacement: an animal study using a free non-pedicled graft\u003c/b\u003e. 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Eur Urol. 2018; \u003cb\u003e73\u003c/b\u003e(3):419\u0026ndash;426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Y, Sun L, Pan Q, Hua X, Li B: \u003cb\u003eA new technique for ureteral reconstruction using lingual mucosa grafts in a beagle model\u003c/b\u003e. 2021;\u003cb\u003e53\u003c/b\u003e(1):83\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong S, Wang J, Zhu W, Yang K, Ding G, Li X: \u003cb\u003eOnlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review\u003c/b\u003e. 2020;6178286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi B, Xu Y, Hai B, Liu B, Xiang Y, Hua X, Hou T: \u003cb\u003eLaparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stricture\u003c/b\u003e: \u003cb\u003einitial experience and 9\u003c/b\u003e-\u003cb\u003emonth follow\u003c/b\u003e-\u003cb\u003eup\u003c/b\u003e. \u003cem\u003eInternational urology and nephrology\u003c/em\u003e 2016, \u003cb\u003e48\u003c/b\u003e(8):1275\u0026ndash;1279.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao LC, Yamaguchi Y, Bryk DJ, Adelstein SA, Stifelman MD: \u003cb\u003eRobot-Assisted Ureteral Reconstruction Using Buccal Mucosa\u003c/b\u003e. Urology.2015;\u003cb\u003e86\u003c/b\u003e(3):634\u0026ndash;638.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarien T, Bjurlin MA, Wynia B, Bilbily M, Rao G, Zhao LC, Shah O, Stifelman MD: \u003cb\u003eOutcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients\u003c/b\u003e. BJU Int.2015; \u003cb\u003e116\u003c/b\u003e(4):604\u0026ndash;611.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang K, Fan S, Wang J, Yin L, Li Z, Xiong S, Han G, Meng C, Zhang P, Li X \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eRobotic-assisted Lingual Mucosal Graft Ureteroplasty for the Repair of Complex Ureteral Strictures: Technique Description and the Medium-term Outcome\u003c/b\u003e. Eur Urol. 2022; 81(5):533\u0026ndash;540.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang C, Wang J, Hai B, Xu Y, Zeng J, Chai S, Chen J, Zhang H, Gao X, Cheng G \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eLingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture\u003c/b\u003e: \u003cb\u003e6 Years of Experience with 41 Cases\u003c/b\u003e. \u003cem\u003eEur Urol.\u003c/em\u003e 2022; S0302-2838(22)02340-5.\u003c/span\u003e\u003c/li\u003e\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":"Ureteral stenosis, ileal substitution, lingual mucosa graft, Boari bladder flap, ureteroplasty","lastPublishedDoi":"10.21203/rs.3.rs-1986531/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1986531/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical management of long ureteral stenosis is challenging. We describethe different modalities used in our center to treat long ureteral stenosis and report ourlong-term results.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is a 17-year retrospective study to evaluate the efficacy of ureteroplasty with different surgical procedures in 12 patients with long ureteral stenosis. This study has passed ethical approval. Data were collected between May 2005 and September 2021. The mean age was 41 years. Recurrent stenosis was treated with long-term ureteral stent placement. The main observation index was the success rate of surgery. The secondary index was the rate of surgical complications and recurrent stenosis. The mean is used to describe parametric continuity variables, and the median and quartile range (IQR) are used to describe nonparametric continuity variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwelve patients were included. There were iatrogenic injuries in nine patients (75%), bilateral polyps in one (8.3%), ureteral occupation in one (8.3%), and unknown origins in one (8.3%). Ileal replacement was performed in three (25%) patients, lingual mucosa grafts in four(33.3%) patients, and boari bladder flaps in five (41.7%) patients. One of the surgeries was performed laparoscopically. The median follow-up was 49 months (range 8-204), and three patients (25%) had major postoperative complications. One patient\u0026rsquo;s treatment failed, requiring special reintervention, and two patients (16.7%) underwent ureteral stent placement. We accept the limitations of this small retrospective single-surgeon series, where the surgeon had a certain surgical selection preference.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIatrogenic injury is the most common cause of long ureteral stenosis.There are many surgical methods for ureteral reconstruction, and the boari bladder flap is a preferred method for repairing long ureteral stenosis due to fewer postoperative complications and a low treatment failure rate.\u003c/p\u003e","manuscriptTitle":"Long-term follow-up of ureteroplasty with different methods for long ureteral stenosis: A Single Institution Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-21 18:02:37","doi":"10.21203/rs.3.rs-1986531/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":"b5d2dcdf-fbbf-4892-ba37-34da09dd82d5","owner":[],"postedDate":"September 21st, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-06-28T09:44:34+00:00","versionOfRecord":[],"versionCreatedAt":"2022-09-21 18:02:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1986531","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1986531","identity":"rs-1986531","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}