以盲腸修補輸尿管損傷:病例報告與文獻回顧

吳英龍¹, 黃逸修^1,2, 黃志賢^1,2

臺北榮民總醫院泌尿部¹；國立陽明交通大學醫學院泌尿學科及書田泌尿科學研究中心²

Repair of ureteral transection with appendix: a case report and literature review

Ying-Long Wu¹, Eric Yi-Hsiu Huang^1,2, William J.S. Huang^1,2

Department of Urology, Taipei Veterans General Hospital¹,

Department of Urology, College of Medicine and Shu-Tien Urological Science Research Center, National Yang Ming Chiao Tung University², Taipei, Taiwan

Introduction

The appendix can occasionally be utilized for repairing lower and middle third ureter injuries, with low morbidity and high success rates. We present a specific case in which the ureter was successfully repaired with the appendix.

Case presentation

        A previously healthy 50-year-old female experienced anuria on the first postoperative day following an open abdominal total hysterectomy for a large uterine myoma. Further examination revealed bilateral ureteral transection with hydronephrosis, which necessitated the immediate insertion of bilateral percutaneous nephrostomy (PCN) tubes. The patient sought a second opinion at our hospital, where she underwent bilateral ureteroscopy, antegrade pyelography (AP) and retrograde pyelography (RP). These procedures revealed bilateral lower ureter injuries with very limited ureteral stump attached to the urinary bladder. The defect in the right ureter measured 6 cm, while the defect in the left ureter measured 4 cm. She underwent bilateral ureteral reconstruction thereafter. Right ureter substitution with appendix and left ureteral reimplantation was successfully performed. The postoperative course was uneventful and bilateral double-J stents were removed 3 months after the surgery. The follow-up renal function and computed tomography showed bilateral patent ureters.

Discussion

The technique (appendicoureteroplasty or AUP) was first introduced more than a century ago by Melnikoff in 1912. The theoretical advantages of AUP are: similar diameter between the organ and ureter, self- peristalsis, antireflux effect be achieved if in isoperistaltic position and low electrolyte resorption. The appendix is used for lower to middle third ureteral reconstruction average about 3 cm. Contraindications include absent appendix due to previous surgery, scarred or narrow appendix caused by inflammation.

There are only few case reports and case series available. In the study by Boris Komyakov, 26 patients were included, which was the largest case study. The follow-up period was from 1 to 21 years, and the stricture rate of the anastomosis site was 15.4%. Kidney function was preserved in all patients (N=26); good short-term results were achieved in 84.6% of patients and good long-term results of 96.2%. There were no electrolyte imbalance noted including Na⁺,Cl^- and bicarbonate.

Conclusion

In select patients with lower to middle third ureteral injuries, a healthy and well-vascularized appendix may be a suitable material for ureteral reconstruction. Studies have shown that this approach can be successful, although careful patient selection is important.