使用Yang-Monti手術修復雙側輸尿管狹窄 ─ 案例報告

戴盟哲¹、林子平^1,2、林登龍^1,2、陳光國^1,2

台北榮民總醫院 泌尿部¹；國立陽明大學醫學院 泌尿學科 書田泌尿科學研究中心²

Repair bilateral ureteral stricture by Yang-Monti surgery ─ A Case Report

Meng-Che Tai¹, Tzu-Ping Lin^1,2, Alex T.L. Lin^1,2, Kuang-Kuo Chen^1,2

Department of Urology, Taipei Veterans General Hospital¹

Department of Urology, School of Medicine and Shu-Tien Urological Institute, National Yang-Ming University, Taipei, Taiwan²

Introduction:

Ureteral stricture may be managed conservatively such as internal diversion with JJ stent, which may result in significant debilitating side effect and may not prevent renal function deterioration. For high grade ureteral obstruction, reconstruction surgery may be mandatory. Yang-Monti surgery, a modified form of ileal ureter in essence, had emerged to be a viable alternative for long or multiple ureteral strictures. Here, we report our experience of complete bilateral ureteral substitution with extended Yang-Monti surgery.

Case report:

This is a 60-year-old woman suffered from L2-5 disc degeneration with calcification and she received posterior decompression and instrumentation with Dynesys on January, 2010. However, bilateral psoas muscle abscess occurred in a delayed fashion and caused bilateral hydronephrosis since October, 2013. Bilateral diagnostic ureterorenoscopy was performed and stricture over both upper third ureter were noted. Then, she received regular JJ stent replacement since then. Psoas muscle abscess was managed with long term antibiotics. Bilateral extended paraspinal fibrosis ensued as expected. The patient was JJ stent dependent bilaterally. Furthermore, renal function deterioration was found despite adequate JJ stents position. Thus, total bilateral ureteral replacement from renal pelvis using extended Yang-Monti surgery was performed in August, 2016.

Intraoperative findings revealed bilateral ureteropelvic junction and upper ureter with severe adhesion to psoas muscle, which was compatible with previous psoas muscle abscess history. 12.5 cm ileum bowel loop was harvested and divided into five segments with corresponding mesentery. Each bowel segment was incised along its longitudinal axis. The adjacent bowel segment were sewn together with continuous 4-O PDS after each segment was rotated 90 degree. And then form an ileal tube by sewing the ileal plate over a 16 Fr Foley. Of note the proximal ileal tube was transposed to retroperitoneum and anastomosed to right renal pelvis with 2 double-J stents in the ileal tube. Distal end of ileal tube was anastomosed with bladder by an anti-reflux fashion. Another 12.5 cm ileum loop was harvested and the same procedure was done on the left side. This is the 1^st case report utilizing Yang-Monti principle ileal substitution for total ureteral replacement in a single session.

Post-operative condition was good. Anter-grade pyelography showed patent outlet of bilateral collecting system with persisting bilateral hydronephrosis. Her creatinine level was around 1.0 after surgery and we will follow up her clinical condition

Conclusions:

For long ureteral stricture, ureteral replacement with ileal interposition graft is a challenging yet useful procedure. Our experience showed good functional outcome after surgery.