Reconstruction and undiversion of the short or severely dilated ureter: the antireflux ileal nipple revisited.

Abstract

Patients undergoing reconstruction of short or severely dilated aperistaltic ureters are at significant risk for mechanical or functional obstruction and reflux, particularly when the ureters are being reimplanted into gastric or intestinal segments. For this problem we describe a simple handsewn, "stapleless" antireflux ileal nipple, which serves as a useful bridge between a short ureter and the bladder or reservoir. A total of 12 patients, 4 to 42 years old (mean age 19), 9 with severely dilated and 3 with short ureters have received the stapleless antireflux ileal nipple as part of various reconstructive efforts. Briefly, a 12 to 15 cm. segment of ileum is isolated and the mesentery is stripped from the middle 8 cm. of the isolated segment, preserving the blood supply to the proximal and distal 2 cm. of ileum. Intussusception is created and maintained with multiple (5 to 7) circumferential rows of 4 to 6 interrupted seromuscular stitches of 3-zero silk. Mean followup is 27.5 months (range 6 to 60). Upper tract dilatation has stabilized or improved in all patients, deteriorating temporarily in 1 who had distal nipple stenosis. All patients underwent followup video urodynamic studies, which demonstrated no reflux. Nipple related complications included nipple stenosis in 1 patient and dessusception in another. Both complications were corrected without sequelae. Ureteroileal stenosis or stone formation has not occurred. The stapleless antireflux ileal nipple is safe and reliable in preventing reflux. It is a versatile adjunct to urinary reconstruction in patients with short or severely dilated, aperistaltic ureters in whom the alternative of a tapered reimplantation into a segment of bowel or stomach poses a significant complication threat.