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Update Harnleiterrekonstruktion 2024

Update on ureteral reconstruction 2024

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Zusammenfassung

Harnleiterstrikturen können im gesamten Harnleiterverlauf auftreten. Die Genese ist dabei vielfältig. Ursächlich für die Entstehung sind u. a. angeborene Anomalien, iatrogene Verletzungen im Rahmen von endoskopischen sowie offenen oder minimalinvasiven viszeralchirurgischen, gynäkologischen und urologischen Eingriffen sowie eine zuvor erfolgte Radiatio. Die Therapieplanung bei Harnleiterstrikturen erfordert eine detaillierte Auseinandersetzung mit Striktur- und Patientencharakteristika. Angesichts der vielfältigen Optionen zur Harnleiterrekonstruktion müssen verschiedene Methoden für jeden Patienten in Betracht gezogen werden. Kurzstreckige proximale Engen sowie Engen am pyeloureteralen Übergang werden operativ meist mittels Nierenbeckenplastik nach Anderson-Hynes versorgt. Bei kurzstreckigen proximalen und mittleren Harnleiterstrikturen kann eine End-zu-End-Anastomosierung erfolgen. Bei distalen Strikturen kommt die Ureterozystoneostomie zum Einsatz und wird häufig mit einer Boari- und/oder Psoas-Hitch-Plastik kombiniert. Vor allem die Behandlung von langstreckigen Strikturen im Bereich des proximalen und mittleren Harnleiters stellt weiterhin eine chirurgische Herausforderung dar. Hier bietet die Verwendung von Darminterponaten eine anerkannte Therapieoption mit guten funktionellen Ergebnissen, jedoch auch damit assoziierten potenziellen Komplikationen. Die offen-chirurgische Harnleiterrekonstruktion stellt jedoch weiterhin vor allem nach multiplen abdominellen Voroperationen ein etabliertes Verfahren dar.

Abstract

Ureteral strictures can occur along the entire course of the ureter and have many different causes. Factors involved in the development include, among other things, congenital anomalies, iatrogenic injuries during endoscopic as well as open or minimally invasive visceral surgical, gynecological, and urological procedures as well as prior radiation therapy. Planning treatment for ureteral strictures requires a detailed assessment of stricture and patient characteristics. Given the various options for ureteral reconstruction, various methods must be considered for each patient. Short-segment proximal strictures and strictures at the pyeloureteral junction are typically surgically managed with Anderson–Hynes pyeloplasty. End-to-end anastomosis can be performed for short-segment proximal and middle ureteral strictures. Distal strictures are treated with ureteroneocystostomy and are often combined with a Boari and/or Psoas Hitch flap. Particularly, the treatment of long-segment strictures in the proximal and middle ureter remain a surgical challenge. The use of bowel interposition is an established treatment option for this, offering good functional results but also potential associated complications. Robot-assisted surgery is increasingly becoming a minimally invasive treatment alternative to reduce hospital stays and optimize postoperative recovery. However, open surgical ureteral reconstruction remains an established procedure, especially after multiple previous abdominal operations.

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Authors and Affiliations

  1. Abteilung für Urologie, Asklepios Klinik Barmbek, Rübenkamp 220, 22307, Hamburg, Deutschland

    S. Hook, A. J. Gross, C. Netsch, B. Becker, S. Filmar &  C. M. Rosenbaum

  2. Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland

    M. W. Vetterlein

  3. Klinik für Urologie, Universitätsklinikum Frankfurt am Main, Frankfurt am Main, Deutschland

    L. A. Kluth

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S. Hook, A.J. Gross, C. Netsch, B. Becker, S. Filmar, M.W.V. Vetterlein, L.A. Kluth und C.M. Rosenbaum geben an, dass kein Interessenkonflikt besteht.

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Hook, S., Gross, A.J., Netsch, C. et al. Update Harnleiterrekonstruktion 2024. Urologie 63, 25–33 (2024). https://doi.org/10.1007/s00120-023-02232-z

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