The search for an optimal method for reconstruction or replacement of the diseased ureter is a classic example of the way urologists seek solutions to complex genitourinary problems. Numerous types of grafts have failed, including those using blood vessels, fallopian tubes, peritoneal tubes, and metal and plastic. Ureteral replacement with ileal bowel segments has become part of the urologic surgeon's armamentarium more than 35 years after Goodwin et al<sup>10 Goodwin W.E., Winter C.C., Turner R.D. Replacement of the ureter by small intestine: Clinical application and results of the “ileal ureter.” J Urol 1959 ;  81 : 406-418

Cliccare qui per andare alla sezione Riferimenti</sup> first popularized the procedure.

Fenger<sup>7 Fenger C. Surgery of the ureter Ann Surg 1894 ;  20 : 257

Cliccare qui per andare alla sezione Riferimenti</sup> is credited with the first written proposal for reconstructing the ureter with small bowel. In 1900, the operation was successfully performed on three dogs by d'Urso and de Fabii.<sup>6 d'Urso Fabii, de Moore E.V., Weber R., Woodward E.R. , e al. Isolated ileal loops for ureteral repair Surg Gynecol Obstet 1956 ;  102 : 87-99

Cliccare qui per andare alla sezione Riferimenti</sup> In 1906, Shoemaker<sup>18 Shoemaker, Moore E.V., Weber R., Woodward E.R. , e al. Isolated ileal loops for ureteral repair Surg Gynecol Obstet 1956 ;  102 : 87-97

Cliccare qui per andare alla sezione Riferimenti</sup> carried out the first repair in a human by replacing the ureter of an 18-year-old woman who was presumed to have genitourinary tuberculosis. Melnikoff<sup>15 Melnikoff A.E. Sur le replacement de l'uretere par une anse isolée de l'intestin grêle Rev Clin Urol 1912 ;  1 : 601

Cliccare qui per andare alla sezione Riferimenti</sup> published a classic treatise in 1912 on the history of the procedure but, by 1950, only three case reports were found in the literature. In 1959, the summary by Goodwin et al<sup>10 Goodwin W.E., Winter C.C., Turner R.D. Replacement of the ureter by small intestine: Clinical application and results of the “ileal ureter.” J Urol 1959 ;  81 : 406-418

Cliccare qui per andare alla sezione Riferimenti</sup> popularized the procedure.

In general, the indications for intestinal replacement of the ureter remain the same today:

This is because ileal ureter reconstruction should usually be considered when all other more conservative procedures, such as ureteroneocystostomy, ureterocalicostomy, Boari flap, transureteroureterostomy, and in some cases autotransplantation, are not applicable.

Contraindications to ileal ureter replacement include an inadequate length of usable bowel or inflammatory bowel disease:

Patients with hepatic dysfunction are at risk for the development of hepatic encephalopathy secondary to absorption of nitrogenous waste into the enteric circulation. This risk is particularly noteworthy in a patient with portacaval shunt.<sup>14 McDermott W.V. Diversion of urine to the intestines as a factor in ammoniagenic coma N Engl J Med 1957 ;  256 : 460-462  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Furthermore, to avoid high-pressure reflux and subsequent renal deterioration, any difficulty with emptying the bladder should be evaluated and ruled out before operation.

Pre-existing azotemia has been a relative contraindication, particularly when the serum level of creatinine is greater than 2 mg/dL. Infrequently, however, we are faced with a patient with a level of creatinine greater than 2 mg/dL who wishes to risk metabolic complications to avoid a less palatable alternative. We recommend using a much smaller area of bowel as a segment or interposition graft. The safe use of small segments with caution to replace damaged ureters has been reported by Casale et al<sup>5 Casale A.J., Colodny A.H., Bauer S.B., Retik A.B. The use of bowel interposed between proximal and distal ureter in urinary tract reconstruction J Urol 1985 ;  134 : 737-740

Cliccare qui per andare alla sezione Riferimenti</sup> and Lytton and Schiff<sup>13 Lytton B., Schiff M. Interposition of an ileal segment for repair of ureteral injuries J Urol 1981 ;  125 : 739-741

Cliccare qui per andare alla sezione Riferimenti</sup> in humans and Waters et al<sup>24 Waters W.B., Herbster G., Jablokow V.R., Reda D.J. Ureteral replacement using ileum in compromised renal function J Urol 1989 ;  141 : 432-436

Cliccare qui per andare alla sezione Riferimenti</sup> in dogs.

Experience at the Lahey Hitchcock Medical Center now totals 61 ureteral replacements. In this group were 17 solitary kidneys and 11 segmental replacements, 3 of which are true interposition grafts.