Successful Laparoscopic BMG Ureteroplasty for Complex Right Upper Ureteric Stricture

PACE Hospital’s expert Urology team successfully performed a Right Laparoscopic Ureteric Reconstruction with Buccal Mucosal Graft (BMG) Ureteroplasty on a 37-year-old male patient diagnosed with a complex right upper ureteric stricture measuring 6 cm in length with a severely narrowed lumen (3 Fr caliber), associated with right upper ureteric calculi and a poorly functioning right kidney with a differential renal function of 18%. The procedure was undertaken to relieve the ureteric obstruction, restore normal urinary drainage, preserve the remaining kidney function, and improve the patient’s long-term renal and urological outcomes.

Chief Complaints

A 37-year-old male patient with a body mass index (BMI) of 21 presented to the Urology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of right-sided flank pain.

The patient had a history of right upper ureteric calculus for which he had previously undergone Ureteroscopic Lithotripsy (URSL) with double-J (DJ) stent placement at another healthcare facility. Subsequent evaluation revealed a long-segment right upper ureteric stricture associated with residual ureteric calculi and reduced function of the right kidney. There was no documented history of significant medical comorbidities.

On examination, the patient was conscious, coherent, and oriented and hemodynamically stable. Cardiovascular and respiratory system examinations were normal with normal heart sounds and bilateral clear air entry. Abdominal examination revealed right flank tenderness without guarding or rigidity, and no palpable mass was noted. Surgical site examination was normal with no evidence of active bleeding or discharge.

Bowel sounds were normal. No peripheral edema or lymphadenopathy was observed. Overall systemic examination findings were within normal limits except for mild right flank tenderness consistent with the underlying urological condition.

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Urology team, including a detailed review of his medical history and a comprehensive clinical examination. He presented with right-sided flank pain. Based on the initial assessment, a provisional diagnosis of right upper ureteric stricture with calculus was made.

The patient was further evaluated with relevant investigations, including complete blood picture, which showed neutrophilic leukocytosis at initial assessment with subsequent normalization trend, serum electrolytes which were within normal limits, renal function tests including serum creatinine and blood urea which remained within normal range, liver function tests which were within normal limits, coagulation profile including PT, INR, APTT, bleeding time, and clotting time which were within normal limits, urine routine examination which was normal with no hematuria, proteinuria, or evidence of infection.

Urine culture and sensitivity which showed no bacterial growth, blood grouping and Rh typing which revealed B positive blood group, viral screening including HIV, HBsAg, and HCV which were non-reactive or negative, chest X-ray PA view which was normal with clear lung fields, X-ray KUB which demonstrated right-sided DJ stent in situ, 2D echocardiography which showed normal cardiac chamber sizes, good biventricular function, grade I diastolic dysfunction, and no significant structural abnormalities, and ultrasound soft tissue examination of the left shoulder and axilla which revealed mild subcutaneous edema in the left scapular region with no mass or lymphadenopathy.

Based on these confirmed findings, the patient was advised to undergo Right Upper Ureteric Stricture with Calculus Treatment in Hyderabad, India, causing obstructive uropathy and reduced right renal function under the expert care of the Urology Department.

After a detailed consultation with Dr. Vishwambhar Nath, Senior Consultant Urologist & Renal Transplant Surgeon, and Dr. Abhik Debnath, Consultant Laparoscopic Urologist, Endourologist, Andrologist & Kidney Transplant Surgeon, a comprehensive evaluation was conducted focusing on the patient’s presentation of right flank pain and obstructive uropathy. Clinical examination and diagnostic assessment, including complete blood picture, serum electrolytes, renal function tests, liver function tests, coagulation profile, urine routine examination, urine culture and sensitivity, viral markers, blood grouping and Rh typing, X-ray chest PA view, X-ray KUB, and 2D echocardiography, confirmed the presence of right upper ureteric stricture with associated ureteric calculi causing significant urinary obstruction and a reduced functioning right kidney with moiety function of 18 percent, with no evidence of active infection or major cardiopulmonary contraindications for intervention.

It was determined that Right Laparoscopic Ureteric Reconstruction with Buccal Mucosal Graft (BMG) Ureteroplasty was the most appropriate intervention in view of the long segment right upper ureteric stricture with associated ureteric calculi causing obstruction to urine flow and deterioration of renal function, with the aim of relieving obstruction, restoring urinary drainage, and preserving the remaining renal function.

The patient and his family members were informed about the diagnosis of right upper ureteric stricture with calculus causing obstructive uropathy and reduced renal function, the planned management approach, the associated risks, benefits, and expected outcomes, and consent was obtained for proceeding with surgical treatment.

Following the decision, the patient was scheduled to undergo Right Laparoscopic Ureteric Reconstruction with Buccal Mucosal Graft (BMG) Ureteroplasty Surgery in Hyderabad at PACE Hospitals, under the expert care of the urology department.

The procedure involved the following steps:

• Patient Positioning and Anaesthesia: The patient was taken up for surgery under general anaesthesia and positioned appropriately for laparoscopic renal and upper ureteric access. Standard aseptic precautions were followed, and pneumoperitoneum was created for laparoscopic entry.

• Intraoperative Ureteric Assessment: Intraoperative evaluation confirmed a long segment right upper ureteric stricture of approximately 6 cm with 3 Fr calibre. Associated findings included upper ureteric residual calculi measuring 8 mm each, along with small renal calculi measuring 2 to 3 mm. Retrograde pyelography demonstrated a long segment stricture not permitting passage of a 4 Fr ureteric catheter; however, a 0.025-inch guidewire was successfully negotiated across the stricture up to the pelvicalyceal system. Ureteroscopy findings were consistent with RGP, showing a normal and accommodative distal and mid ureter.

• Laparoscopic Exposure and Adhesiolysis: Laparoscopic access to the right upper ureter was obtained. Moderate adhesions were noted around the upper ureter below the pelviureteric junction, which were carefully released to expose the diseased ureteric segment.

• Stricture Management and Graft Preparation: The strictured ureteric segment was identified, and a small portion of the stricture was sent for histopathological biopsy. A lateral stricturotomy was performed to open the narrowed segment. Buccal mucosal graft (BMG) was harvested and tailored appropriately for ureteric reconstruction.

• Ureteroplasty and Stenting: Buccal mucosal graft was placed as a patch over the opened ureteric segment, and ureteroplasty was completed over a 6 Fr long-duration ureteric stent. Adequate reconstruction was achieved, ensuring free drainage and patency of the ureter. Hemostasis was secured, and the surgical field was closed in standard layers.

The patient had an uneventful intraoperative and postoperative course with stable recovery. Postoperative X-ray KUB confirmed correct placement of the ureteric stent with no residual stones.

Mild hematuria (blood in urine) was noted initially and resolved by postoperative day 2 without intervention. Urethral catheter was removed on postoperative day 4, and the drain was removed on postoperative day 5 after confirming normal drain fluid creatinine levels and no evidence of urinary leak.

The patient received postoperative care including infection prophylaxis, pain control, gastric protection, ureteric spasm prevention, and supportive measures. The histopathology report showed ulcerated ureteric mucosa with fibrosis and was negative for granulomas and malignancy. He recovered well and was discharged in stable condition.

The patient was prescribed medication for the prevention of postoperative infection following urological reconstructive surgery. Medication was advised for relief of postoperative pain and was to be used regularly for a short duration and then as needed. Therapy was given for the protection of the stomach lining and to prevent acidity during recovery. Oral medications and topical applications were advised to promote healing of the oral donor site and maintain oral hygiene following graft harvest.

Urinary alkalinization therapy was prescribed to maintain urine pH and reduce risk of crystallization during recovery. Medication was advised to reduce ureteric spasm and improve urine flow around the indwelling ureteric stent. Supportive supplementation was given to aid postoperative healing and renal recovery. Antihypertensive medication was continued for blood pressure control during the postoperative period.

The patient was advised to follow up with a local physician after 1 month for blood pressure monitoring and adjustment of antihypertensive therapy as required. He was instructed to continue physiotherapy measures, including regular mouth exercises as demonstrated during the hospital stay, and spirometry exercises to improve pulmonary function.

Application of an ice pack to the cheek was advised twice daily for 5 minutes to reduce postoperative discomfort and swelling at the oral graft site.

The patient was advised to maintain adequate hydration with a fluid intake of 3–4 litres per day. Inclusion of citrus fruits and juices was recommended. A low-purine and low-salt diet was advised to support renal health and reduce stone formation risk. A soft diet was recommended for a period of 2 weeks. The patient was instructed to avoid hard-to-chew and spicy foods during the initial 2-week recovery period.

The patient was instructed to contact the emergency ward at PACE Hospitals in the event of an emergency or if symptoms such as fever, severe flank or abdominal pain, vomiting, reduced urine output, or urinary blockage occur.

The patient was advised to return for follow-up with the Urologist in Hyderabad at PACE Hospitals after 2 weeks for Fourier Transform Infrared Spectroscopy (FTIR) stone analysis review, wound inspection, and suture removal. Further, the patient was advised to undergo ureteroscopic evaluation and DJ stent removal after 3 months.

This case highlights a right upper ureteric stricture with associated ureteric calculi and reduced right renal function. The patient underwent successful laparoscopic ureteric reconstruction with buccal mucosal graft ureteroplasty and stenting. He had an uneventful recovery and was discharged in stable condition with planned follow-up for stent removal and further evaluation.