A narrative review of definitive ureteral reconstructive surgical techniques

Introduction

Ureteral reconstruction is often indicated for a defect or injury that compromises the natural flow of urine from the kidney to bladder. While the most common etiology of ureteral stricture is iatrogenic surgical injury, other causes include traumatic injury, kidney stone passage, malignancy, retroperitoneal fibrosis, and idiopathic conditions (1). The most common cause of iatrogenic injury is laparoscopic gynecologic surgery (64%), which often involves the distal third of the ureter (2). General surgical procedures (26%) and urologic procedures (11%) are also associated with iatrogenic ureteral injury. For traumatic etiologies, penetrating injury mechanisms are far more common than blunt injury (95% vs. 5% respectively) (3). Traumatic ureteral injuries are often a delayed diagnosis and are frequently associated with other abdominal injuries.

There are a variety of surgical techniques used to repair or reconstruct injuries and strictures of the ureter, and technique selection is dependent on several factors. Location of the ureteral defect is an important consideration given proximity to surrounding structures such as the bladder, kidney, and bowel. The ureter is classically divided into three anatomical segments. The proximal ureter is traditionally defined as the portion extending from the ureteropelvic junction to the sacroiliac joint, the mid ureter coursing the bony pelvis, and the distal ureter as the segment from the iliac vessels to the bladder. The arterial blood supply of the proximal ureter is primarily from branches of the renal artery medially, the mid ureter is supplied posteriorly by branches of the common iliac artery, and the distal segment is supplied laterally by the superior vesical artery (4). Strong understanding of ureteral blood supply and surrounding anatomy is crucial for surgeons to effectively perform ureteral reconstruction.

In addition to location, defining the length of the ureteral defect is an essential consideration before undergoing repair. This is often achieved through use of both antegrade and retrograde techniques including pyelography or computed tomography with ureteral-filling phase. Additional methods such as mercaptuacetyltriglycineag-3 (MAG-3) renograms may be used to further evaluate function in cases of possible renal insufficiency, and ureteroscopy with biopsy or washing is indicated when the possibility of malignancy exists (5).

Overall, the evaluation and diagnosis of a ureteral injury or stricture is extensive, and there are a variety of treatment options for surgeons to consider. Endoscopic procedures such as balloon dilation and endopyelotomy serve as less-invasive strategies but demonstrate high rates of recurrence (6). Ureteroureterostomy is a successful surgical technique for short (less than 3 cm) strictures of the middle and distal ureter (4). While adjunctive techniques such as downward nephropexy and contralateral bladder pedicle division may achieve greater mobilization, complicated ureteral pathologies involving longer and/or multiple segments warrant alternative surgical approaches. The goal of this review is to describe techniques utilized by surgeons in the reconstruction of the upper urinary tract and evaluate the effectiveness of these methods. We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-23-236/rc).

Methods

Here, we describe various techniques used to reconstruct the ureter, including ureteroneocystostomy with and without Boari flap or psoas hitch, buccal mucosa graft (BMG) ureteroplasty, ileal ureter, appendiceal ureteroplasty, autotransplantation, and transureteroureterostomy (TUU). We first explain the history of each technique, followed by a general description of the technique and its variations. We subsequently highlight the relevant literature regarding the effectiveness of each technique.

Table 1 describes the search criteria. Data was obtained via a comprehensive literature search using PubMed. Search keywords included the aforementioned reconstruction techniques, as well as “ureteral reconstruction”, “ureteral repair”, and “ureteroplasty”, either alone or in combination. Additional searches were also conducted using Clinical Key for technique descriptions in surgical textbooks. All identified articles, including reviews, case reports, book chapters, and single- or multi-institutional reviews published in English were considered. Publications from any date were considered. The work presented represents an interpretation of the identified literature on predominant ureteral reconstruction techniques and is not a meta-analysis capable of comparing technique effectiveness. The selection of the studies cited in this review was compiled by the authors with the focus of including recent publications to present a contemporary discussion of the techniques of interest. Table 2 provides a list of recent publications (from 2017 or later) with summarized findings.

Ureteral reconstruction techniques

Ureteroneocystostomy with or without psoas hitch/Boari flap

Ureteroneocystostomy, the reimplantation of the ureter into the bladder, was first reported by Dr. Nussbaum in 1876 and over the next century, the procedure has become a mainstay for reconstruction of adult and pediatric ureteral pathologies and injuries (19). In pediatrics, ureteroneocystostomy is the gold standard treatment for vesicoureteral reflux (VUR) or obstructing megaureter in patients that experience recurrent urinary tract infections or have persistent high-grade (IV-V) VUR (20). In adults, ureteroneocystostomy is most often indicated for injury, stricture, malignancy or obstruction of the distal ureter (21).

The goal of a ureteroneocystostomy is to reimplant the ureter in a tension-free manner with adequate submucosal tunneling to ensure it is non-refluxing (22). Simple ureteroneocystostomy is most often performed for distal ureteral defects 3–4 cm in length. However, larger defects requiring repair and reimplantation may occur, and psoas hitch (6–10 cm) or Boari flap (10–15 cm) maneuvers may be indicated (1). The Boari flap, in which a bladder flap is used to reconstruct the ureter, was first described in 1894 by Italian surgeon Dr. Achille Boari on a dog and subsequently performed by Dr. Ockerblad in a patient for repair of a distal ureteral injury following a hysterectomy in 1936 (23). The psoas hitch, which involves ureteral reimplantation into a mobilized bladder dome, was first described by Zimmerman et al. in 1960 (24).

For ureteral reimplantation, the bladder is exposed and mobilized by dissecting it off the anterior abdominal wall and developing the space of Retzius. A midline cystostomy is made with stay sutures placed on either side to the cystotomy near the dome of the bladder. The trigonal area is identified and the distal ureter requiring transection and reimplantation is located. A region near the trigone for reimplantation is identified, and a submucosal tunnel can be created with a right-angle clamp or tenotomy scissors, ideally 1.5–2 cm in length. The ureter is then brought through the bladder wall and under the submucosal tunnel, and then sutured into place circumferentially for the neoureteral orifice (1,22). In smaller defects, simple ureteroneocystostomy can be performed; however, in instances of larger defects, psoas hitch or Boari flap maneuvers may be required for a tension-free anastomosis (1,25).

A psoas hitch involves suture fixation of the posterior bladder wall to the psoas muscle tendon to ease tension while protecting the genitofemoral nerve (21). Further mobilization of the bladder can be achieved with utilization of the technique originally described by Warwick (26). The anterior bladder is incised transversely, up to over one half of the bladder circumference. The bladder is elevated in a superolateral direction where it can be anchored to the psoas without tension. The ureter is reimplanted in a non-refluxing fashion through the previously described sub-mucosal tunnel technique. The original transverse incision is then closed in a vertical fashion. While there are no absolute contraindications to the psoas hitch, small, contracted bladders that have been exposed to pelvic radiation or have a compromised blood supply may make bladder mobilization difficult (1). Figure 1 demonstrates this technique.

Figure 1 Illustrative demonstration of psoas hitch technique.

In some cases, the psoas hitch is not sufficient to create an anastomosis free of tension and a Boari flap is indicated. This is created by incising the bladder in a “U” shape to create the flap with the point of the “U” at the distal-most part of the bladder. The apex of the Boari flap is anastomosed to the ureter and the flap is tubularized using running synthetic absorbable suture (21). The bladder is closed and a ureteral stent is left in place for 4–6 weeks along with a urethral catheter for 1–3 weeks (22). As with most urologic surgeries, these surgeries have been performed in open, laparoscopic, and robotic fashion (1,19,27).

One of the most prevalent postoperative problems related to ureteroneocystostomy is obstruction caused by edema, potentially presenting as oliguria/anuria, flank pain, abdominal pain, nausea and vomiting, ileus, or sepsis (20). Other postoperative complications related to ureteroneocystostomy include persistent or recurrent VUR and contralateral VUR. In both of these complications, reoperation is usually indicated after secondary causes are ruled out, such as neuropathic bladder, voiding dysfunction, and posterior urethral valves (20). The predominant complication of psoas hitch or Boari flap is an anastomotic leak, as indicated by flank pain, fever, decreased urinary output, urinoma on radiographic imaging and can be managed by prophylactically by placement of ureteral stent, foley catheter, or pelvic drain (25). For the Boari flap specifically, an important consideration is that the bladder is no longer spherical in shape and therefore has smaller filling capacity. Thus, preoperative counseling should be thorough and include expectations related to bladder capacity (25). In a recent study by Hardesty et al., it was found that 28% of patients undergoing Boari flap reconstruction reported new lower urinary tract symptoms (LUTS) postoperatively (28). Preoperative evaluation that reveals detrusor overactivity or history of radiation may warrant further investigation before a patient undergoes reconstruction with Boari flap.

The surgical techniques used for repair of distal ureteral strictures are well-established, and success rates for these procedures are cited as high as 96.7% (29). In recent years, minimally invasive approaches have become more popular. In a retrospective cohort study of 10 patients undergoing robotic-assisted laparoscopic ureteral reimplantation with psoas hitch and six who underwent traditional laparoscopic psoas hitch for ureteral reconstruction, there was no significant differences in operative outcomes between robotic and laparoscopic approaches. The outcomes measured were mean operative time, mean estimated blood loss, mean duration of catheter retention, and mean postoperative hospital stay. Patients were followed for 13.5 months postoperative and none of the patients had anastomotic leak, VUR, or hydronephrosis. However, robotic-assisted laparoscopy for psoas hitch increased surgical precision and is thought to decrease the amount of pelvic adhesions in the long term (7). Slawin and colleagues recently describe a novel technique utilizing ureteral reimplantation with side-to-side anastomosis via nontransecting robotic approach (8). In their cohort of 16 patients, they found that 93.8% of patients had symptomatic improvement in flank pain and all patients had a decrease in the degree of hydronephrosis at mean follow-up of 12.5 months.

BMG ureteroplasty

BMGs were first introduced in urology in the late 19th century by Ukrainian surgeon Kirill Sapezhko for urethroplasty (30). While now standard for urethral repair, BMGs are increasingly being utilized for ureteral reconstruction (31). In 1999, Naude published the first results of BMGs for ureteral repair in 6 patients with complicated strictures, reporting established patency and no complications in all patients (32).

Candidates for BMG ureteroplasty must undergo evaluation for adequate buccal mucosa tissue prior to surgery. Patients are examined for available buccal mucosa and additional exclusion criteria such as oral infections, head/neck irradiation, and anatomical defects limiting exposure (33). While smoking/tobacco use is frequently cited as a contraindication, recent investigations interestingly have been unable to demonstrate histologic changes from smoking in BMGs of tobacco users, raising the question if this is a true contraindication (34). Following approval, the patient undergoes both harvesting of BMG and ureteroplasty on the same day in the same operating room setting. An oral retractor may be used for exposure and identification of important anatomy such as the Stensen (parotid) duct near the second molar. Then, after determining the size of graft required, the graft mucosa can be dissected off the muscle and closed with absorbable suture or left open to heal (33). Typically, the graft is 3–6 cm in length and 1–1.5 cm wide but can reach longer lengths if required (35). While both closure and non-closure of the harvest site has been described, recent data of BMG harvest for urethroplasty suggested that the non-closure technique was superior in terms of minimizing postoperative oral pain (36).

To perform BMG ureteroplasty, the damaged ureteral segment is first identified. When the ureter is narrowed but patent with healthy surrounding tissue, the stenotic region is incised and the BMG can be anastomosed to the healthy ureter in an onlay fashion (35). In situations where the ureter is completely stenosed or destroyed, the entire length of the deformity may be excised. Following excision, the proximal and distal sections of the ureter are spatulated, and then the non-spatulated ends are joined. The BMG is then able to be applied to the spatulated ends in onlay fashion to fill the defect (35). The new anastomosis is protected with a ureteral stent for 4–6 weeks with additional consideration of omental flap coverage as a vascular supply (35,37). This technique is illustrated in Figure 2.

Figure 2 Illustrative demonstration of buccal mucosa graft ureteroplasty.

Several studies have examined the effectiveness of BMG for ureteral repair. As mentioned, Naude first presented 6 patients with complicated ureteral strictures repaired with buccal patch grafts (n=5) or tubularized buccal mucosa (n=1) and found prolonged patency with no complications on routine follow up (32). Several other studies including a total of 20 patients reported nearly 100% success rate in patients undergoing BMG ureteral repair primarily of the mid to proximal ureter with typical defect lengths of 3–6 cm (9,38-40). In 7 BMG ureteral repairs by Kroepfl et al., 2 repairs had stricture recurrence managed with JJ stenting, however, the strictures occurred distal to the repair and were attributed to misjudgment of the degree of extension of the original stricture (37). Finally, in the largest series to date, Lee et al. present 54 patients that underwent robotic ureteral repair with BMG (80% onlay, 20% anastomotic) for a mean defect length of 3 cm located in the mid-to-proximal ureter (11). Success rate was 87%, with all patients (n=7) experiencing recurrence managed with either chronic ureteral stenting, serial imaging, or balloon dilation, aside from 1 that underwent nephrectomy (11). Though data is limited, overall success rate for BMG ureteroplasty appears to be around 90% and best for repair of the proximal-to-mid ureter (10).

In addition to buccal mucosa, lingual mucosa has been used for oral mucosal graft ureteroplasty. The graft is harvested from the ventral surface of the tongue and anastomosed in a similar fashion to buccal mucosa (41). In their cohort of 41 patients, Liang and colleagues found a 97.6% rate of symptom resolution and/or absence of stricture on repeat imaging. While both lingual and buccal mucosa have demonstrated considerable success for proximal-mid ureteral strictures, there is a need for future studies to investigate if there is superiority of one technique to another.

Ileal ureter

The utilization of ileal segment for ureteral reconstruction was first described in 1906 by Shoemaker, and then later popularized by Goodwin in the 1950s (42,43). This technique is typically reserved for strictures involving long or complete ureteral defects. Stricture following genitourinary surgery, radiation-induced stricture, non-urologic iatrogenic surgical injury, stone chute, and retroperitoneal fibrosis have all been described as indications for ileal ureter (44).

Initially, the ileal ureter technique was described as utilization of 15 to 25 cm of ileum repositioned to an end-to-side or end-to-end anastomosis in an isoperistaltic manner (43). If there is not enough viable ureter to complete the ureteroileal anastomosis, the renal pelvis can be utilized instead. Over time, this original technique has evolved with several modifications. An anti-refluxing nipple valve is formed by intussusception of the distal 5 cm of ileal segment, which is then fixed to the bladder wall (45). While this is believed to reduce potential damage to the upper tract, evidence varies regarding whether or not an anti-refluxing mechanism is truly superior at preserving kidney function (46-48). To minimize intestinal length, a Boari flap-psoas hitch method can be implemented, which may be particularly useful when dealing with full-length ureteral defects (13). Additionally, the Yang-Monti technique of spiral tubularization of short ileal segments has been applied to ureteral reconstruction. This method is estimated to require one-third of the amount of bowel used in a traditional ileal ureter, and the decreased surface area is believed to reduce mucus production and electrolyte abnormalities (14). In cases of bilateral ureteral damage, the ileal ureter may be especially useful. This is achieved through a longer segment of ileum traversing between the kidneys, creating the appearance of a “seven” or “reverse-seven” orientation (44).

Given the relatively invasive nature of this method compared to other ureteral reconstruction techniques and requirement for manipulation of bowel, the ileal ureter is reserved for complicated patient presentations. Despite this, the ileal ureter has demonstrated considerable success in the reconstruction of these complex ureteral strictures. Xu et al. describe a success rate of 97.7% in their series of 43 patients, which they defined as the improvement in the degree of hydronephrosis and recovery of renal function (49). Launer and colleagues recently reported their series of 46 patients over a 16-year period which showed that 83% of patients did not need to undergo further open surgery following ileal ureter interposition or replacement (15). Roth et al. presented a series of 108 patients, which showed a 15% risk of renal deterioration at 5 years and a 20% risk of renal impairment at 20 years (12). Reported complications included incisional hernia (10.2%), small bowel obstruction (8.3%), fistula (5.6%), hyperchloremic metabolic acidosis (3.7%), and renal failure requiring dialysis (1.9%). Chung and colleagues demonstrated that only three of their 56 patients had worsening kidney function following surgery, all of which had a preoperative creatinine of >2.0 mg/dL (50). When selecting patients without pre-existing renal insufficiency, the success rate for ileal ureter may increase to 90–100% (51,52). Overall, these success rates encourage the use of ileal ureter in patients with long-segment ureteral disease or in scenarios not suitable for other ureteral reconstructive techniques.

Appendiceal ureteroplasty

The use of appendix in ureteral reconstruction was first described by Melnikoff in 1912 (53). Appendiceal ureteroplasty has been utilized for proximal to mid-ureteral strictures (54). While most reports of this technique are for right-sided strictures, some cases of left-sided appendiceal ureteroplasty have been used in pediatric populations (55).

There are notable variations to this technique, specifically appendiceal interposition and onlay graft. Interposition is achieved with end-to-end anastomosis of the appendix as replacement of the ureter. In several descriptions of interposition, some have utilized a cecal cuff in the graft which allows the surgeon to accommodate the size of a dilated renal pelvis or a large bladder defect (56,57). Both isoperistaltic and antiperistaltic techniques have demonstrated success, and superiority of one orientation to another has been debated (55). While some believe the isoperistaltic technique may aid in the passage of urine, others describe the antiperistaltic orientation as having no effect on urinary transport while reducing the risk for mesoappendix torsion (56). In the appendiceal onlay graft, the appendix is detubularized along the antimesenteric border and is grafted to a ureteral plate (16). With this technique, the new ureteral lumen is increased, reducing the concern for stricture recurrence compared to interposition (54). While described as an effective method, the use of onlay graft may be limited in some cases as it requires a viable segment of ureter to be used as a plate. The onlay method is illustrated below in Figure 3. Appendiceal ureteroplasty has traditionally been performed laparoscopically, but most recently a robotic approach has been popularized (16,54-57).

Figure 3 Illustrative demonstration of appendiceal ureteroplasty.

Despite this technique being relatively uncommon compared to other methods of ureteral reconstruction, multiple case series describe its success. Dagash and colleagues presented a case series of 10 pediatric patients that underwent appendiceal interposition, all of which utilized a renal pelvic anastomosis with a cecal cuff. Of the ten patients, only one had decline in renal function found on follow-up evaluation (56). In a smaller series of four pediatric patients, Cao et al. utilized a laparoscopic interposition technique, using an isoperistaltic technique in one patient and anti-peristaltic in the other three. All patients were found to have a reduction in hydronephrosis with good drainage on Tc-99m DTPA scans during follow-up, and the authors suggest that the peristaltic orientation is a nonfactor, and surgeons should prioritize a technique that allows for a wide and tension-free anastomosis to minimize risk of necrosis and stenosis (55). Duty and colleagues presented a series of 6 patients with an average stricture length of 2.5 cm undergoing laparoscopic appendiceal onlay flap ureteroplasty. All six patients were found to have radiographic or endoscopic evidence of stricture resolution (54). Recently, Jun et al. shared a series of adult patients who underwent robotic reconstruction with either utilization of onlay flap or interposition flap. There was demonstrated radiographic success in 11/12 patients at a mean follow up of 14.6 months (16).

Autotransplantation

Renal autotransplantation for ureteral injury repair was first described by Hardy in 1963 and has since then been used for other indications such as renovascular disease, trauma, loin-pain hematuria syndrome, and urologic neoplasms (58,59). Similar to ileal ureter, autotransplantation is a technique reserved for complex ureteral strictures, however it may be favorable to ileal ureter for patients with previous bowel surgery or disease (60). Contraindications to renal autotransplantation include vascular or fibrotic disease of the iliac vessels and renal parenchymal disease (61).

The surgical principles of renal autotransplantation follow the methodology of living donor nephrectomy, such that a proximal vascular dissection is performed to ensure optimal length of vascular and ureteral segments (18,60-62). To reduce ischemia time, the iliac vessel dissection is performed before the autotransplantation. In some cases, intracorporeal bench surgery can be performed to avoid reimplantation of the ureter (18). In cases of complete ureteral loss, autotransplantation can be achieved through use of pyelovesicostomy (61). Both open and minimally invasive techniques are appropriate, and recently a robotic-assisted approach has been described, however surgeons should select an approach that minimizes ischemia time (63).

While autotransplantation requires considerable surgical expertise, it has shown relative success as a method for complex ureteral reconstruction. Multiple groups report maintained success rates ranging from 80–90% (18,60-62). In a national database of 817 patients undergoing autotransplantation, 17% of which were performed for patients with ureteral disease, Moghadamyeghaneh and colleagues reported an overall postoperative complication rate of 29.5% and a 7.2% transplanted kidney failure rate (17). Other complications included prolonged ileus (10.9%), ureteral stricture (7.9%), urinary tract infection (3.6%), hemorrhagic complications (7.2%), and renal vein thrombosis (3.6%) (17). In their cohort of 52 patients, Tran and colleagues report a major complication (Clavien-Dindo Grade 3a or higher) rate of 12%, none of which were Grade 4 or 5 complications (62).

TUU

TUU, in which one ureter crosses the midline to join the contralateral ureter, is a technique often reserved for lengthy ureteral defects and has been used most often in the setting following resection of metastatic abdominopelvic malignancies (64). Popularized by Hendren in the 1970s, TUU was mostly utilized in pediatric populations (65). Since its success is limited by viability of the recipient ureter, contraindications to TUU include retroperitoneal fibrosis or stricture of the distal recipient ureter (64). Overall, TUU is limited to situations when other ureteral reconstructive techniques may not be available.

One of the benefits of TUU is the relative simplicity of the procedure compared to other techniques used for reconstruction of lengthy ureteral defects. The donor ureter of the injured unit is translocated to the contralateral side, usually above the level of the inferior mesenteric artery (64). The recipient ureter is mobilized medially, and an end-to-side anastomosis is completed with the donor ureter. Some authors note key principles to successful TUU. For instance, surgeons should perform careful examination of the distal end of the donor ureter to ensure that the ureter is non-ischemic (64). When the recipient ureter is mobilized medially to allow for a tension-free anastomosis, the mobilization should not compromise the vascular supply of either ureter (64). The decision of placing a ureteral stent in the recipient ureter, donor ureter, or both is variable, and surgeons may consider it on a case-by-case basis (64,66). There are several contraindications to TUU, such as inadequate length of the donor ureter, as well as history of urothelial carcinoma or nephrolithiasis in the recipient ureter (58,60). This technique is illustrated in Figure 4.

Figure 4 Illustrative demonstration of transureteroureterostomy.

Although the evidence supporting TUU as a method of ureteral reconstruction is limited, several retrospective studies have described its success. In a study by Pisters et al., the authors found no significant difference between preoperative and postoperative GFR in their 12 patients with a mean follow up of 15 months (64). In a study comparing 28 patients undergoing TUU and 17 patients undergoing ureteroureterostomy or ureteroneocystostomy for resection of non-urologic cancers, Joung et al. demonstrated no significant difference in rates of hydronephrosis, azotemia, urine leak, and acute pyelonephritis following surgery (67). In the largest reported series studying 63 patients who underwent TUU, Iwaszko and colleagues showed significant improvement in postoperative GFR in patients (62.8 vs. 71.8), and complications included urine leak (9.5%), bacteremia (6.3%), renal failure (4.7%) (66). Despite its reported success, TUU is an uncommon method for ureteral reconstruction as potential obstruction to the common ureter may cause damage to both renal units. However, it can give surgeons greater flexibility in situations when the bladder cannot be mobilized into a psoas hitch or Boari flap.

Conclusions

Multiple reconstructive techniques have been reported in the literature to repair the ureter following stricture, injury, or other causes of obstruction. While all have exhibited relatively acceptable rates of success, the utility of these techniques depends on various patient and disease specific factors such as reconstruction length, etiology, location along ureter, and patient risk factors. For example, techniques such as ureteroneocystostomy, Boari flap, and psoas hitch are effective methods for treating distal ureteral strictures. However, these techniques may not be suitable for patients with complicated strictures involving the proximal to mid ureter. Surgeons may elect to transpose segments of the gastrointestinal tract to perform ileal ureter and appendiceal ureteroplasty, or they may harvest oral mucosa to perform buccal graft ureteroplasty. In select cases, patients may benefit from more uncommon methods such as renal autotransplantation or TUU.

While the studies discussed in this review provide insights into the various surgical techniques utilized for ureteral reconstruction, certain limitations are important to note. Outcomes differ in criteria, and surgical success has been defined by metrics such as symptomatic relief, resolution of hydronephrosis, preservation of renal function, radiologic evidence of ureteral patency, and more. Many of these studies present retrospective data from a single institution which has its own inherent limitations. Most of these techniques can be executed through open, laparoscopic, and robotic-assisted approaches which further stratifies the current literature. It is important for surgeons to consider these different factors when applying this information to clinical scenarios.

Acknowledgments

We thank Barbara Sturonas-Brown, MFA (contact: sturonasbrown@gmail.com) for providing the illustrations to this manuscript.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-23-236/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-23-236/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (https://amj.amegroups.com/article/view/10.21037/amj-23-236/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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