Antegrade Pyelography Research Articles

A Path Less Traveled: Xanthogranulomatous Pyelonephritis Presenting with Thoracic Empyema and Complicated By Rare Pyeloduodenal Fistula

Xanthogranulomatous pyelonephritis (XGP) is a rare and diffusely destructive variant of pyelonephritis. Diagnosis is made using the characteristic radiological findings of renal enlargement with pelvicalyceal dilatation (the ‘bear paw’ sign) with histological analysis demonstrating replacement of renal parenchyma with foamy lipid-laden histiocytes. Treatment of XGP invariably requires nephrectomy. Two particularly rare complications of XGP are thoracic empyema and pyeloduodenal fistula; this case, to our knowledge, is the first such instance of XGP complicated by both. The patient underwent chest drain placement for treatment of empyema, and, following the identification of the pyeloduodenal fistula on antegrade pyelography, underwent surgical treatment with partial right-sided colectomy, radical nephrectomy, and primary duodenal fistula closure. XGP was subsequently identified on pathological analysis of the removed kidney.

The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries.

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Transient ureteral obstruction after mini-percutaneous nephrolithotomy is associated with stone volume and location: results from a single-center, real-life study

PurposeTo evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones.MethodsWe analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient’s demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization.ResultsOverall, median (IQR) age and stone volume were 56 (47–65) years and 1.7 (0.8–4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time.ConclusionOne out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.

Hybrid technique has lower stricture rates than Wallace and Bricker

IntroductionA clear consensus has not yet been reached on the optimal ureteroenteric anastomosis technique for ileal conduit urinary diversion following radical cystectomy. This study aims to determine the incidence of strictures and their management associated with these anastomosis techniques. MethodsWe conducted a retrospective, single-center study of patients who underwent radical cystectomy and urinary diversion between March 2014 and August 2022. Patients were categorized based on the ureteroenteric anastomosis technique used: Wallace, Bricker, or Hybrid. Strictures were identified through antegrade pyelography following nephrostomy placement. ResultsA total of 141 patients were included in the study, with 60 patients in the Wallace group (42 %), 42 patients in the Bricker group (30 %), and 39 patients in the Hybrid group (28 %). The overall incidence of ureteroenteric strictures was 15 %, with 7 patients in the Wallace group, 11 patients in the Bricker group, and 3 patients in the Hybrid group experiencing strictures. There was no statistically significant difference in stricture rates between the Wallace and Bricker groups (11 % vs. 26 %, p = 0.09) or between the Wallace and Hybrid groups (11 % vs. 7 %, p = 0.73). However, a statistically significant difference was observed between the Bricker and Hybrid groups (26 % vs. 7 %, p = 0.03). The mean time to stricture development was 9.2 ± 3.3 months for the Wallace group, 9.5 ± 3.7 months for the Bricker group, and 12.6 ± 5 months for the Hybrid group (p = 0.407). ConclusionThe Hybrid ureteroenteric anastomosis technique exhibits a lower stricture rate compared to the Bricker and Wallace techniques. It represents a safe and feasible alternative technique.

Ureteroureteral Fistula as a Rare Complication of Ileal Conduit Urinary Diversion: a Case Report

Long-term studies on ileal conduit have shown a complication rate of up to 66%. Fistulas are a rare late complication of ileal conduit. To our knowledge, no data about ureteroureteral fistulas has been published yet. We present the case of a 73-year-old man with non-muscle invasive high-grade urothelial carcinoma of the bladder who failed to BCG due to intolerance and developed a cripple bladder. He underwent a cystoprostatectomy, pelvic lymphadenectomy, and an ileal conduit urinary diversion. Four months after the surgery, a raised creatinine level was discovered. Sonography revealed bilateral hydro-ureteronephrosis. Shortly after, the stomal urinary production became minimal, and a nephrostomy was introduced to the right kidney. As a result, the right- as well as the left-sided hydronephrosis diminished, as assessed by ultrasound. Through a loopogram and anterograde pyelography, a stenosis at the ureteroileal anastomosis as well as a connection between the two ureters was proven. As an endoscopic intervention to resolve the obstruction failed, a re-laparotomy to make a neo-anastomosis from the ureters to the ileal conduit was performed. We suspect that total obliteration of the oral end of the ileal conduit caused fistula formation of the ureters. We would like to address this rare phenomenon as a complication of ileal conduit to be mentioned in the differential diagnosis if the outcome of urine is in question. It is not a simple stenosis of the distal portion of the ureters and demands an adapted surgical reconstructing technique as well.

PD31-03 EFFECTIVENESS OF ENDOUROLOGICAL MANAGEMENT OF URETERAL STENOSIS IN KIDNEY TRANSPLANT PATIENTS: EAU-YAU KIDNEY TRANSPLANTATION WORKING GROUP COLLABORATION

You have accessJournal of UrologyCME1 Apr 2023PD31-03 EFFECTIVENESS OF ENDOUROLOGICAL MANAGEMENT OF URETERAL STENOSIS IN KIDNEY TRANSPLANT PATIENTS: EAU-YAU KIDNEY TRANSPLANTATION WORKING GROUP COLLABORATION Alejandra Bravo-Balado, Angelo Territo, Iulia Andras, Riccardo Campi, Alessio Pecoraro, Vital Hevia, Thomas Prudhomme, Michael Baboudjian, Andrea Gallioli, Isabel Sanz, Jorge Robalino, Paolo Verri, Mathieu Charbonnier, Romain Boissier, and Alberto Breda Alejandra Bravo-BaladoAlejandra Bravo-Balado More articles by this author , Angelo TerritoAngelo Territo More articles by this author , Iulia AndrasIulia Andras More articles by this author , Riccardo CampiRiccardo Campi More articles by this author , Alessio PecoraroAlessio Pecoraro More articles by this author , Vital HeviaVital Hevia More articles by this author , Thomas PrudhommeThomas Prudhomme More articles by this author , Michael BaboudjianMichael Baboudjian More articles by this author , Andrea GallioliAndrea Gallioli More articles by this author , Isabel SanzIsabel Sanz More articles by this author , Jorge RobalinoJorge Robalino More articles by this author , Paolo VerriPaolo Verri More articles by this author , Mathieu CharbonnierMathieu Charbonnier More articles by this author , Romain BoissierRomain Boissier More articles by this author , and Alberto BredaAlberto Breda More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stenosis (US) in kidney transplant (KT) recipients is associated with poorer long-term graft survival. Surgical repair is the standard of care, and endoscopic treatment may represent an alternative for stenosis<3 cm. We aimed to determine the effectiveness and safety of endourological management of US in KT patients and predictors of success. METHODS: A retrospective multicenter study was conducted in four European referral centers, including all KT patients with US managed endoscopically between 2009 and 2021. Clinical success was defined as the absence of upper urinary tract catheterization, surgical repair or transplantectomy during follow-up. RESULTS: A total of 44 patients were included. The median time to US onset was 3.5 months (IQR 1.9-10.8), the median length of stricture was 10 mm (IQR 7-20). Management of US involved balloon dilation and laser incision in 36 (82.5%) and 5 (13.2%) cases, respectively. Clavien-Dindo complications were infrequent (10%) and only one Clavien ≥III complication was reported. Clinical success was 61% at last follow-up visit (mean of 44.6% months). In the univariate analysis, sharp stenosis (vs. flat/concave) was associated with treatment success (RR 0.39, p 0.04), while late onset stenosis (>3 months post KT) with treatment failure (RR 2.00, p 0.02). Figure 1 shows two antegrade pyelograms of ureteral stenosis: A. Sharp or duckbill shape. B. Flat or concave shape. CONCLUSIONS: The success rate of the endoscopic management of ureteral stenosis in KT is 61%. Considering this technique is associated with a minimal level of complications, we conclude that in this setting an endoscopic treatment could be proposed first. Patients with a 10 mm sharp US diagnosed<3 months post KT are the best candidates. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e901 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alejandra Bravo-Balado More articles by this author Angelo Territo More articles by this author Iulia Andras More articles by this author Riccardo Campi More articles by this author Alessio Pecoraro More articles by this author Vital Hevia More articles by this author Thomas Prudhomme More articles by this author Michael Baboudjian More articles by this author Andrea Gallioli More articles by this author Isabel Sanz More articles by this author Jorge Robalino More articles by this author Paolo Verri More articles by this author Mathieu Charbonnier More articles by this author Romain Boissier More articles by this author Alberto Breda More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-02 PROPOSAL AND VALIDATION OF A URETERAL STRICTURE CLASSIFICATION SYSTEM

You have accessJournal of UrologyCME1 Apr 2023MP42-02 PROPOSAL AND VALIDATION OF A URETERAL STRICTURE CLASSIFICATION SYSTEM Eric Cho, Lee Zhao, Michael Witthaus, Ameen Chaudry, Nejd Alsikafi, Benjamin Breyer, Joshua Broghammer, Sean Elliott, Bradley Erickson, Shawn Grove, Jeremy Myers, Andrew Peterson, Keith Rourke, Thomas Smith, Alex Vanni, Bryan Voelzke, and Jill Buckley Eric ChoEric Cho More articles by this author , Lee ZhaoLee Zhao More articles by this author , Michael WitthausMichael Witthaus More articles by this author , Ameen ChaudryAmeen Chaudry More articles by this author , Nejd AlsikafiNejd Alsikafi More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , Joshua BroghammerJoshua Broghammer More articles by this author , Sean ElliottSean Elliott More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Shawn GroveShawn Grove More articles by this author , Jeremy MyersJeremy Myers More articles by this author , Andrew PetersonAndrew Peterson More articles by this author , Keith RourkeKeith Rourke More articles by this author , Thomas SmithThomas Smith More articles by this author , Alex VanniAlex Vanni More articles by this author , Bryan VoelzkeBryan Voelzke More articles by this author , and Jill BuckleyJill Buckley More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The surgical management of ureteral stricture disease is contingent upon multiple factors such as stricture length, location, and etiology. Ureteral strictures are conventionally characterized descriptively. Unlike urethral stricture disease, there is currently no widely adopted classification system. Herein, we aim to propose a ureteral stricture classification system for the purpose of creating a standard nomenclature with the goal of validating classification with reconstructive surgical techniques. METHODS: Consensus was obtained from 14 reconstructive urologists. All reviewers had completed a Society of Genitourinary Reconstructive Surgeons (GURS) fellowship and were in clinical practice. Consensus was formulated regarding three primary elements: length of ureteral stricture (L); stricture segment (S); and modifiers (M). These constituted the cLSM classification system (Table 1). Each reviewer was presented with an image(s) of fluoroscopic studies for 24 various ureteral strictures with no additional clinical history and were tasked with assigning a cLSM grade for each individual clinical vignette. These results were tabulated and interrater reliability was determined by a Fleiss Kappa analysis. Etiology of stricture was included in the final version of the cLSM classification system but was not designed to be included in this analysis (Table 1). RESULTS: Of the 24 ureteral strictures, 11 (45.8%) were proximal, 10 (41.7%) were distal, 2 (8.3%) were mid-ureter and 1 (4.2%) was of overlapping sites. Distal ureteral injuries were assessed with only an antegrade pyelogram hindering a precise length measurement. There was substantial agreement across experts demonstrated by an overall Fleiss Kappa score of 0.677 (0.667 – 0.686) for the 24 clinical vignettes for ureteral length, segment and modifiers. CONCLUSIONS: The cLSM ureteral classification system shows a strong interrater reliability by experienced reconstructive urologists. Consistent nomenclature and application of the classification system will standardize discussion of types of ureteral injuries as well as allow for assessment of outcomes. The final ureteral classification system will include etiology (cLSE) to further characterize ureteral injuries and compare reconstructive operative techniques. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e566 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Cho More articles by this author Lee Zhao More articles by this author Michael Witthaus More articles by this author Ameen Chaudry More articles by this author Nejd Alsikafi More articles by this author Benjamin Breyer More articles by this author Joshua Broghammer More articles by this author Sean Elliott More articles by this author Bradley Erickson More articles by this author Shawn Grove More articles by this author Jeremy Myers More articles by this author Andrew Peterson More articles by this author Keith Rourke More articles by this author Thomas Smith More articles by this author Alex Vanni More articles by this author Bryan Voelzke More articles by this author Jill Buckley More articles by this author Expand All Advertisement PDF downloadLoading ...

Каликовенозная фистула: интраренальное осложнение перкутанной нефролитотрипсии

Bleeding is a serious complication of percutaneous nephrolithotomy (PCNL). A rare cause of gross hematuria is a calico-venous fistula. A clinical case of successful intraoperative diagnosis and treatment of calico-venous fistula during PCNL is presented in the article. Description of a clinical case. A patient J., 53 years old, underwent examination and treatment at the Institute of Urology and Reproductive Health, FGAOU VO I.M. Sechenov First Moscow State Medical University with a diagnosis of staghorn stone of the right kidney, a stone of the left kidney, chronic right-side pyelonephritis. On June 15, 2021, mini-PCNL was performed for the staghorn stone of the right kidney. The procedure seemed to be unremarkable, but during intraoperative antegrade pyelography, the inflow of contrast agent from the lower calyxes into the posterior segmental vein of the right kidney was detected, which was managed by creating sufficient traction of the nephrostomy drainage. Communication of the collecting and venous systems of the kidney is associated with a risk of both severe gross hematuria and urine flow into the venous bed. The urine flow into the bloodstream may result in hemodynamic disturbances, up to collapse followed by cardiac arrest. In order to prevent complications of PCNL it is necessary to analyze the kidney anatomy based on three-dimensional modeling of contrast- enhanced computed tomography. A calicovenous fistula can be a source of risk of bleeding and severe complications. To minimize intraoperative damage to parenchymal structures, an analysis of three-dimensional modeling of a kidney in patients with staghorn calculus based on computed tomography is required, which allows rational planning of surgical tactics.

Рентген-эндоскопическое лечение облитерации уретерорезервуароанастомоза после перенесенной ортотопической пластики мочевого пузыря

Strictures and obliterations of ureteral anastomosis after radical cystectomy with orthotopic neobladder reconstruction occur in 8-13% of cases, mainly in the first 2 years after surgery. According to the European Association of Urology guidelines, open reconstruction is considered the "gold standard" for the treatment of those patients. At the same time, according to various publications, X-ray endoscopic treatment of ureteral anastomotic strictures can be performed, especially in patients who have undergone orthotopic neobladder reconstruction.Three clinical cases of endoscopic treatment of ureteral anastomotic obliteration after orthotopic neobladder formation are presented. In all patients, nephrostomy tube was initially put due to acute pyelonephritis. Obliteration of the ureteral anastomosis was diagnosed by contrast-enhanced multispiral computed tomography and antegrade pyelography. The length of obliteration in all patients did not exceed 1.0 cm. The recurrence of the bladder cancer was excluded. After percutaneous opacification of the pelvicalyceal system and advancement of two guidewires ("working" and "safety") to the level of ureteral obliteration, a catheter with a built-in fiber optic light source was put in antegrade fashion along the "working" guidewire to the area of obliteration. During transurethral inspection of the reservoir, the distal end of the light source was visualized and the reservoir wall was cut "to the light" using electrosurgery (n=2) and a thulium fiber laser (one case). For adequate kidney drainage, two internal stents of 6 Fr were put for a period of 6 months in two patients and for 2 months in another case.All patients had an adequate diameter of the ureteral anastomosis after removal of the stents. In two cases, an adequate passage of the contrast agent through both ureters was maintained for 42 and 37 months after procedure (according to the follow-up computed tomography and excretory urography). One patient had an attack of acute pyelonephritis 2 months after the removal of internal stents due to recurrent stricture. After repeated endoscopic ureteral recanalization with putting of two internal stents for a period of 6 months, no recurrence of the stricture was observed during 28 months of follow-up.Endoscopic treatment of both primary and recurrent short ureteral anastomotic obliterations in patients with orthotopic neobladder allows for adequate ureteral patency, provided that two internal stents are left in place for 6 months.

Management of hydronephrosis after radical cystectomy and urinary diversion for bladder cancer: A single tertiary center experience.

To clarify the incidence of postoperative hydronephrosis and verify the validity of diagnostic and therapeutic approaches for hydronephrosis after cystectomy and urinary diversion for bladder cancer. Totally, 290 patients receiving urinary diversion from 2005 through 2017 with complete data were enrolled, including 258 (89.0%) with an ileal conduit and 32 (11.0%) with an ileal neobladder. Postoperative radiographic images were reviewed. In patients with postoperative hydronephrosis, antegrade pyelography and ureteroscopy were performed to exclude malignant etiology. Balloon dilation and open surgical revision were performed according to the conditions. Forty-six patients (58 renal units) developed postoperative hydronephrosis. The cumulative incidence was 11.4% by a median follow-up of 59.5 months. Ureteral recurrence was detected by antegrade examinations in two patients, whereas malignant strictures were subsequently revealed in three patients. Thus, malignant etiology was found in hydronephrosis in five renal units (12.8%) of five patients (16.1%). The median times to diagnosis of hydronephrosis were 0 (interquartile range [IQR] 0-4) and 14 months (IQR 9-12) for benign and malignant strictures, respectively (p = 0.003). Of them, 31 patients (39 renal units) received interventions. Balloon dilation was performed in 13 renal units with benign strictures, and was successful in two (15.4%). Open surgical revision was performed in eight patients (11 renal units), including two with failed balloon dilation, all of which was successful. Postoperative hydronephrosis is potentially associated with recurrent disease. Accurate differential diagnosis is challenging although antegrade procedures may be helpful in some cases. Open surgical revision is highly effective to treat benign strictures.

Totally intracorporeal robotic ileal ureter replacement: focus on surgical technique and outcomes

The aim of the present study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations. Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences. Median operative time was 270 (range 240-300) min. No Clavien-Dindo complication >2 was collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found. Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Retrograde endoscopic assisted percutaneous treatment of urinary fistulas after partial nephrectomy

Background. Urinary fistulas (UFs) are one of the most significant complications after partial nephrectomy. Placement of an ureteral stent eliminates urine extravasation in the majority of patients. However, some of them have persistent UFs despite upper urinary tract drainage. Such cases require retrograde injection of fibrin glue into the renal cavity through a ureteroscope or via the percutaneous approach. Some authors reported cases of simultaneous use of 2 stents and percutaneous cryoablation of the fistula, but these techniques are rare and, therefore, it is problematic to evaluate their efficacy.Objective: to evaluate the results of the new treatment method for the elimination of persistent UFs using the retrograde endoscopic percutaneous approach.Materials and methods. This study included 5 patients (3 males and 3 females) with UFs developed after kidney resection. Mean age of the patients was 55.8 years. The tumor size was 2.5 to 4.8 cm; mean R.E.N.A.L. score was 7.8. All patients had earlier undergone minimally invasive partial nephrectomy; the time between surgery and UF development varied between 3 and 10 days. Four out of 5 patients had a large amount of discharge from their paranephral drainage system, examination of which confirmed high creatinine level. Patients underwent flexible ureteropyelography in the lithotomy position. During this procedure, we identified the damaged calyx and then performed percutaneous puncture targeting the distal end of the endoscope at this calyx, ensuring that the tip of the needle appeared in the paranephral cavity in front of the injured calyx. Using the flexible ureteroscope, we inserted the needle into the pelvis, dilated the puncture opening along the string, and installed a nephrostomy drainage system (12 Fr). Then the endoscope was removed and the ureter was additionally drained with a stent. The stent was removed after 8-10 days with subsequent antegrade pyelography. If there was no extravasation, the nephrostomy tube was removed and the patient was discharged from hospital to continue treatment in outpatient settings.Results. All patients with UFs resulting from partial nephrectomy was successfully operated on. No complications were registered. The mean surgery time was 45.0 ± 20.5 min (range: 40-65 min). Only two patients had some discharge from the fistula within 1 day after nephrostomy tube removal and it stopped without any additional interventions. Three patients had their fistula healed immediately. The treatment efficacy during the whole follow-up period of 18 ± 4 months (range: 6-26 months) was 100 %.Conclusion. Ureteral stenting ensures elimination of UFs in the majority of patients after partial nephrectomy. In individuals with persistent UFs, retrograde endoscopic percutaneous drainage of the pelvicalyceal system is the method of choice, because it allows rapid and effective treatment of UFs.

Complications and surgical results of stone-directed antegrade pyelography compared to the retrograde pyelographic access method in percutaneous nephrolithotomy using ‘bull’s eye’ technique: A randomized clinical trial

Objectives: This study aimed to evaluate the differences in outcomes and complications in stone-directed antegrade pyelography using the ‘bull’s eye’ technique in patients with renal stones versus the conventional method of percutaneous nephrolithotomy (PCNL). Although conventional PCNL access using retrograde pyelography is useful, it is time-consuming and may cause postoperative discomfort. Herein, we report our experience in the application of this new technique. Methods: Between January 2017 and June 2018, 100 patients participated in this randomized clinical trial. Stone-directed antegrade pyelography using the ‘bull’s eye’ technique under fluoroscopic guidance was used for percutaneous access in the intervention group. The second group, consisting of those who had undergone conventional PCNL using retrograde pyelography and ‘bull’s eye’ technique in the same period, were considered as the controls. Pre- and postoperative laboratory examinations, surgical results and complications were recorded and compared between the two groups. Results: A single calyceal puncture in partial staghorn and staghorn stone patients was sufficient in 72.2% of the antegrade group and in 78.9% of the retrograde group ( p=0.69). The double-puncture technique was necessary for 71.9% of renal pelvis stones in the antegrade group and for 9.4% in the retrograde group ( p&lt;0.001). The antegrade approach reduced the mean operative time and analgesic requirement significantly ( p&lt;0.001). No statistically significant difference, however, was found between the two groups regarding stone migration to the ureter, radiation time and postoperative complications. Conclusions: The stone-directed antegrade approach using the ‘bull’s eye’ technique is a safe and accurate method in PCNL access in patients with radiopaque and semi-opaque renal stones.

Minimal renal pelvis dilation in cats diagnosed with benign ureteral obstruction by antegrade pyelography: a retrospective study of 82 cases (2012-2018).

The aim of the study was to describe renal pelvis (RP) and ureteral ultrasonographic measurements in a population of cats with confirmed benign ureteral obstruction (UO) by antegrade pyelography. The secondary objective was to further describe clinical findings associated with minimally dilated obstructed kidneys in an attempt to better understand its occurrence. Retrospective case series of cats diagnosed with benign UO were confirmed by antegrade pyelography. Medical records were reviewed and signalment, diagnostic imaging results, serum creatinine (SCr) concentration and urine culture results were recorded. Each obstructed kidney was categorized into two groups: group 1 included all RP measurements ⩽4 mm and group 2 included all RP measurements >4 mm. A total of 82 cats with 114 obstructed ureters met the inclusion criteria. Fifty (61%) cats had a unilateral UO and 32 (39%) had a bilateral UO. Thirty (26%) kidneys were included in group 1 while 84 (74%) were included in group 2. Nine (8%) kidneys had an RP dilation ⩽2 mm. Median RP and ureteral diameters were 6.6 mm (range 1.1-37.0 mm) and 3.2 mm (range 0.0-11.0 mm), respectively. RP size correlated positively with ureteral diameter in the study population (P <0.0001), but not in group 1 when analyzed separately (P = 0.47). UO was secondary to stones in 80 (70%) ureters. Seventeen (21%) cats had a positive urine culture. At admission, 79 (96%) cats were azotemic with a median preoperative SCr concentration of 444 µmol/l (range 108-1326 μmol/l). The mean (95% confidence interval [CI]) preoperative SCr concentration was significantly higher in group 1 (762 µmol/l [498-1165 μmol/l]) than in group 2 (409 µmol/l [333-502 μmol/l]). RP size in the two groups correlated negatively with preoperative SCr concentration (P = 0.0002). Feline UO may be associated with minimal RP dilation and the severity of RP and ureteral dilation can be highly variable. Absence of significant RP dilation does not rule out UO in cats.

Totally intracorporeal robotic ileal ureter replacement: focus on surgical technique and outcomes.

Background Aim of the study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations. Methods Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as, perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences. Results Median operative time was 270 (range 240-300) min. No Clavien-Dindo complications >2 were collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found. Conclusions Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Laparoscopic “reverse 7” ileal ureteral replacement for bilateral extensive ureteral strictures performed completely intracorporeally: the initial experience

To present our initial experience and evaluate the feasibility of the novel technique of completely intracorporeal laparoscopic "reverse 7" ileal ureteral replacement (IUR). Between December 2018 and September 2019, two patients underwent completely intracorporeal laparoscopic "reverse 7" IUR, which were female patients with bilateral extensive ureteral strictures (BEUS) secondary to radical hysterectomy and pelvic lymph node dissection for cervical cancer and postoperative radiotherapy. Antegrade pyelography and retrograde pyelography showed BEUS preoperatively. The novel technique was performed successfully by the same surgeon without conversion to open surgery. The operating time of each patient was 420min and 410min, respectively. Meanwhile, the estimated blood loss of each patient was 120ml and 100ml, respectively. There were no major complications during the perioperative period. After ureteral stent was removed, antegrade pyelography postoperatively revealed excellent drainage with the resolution of hydronephrosis in both patients. After removing of ureteral stent and nephrostomy tube, no patients have a complaint about the donor site or the onset of flank pain. To our knowledge, we present the initial experience with completely intracorporeal laparoscopic "reverse 7" IUR. With initial follow-up outcomes, this novel minimally invasive technique appears to be feasible and efficacious in treating BEUS in carefully selected patients.

Percutaneous Nephrostomy Catheter Misplacement into Inferior Vena Cava in a Patient with a Horseshoe Kidney.

Background: Percutaneous nephrostomy (PCN) is commonly indicated for upper urinary tract drainage in case of obstruction or fistula. Only a few cases of PCN catheter misplacement into the inferior vena cava (IVC) have been published. Case Presentation: We report a case of a PCN catheter misplaced into the IVC through a fistula between the urinary tract and an ipsilateral renal vein in a patient with horseshoe kidney, after bedside urgent replacement for hemorrhage and hemorrhagic shock. Conclusion: Although a nephrostomy Foley catheter can be used for adequate urinary drainage and hemostatic purposes after percutaneous nephrolithotomy, its placement should be always verified through antegrade pyelography and particular care should be used for horseshoe kidneys. In case of massive hemorrhage, after temporary closure of the PCN catheter, the cause of bleeding should be investigated with urgent angiography or contrast-enhanced CT scan and promptly treated.

Risk factors in the prediction of long-term patency of Resonance metallic ureteric stent in malignant ureteric obstruction.

ObjectivesCancer is the second leading cause of death globally in 2018 with an estimated 9.6 million deaths. The costs of managing malignant ureteric obstruction (MUO) is a significant burden to any healthcare system. However, the management of MUO has long been a challenge for urologists. The standard options of percutaneous nephrostomy or polymer double J stents are fraught with problems. We report a large patient series with long‐term follow‐up in the use of Resonance metallic ureteric stents to relieve MUO, and identification of risk factors associated with stent failure.Patients and methodsAll patients with MUO who were arranged to have Resonance metallic ureteric stent insertion at two university hospitals were included in this cohort study, starting from June 2011 to July 2016. Data were retrieved retrospectively. The primary outcome was the total duration of stent patency before stent failure due to malignant disease progression. Stent failure was defined as ureteric obstruction identified on imaging (functional radioisotope scan or antegrade pyelogram), acute renal failure resolved by subsequent percutaneous nephrostomy, or any other cause requiring stent removal prematurely. Secondary outcomes were identification of factors associated with stent failure, grade III or above complication, and development of a risk‐adopted model to predict metallic ureteric stent patency rates in MUO patients. Median duration of functioning metallic ureteric stent was determined with Kaplan‐Meier survival curve.ResultsA total of 124 renal units in 95 patients with MUO were eligible for the study, with a median follow‐up period of 22.9 months. About 106 (85.5%) renal units had successful metallic stent insertion, of whom 41 (33.1%) renal units ultimately progressed to ureteric obstruction despite the metallic stents, and required subsequent insertion of nephrostomies. Median duration of functioning metallic ureteric stents was 25 months. Female gender (HR 3.0, 95% CI: 1.3‐7.2, P = .014) and suspicious bladder lesion (HR 2.9, 95% CI: 1.4‐6.2, P = .005) were independent risk factors for stent failure, respectively. Stratifying patients into low (0 risk factor), intermediate (1 risk factor), and high (2 risk factors) risk groups, we found that this could predict the duration of stent patency in MUO with the metallic stents. (Low risk: 30.3 months vs intermediate group: 17.8 months vs high risk: 4.9 months, P < .001).ConclusionResonance metallic ureteral stents are able provide a median of 25 months of ureteric drainage in patients with MUO. Determining whether a patient has one or both risks factors (female gender and bladder lesion) will allow one to estimate the duration of metallic stent patency, which in turn may aid in determining cost‐effectiveness in individual patients.

V11-07 ROBOTIC-ASSITED TRANSPLANTED URETERAL STRICTURE MANAGEMENT

You have accessJournal of UrologyTransplant, Misc GU Cancers & Bladder Reconstruction (non-cancer) (V11)1 Apr 2020V11-07 ROBOTIC-ASSITED TRANSPLANTED URETERAL STRICTURE MANAGEMENT Begoña Etcheverry Giadrosich*, Andreu Alabat Roca, Lluis Riera Canals, Maria Fiol Riera, Sergi Beato Garcia, and Francesc Vigués Julià Begoña Etcheverry Giadrosich*Begoña Etcheverry Giadrosich* More articles by this author , Andreu Alabat RocaAndreu Alabat Roca More articles by this author , Lluis Riera CanalsLluis Riera Canals More articles by this author , Maria Fiol RieraMaria Fiol Riera More articles by this author , Sergi Beato GarciaSergi Beato Garcia More articles by this author , and Francesc Vigués JuliàFrancesc Vigués Julià More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000945.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract complications are relevant source of morbidity and mortality after kidney transplantation (KT). Ureteral stricture (US) is the most common urinary complications (0,6%-10,5%). The aim of this video is to present a minimally invasive technique using Da Vinci Robot for the ureteral reimplantation. METHODS: We present three patients with distal US after KT managed by a robot-assisted ureter reimplantation. The first case was a 29 years old man, transplanted on 2018. A Lich-Gregoire extravesical anastomosis was performed, a ureteral stent was placed. At third month he presented renal failure. The second one, was a 59 years old man, he received KT on 1984. A Politano-Lead better intravesical anastomosis was performed, without ureteral stent. He presented worsening renal function after 35 years. The third one was a 67 years old man, transplanted on 2018. A Lich-Gregoire extravesical anastomosis was performed and ureteral stent was placed. He presented an obstructive pyelonephritis two months later. In the three cases an ultrasound demonstrated hydronephrosis, needing the placement of a nephrostomy. The anterograde pyelography showed a distal US. The third patient was treated unsuccessfully with percutaneous balloon dilation. We present three robotic ureterovesical reimplantation after kidney transplant. We present two different ways to visualization the ureter. In the first patient serum through nephrostomy tube was instilled. In the others 2 patients, indocyanine green through nephrostomy tube was instilled and visualized using Firefly system. The ureteral end is spatulated and the anastomosis to the bladder is done with monocryl 4/0 suture. In the first and second patient, an ureterovesical reimplantation according to the Lich-Gregoir technique was performed. We left a 4,8 Ch, 12cm in the first and third patient. RESULTS: Overall, the mean operative time was 149 minutes. Median estimated blood loss was about 70mL. Anterograde pyelography showed good pass of the contrast medium through the ureter until the bladder in the three patients. Serum creatinine value and ultrasound remained stable, with a median follow-up of 7 months.The nephrostomy tube was removed within 2 months.The patients were discharged within 5 days. There were no recurrences neither urological complications. CONCLUSIONS: Minimal invasive Robotic approach for the management of ureteral stricture after kidney transplantation is safe and helpful. The instillation of saline solution and/or indocyanine green may assist with identification of the ureter and the stricture. Source of Funding:. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1016-e1016 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Begoña Etcheverry Giadrosich* More articles by this author Andreu Alabat Roca More articles by this author Lluis Riera Canals More articles by this author Maria Fiol Riera More articles by this author Sergi Beato Garcia More articles by this author Francesc Vigués Julià More articles by this author Expand All Advertisement PDF downloadLoading ...

"Double-Lumen Valve-Controlled Intra-Operative Pyeloplasty Stent (VIPs)": A New Technology for Post-Pyeloplasty Stenting - Proof of Concept Study in a Preclinical Large Animal Model.

BackgroundPyeloplasty is a common surgical operation with a high success rate. However, significant challenges are to be optimized in the design of stenting systems in order to improve perioperative monitoring of urine drainage and enhance patient and family comfort through easier post-operative care.Materials and MethodsIn a preliminary study in six pigs, handling, mechanical and functional features of this stent system were tested. In our main study, six double-lumen stents (230 mm long each) and 6F/9F external diameter were implanted through the ureteric walls of six domestic pigs to allow postoperative drainage and monitoring following ureteroureterostomy. After a 7-day survival period, monitoring with intravenous antibiotic coverage, and pain control, contrast antegrade pyelogram, under valve control, and renal ultrasonography were conducted and stents explanted and the animals were then euthanized.ResultsThe double-lumen valve-controlled stent supported the healing of the neo anastomoses and helped to monitor perioperative urine drainage and perianastomotic leakage accurately. It also guided a well-controlled more informative radiological contrast-supported imaging before removal of the stents that confirmed the healing of the neo anastomotic site and no leak formation. The double-lumen system demonstrated high feasibility regarding its insertion, functionality, and removal capacities. The excellent flexibility of the individual stents allowed exact anatomically controlled implantation.ConclusionThe double-lumen valve-controlled stent system was studied in a porcine model, which demonstrated its feasibility. Preclinical experience revealed favorable results concerning stent implantation, operability and functionality, in the perioperative management of pyeloplasty or ureteric surgery.