Bilateral Ureters Research Articles

A Case of Bilateral Complete Double Renal Pelvis and Ureter with Ectopic Ureterocele Diagnosed during Total Laparoscopic Hysterectomy

A Case of Bilateral Complete Double Renal Pelvis and Ureter with Ectopic Ureterocele Diagnosed during Total Laparoscopic Hysterectomy

Renal adysplasia in fetus: A rare autopsy case report

Renal adysplasia is rare, occurring in only one per 10,000 births. Ultrasonography at 21 weeks of gestation in 33 years woman showed cystically enlarged left kidney in fetus and absent right kidney in fetus for which the pregnancy was terminated. On fetal autopsy, left kidney showed multiple tiny cysts. Microscopy of the left kidney showed features of dysplasia and confirmed the absence of right kidney and bilateral ureters. The diagnosis of renal adysplasia (multicystic dysplasia of left kidney and agenesis of right kidney) was made. This case is presented for its rarity. DOI: 10.21276/APALM.1441

A Case of Bilateral Duplicated Ureter - Gross Anatomy

Duplicated ureter is a frequent malformation that occurs in approximately 1 in 20 people. We herein report the detailed case of bilateral duplicated ureter in which two ureters originated from a single renal pelvis and merged just proximal to the ureterovesical junction.

Protective effect of erythropoietin on renal function after releasing of bilateral ureter obstruction in rats and mechanism

Objective To investigate the mechanism of protective effect of erythropoietin (EPO) on renal function after releasing of bilateral ureter obstruction (BUO) in SD rats. Methods Thirty-two SD rats were divided into 4 groups randomly (BUO group, BUO-R group, BUO-R+ EPO group and Sham group; n=8). The BUO model was built by bilateral ureteral ligation. EPO was given to BUO-R+ EPO rats 1 h after releasing of BUO, and then repeated 12, 24, 36, 48 h thereafter and the same volume of normal saline was simultaneously given to BUO-R rats. The urine samples were collected 24 h before death and then blood samples were collected from inferior vena cava. The kidneys at both sides were harvested 72 h after releasing of BUO to examine the effect of EPO on the expression of tumor necrosis factor-α (TNF-α) and interleukin (IL)-6 by immunohistochemistry and real-time quantitative polymerase chain reaction (Real-time PCR). Results The osmotic pressure in BUO-R+ EPO group was higher than that in BUO-R group, while lower than that in Sham group [(1 164±93) vs. (715±76) vs. (1 835±98) mosm/kg, P=0.000]. The hematal concentrations of urea and CREA in BUO group [(58.40±4.63) mmol/L and (277.30±11.26) μmol/L] were higher than those in other three groups, while they were higher in BUO-R+ EPO group [(12.20±2.34) mmol/L and (34.70±4.58) μmol/L] than those in Sham group [(6.40±0.75) mmol/L and (20.50±3.71) μmol/L], but lower than those in BUO-R group [(25.70±3.26) mmol/L and (52.60±7.83) μmol/L], P=0.000. Immunohistochemistry showed the expression levels of TNF-α and IL-6 were strongest in BUO group and weakest in Sham group, while those were stronger in BUO-R group than in BUO-R+ EPO group. Real-time PCR showed that the expression of TNF-α and IL-6 mRNA in BUO group was the most, while that in Sham group was the least, and that in BUO-R+ EPO group was less than in BUO-R group. Conclusion EPO could promote the recovery of renal function by inhibiting inflammatory reaction in BUO-R rats. Key words: Erythropoietin; Ureter obstruction; Kidney; Inflammatory reaction

Cystoscope-Assisted Laparoscopic Resection of Mullerian Duct Remnant in a Male Presenting with Uterus and Vagina

Background and Aim: Mullerian duct remnant (MDR) is a rare condition and is sometimes accidentally diagnosed during surgery for an inguinal hernia and undescended testes. MDR is always found near the seminal duct and conservatively preserved, preventing injury of the seminal duct. However, recent reports have revealed that MDR has the potential to become malignant.1,2 Cases of deaths among male adolescents have also been reported. As such, surgical extirpation of MDR is recommended. Laparoscopic and robotic approaches have been applied as surgical intervention.3,4 In this video, the combination of laparoscopy and cystoscopy to safely extirpate an MDR is shown. Materials and Methods: Case: A four-month-old boy was initially found to have coronal hypospadias and undescended testes. Laparoscopy was performed at 11 months of age because of nonpalpable testes. A left streak gonad and MDR were found to be presenting as a complete uterus and vagina. Chromosomal examination revealed mixed gonadal dysplasia (46XY (23)/45X (7)). A cystoscope showed that the MDR was connected to the prostatic urethra. At 18 months of age, this patient underwent extirpation of the left streak gonad and urethroplasty for hypospadias. Subsequently, resection of the MDR was planned because of repeated urinary tract infections. Operative Findings and Procedure: The patient was placed in a lithotomy position and a cystoscope was used to confirm the fistula orifice at the urethra. A 5 mm, 30° laparoscope was inserted through the umbilical longitudinal incision. Pneumoperitoneum was established at 8 mmHg CO2 inflation. Two 5 mm ports (left upper abdomen and left lower abdomen) and one 3 mm port (right lower abdomen) were inserted. MDR presenting as a complete uterus and vagina was recognized. The bladder was suspended using extracorporeal 3-0 proline insertion. The bilateral uterus ligaments were coagulated and divided using a vessel sealing system (LigaSure Maryland; Medtronic, Inc., Dublin, Ireland). After opening the peritoneal reflection, the distal side of the MDR was carefully dissected using a 3 mm bipolar (RoBi, KarlStorz, Tuttling, Deutschland) to prevent thermal injury of the pelvic nerve. The distal mullerian duct had a vaginal appearance and was connected to the urethra as a fistula. Before ligation of the fistula, the depth of dissection was confirmed using a cystoscope. Under inspection with the cystoscope, the dissected fistula was retracted, and the level of dissection was confirmed. A transfixing 4-0 PDS (Ethicon, Cincinnati, OH) suture was used to ligate the fistula, which was then resected using a vessel sealing system and ligated using an Endoloop (Ethicon). No injury to the bilateral ureter or urethra was recognized. Results and Conclusion: The postoperative course was uneventful. A pathological diagnosis revealed that the resected MDR showed age-appropriate development. The patient has had a good clinical course since the operation. A laparoscopic approach is feasible and low invasive for the extirpation of an MDR, even in infants. The fistula was safely ligated using a combination of laparoscopy and a cystoscope. This combination approach is useful for preventing injury to the urethra. Acknowledgments: We thank Brian Quinn for his comments and help with the article. This study was supported by grants-in-aid for scientific research from the Japan Society for the Promotion of Science (JSPS, No. 25293360 and No. 26670765), JFE (The Japanese Foundation for Research and Promotion of Endoscopy), J-CASE (Japanese Consortium of Advanced Surgical Endoscopy), Foundation for Promotion of Cancer Research, Foundation for Shinnihon Zaidan, a research grant from the President's Discretionary Expenses of Kagoshima University, a research grant from The UBE Foundation, and a research grant from Japan Medical Education Foundation. No competing financial interests exist. Runtime of video: 6 mins 49 secs

Use of the Ileum for Ureteral Stricture and Obstruction in Bilateral, Unilateral, and Single-kidney Cases

To investigate the functional outcomes of ileal ureter replacement for complex ureteral loss, including bilateral and single ureter stricture, as a result of various etiologies. In 2013-2016, 31 patients underwent ileal ureter replacement surgery. The data for their assessments included etiology, combined surgical procedures, ureteral replacement type, postoperative complications, and changes in renal function. The 31 study patients had a median age of 56.0 (range 18-65) years and were followed for a median of 23.6 (range 6.5-43.2) months. There were 14 bilateral, 12 unilateral, and 5 single-kidney cases. The main indication for surgery was ureteral defects after gynecological surgery and radiation in 24 patients (77.4%). The mean operation time was 370.6 minutes and the median hospital stay was 25.2 (range 6-79) days. Various types of ileal arrangement were performed to cover bilateral ureter loss. After 30 days past surgery, 24 patients (77.4%) were in a stable state and 5 (16.1%) had decreased serum levels of creatinine. Short-term complications greater than grade 3 on the Clavien scale occurred in 10 patients (33.3%), and long-term complications occurred in 27 (87.1%). However, all cases were well relieved by conservative care, and surgical intervention was needed in only 1 case. Apart from 2 patients who died because of the progression of cervical cancer, all patients had stent-free status at 22.4 months. Ileal ureter replacement is a useful reconstructive surgery for complex ureteral loss, such as bilateral and single-kidney cases resulting from various etiologies.

Schwannoma in Pelvis: A Diagnostic Dilemma

Schwannoma is the most common benign nerve sheath tumors generally occurring in head and neck and extremities. Schwannomas are very rarely found in pelvic region and are often labeled as gynecological or urological masses in the preoperative workup. Here we present a 40-year-old female patient who presented with micturition difficulty. Initial evaluation by CT and MRI showed a 10-cm pre-sacral mass abutting the bladder and rectum. Biopsy revealed a benign schwannoma. Laparotomy was planned, and we found a 10 × 10 cm mass in pre-sacral space adherent to sigmoid colon, rectum, posterior wall of uterus, bilateral ureters and left internal iliac vessels. Mass was mobilized from surrounding viscera and was excised in toto. Histopathology revealed a 10 × 7×4 cm benign schwannoma. Patient recovered without any complications. Retroperitoneal schwannomas are very rare, and biopsy is required to ascertain the correct diagnosis as radiological features are non-specific. Surgical excision is the only curative option. Most cases will require simple excision or enucleation of the tumor without requirement of major visceral resections.

Preoperatively Dilated Ureters are a Specific Risk Factor for the Development of Ureteroenteric Strictures after Open Radical Cystectomy and Ileal Neobladder

We evaluated preoperative ureteral obstruction as a risk factor for benign ureteroenteric anastomosis strictures in patients who underwent open radical cystectomy and ileal neobladder diversion. A total of 953 patients in whom bilateral ileoureterostomy was performed between January 1986 and March 2009 formed the study population. A nonrefluxing Le Duc technique was applied in 357 consecutive patients and a refluxing Wallace type technique was applied in 596. We defined ureteroenteric anastomosis stricture as the need for specific therapy (eg stenting, dilatation or reimplantation) or as proven loss of renal function. Kaplan-Meier analysis was done to calculate the likelihood of ureteroenteric anastomosis stricture development. Median followup in the study population was 65 months. Preoperatively 109 patients had unilateral or bilateral obstructed ureters. Unilateral or bilateral obstruction developed in 107 of the 953 patients (127 reno-ureteral units, including 63on the right side and 64 on the left side). Of the reno-ureteral units 98 had benign and 29 had malignant ureteroenteric anastomosis strictures. The overall stricture rate due to any cause in preoperatively obstructed ureters was 19.3% at 10 years vs 6.4% in preoperatively undilated ureters. For the refluxing Wallace type technique the 10-year ureteroenteric anastomosis stricture rate was 2.4% for preoperatively undilated and 7.6% for preoperatively obstructed ureters. For the nonrefluxing technique the corresponding rates at 10 years were 14.2% and 35.54%, respectively. Preoperatively obstructed ureters are at significantly higher risk for benign ureteroenteric anastomosis strictures during the postoperative course after ileal neobladder diversion. Most such Le Duc strictures are bilateral and most such Wallace type strictures are unilateral. The risk of ureteroenteric anastomosis stricture after ureteroenterostomy using the nonrefluxing technique is threefold the risk of the refluxing technique. There was no preponderance of left ureteroenteric anastomosis strictures after each technique.

Isolated bilateral simplex ureteric ectopia: Bladder capacity as an indicator of continence outcome

Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ureteric reimplantation alone does not accomplish continence in all. Identifying the patients needing additional procedures for continence early could prevent multiple operations. Potential preoperative indicators for postoperative continence are explored in eight BSEU girls without cloacal, anorectal, or spinal anomalies. With institutional approval, all patients with BSEU between 1985 and 2012 were retrospectively reviewed. Cystoscopy determined the site of ureteric ectopia (6 of 16 at the bladder neck [BN], 5 of 16 below the BN, and 5 of 16 in the distal urethra). Bladders were assessed by a combination of ultrasound, urodynamics, micturating cystourethrogram, cystoscopic, and intraoperative observations. Expected bladder capacity for age (EBCA) was calculated by 30ml+(30ml×age in years) or 38ml+(2.5ml×age in months) for children greater or less than 2 years, respectively. Continence outcomes were appraised at a minimum of 4 years. The small number of patients precludes credible statistical analysis and therefore raw data are presented. Patients underwent cross-trigonal ureteric reimplantation at 1-5.5 years, in five without BN surgery and in three with a Young-Dees-Leadbetter BN tightening. Of those without BN surgery at reimplantation, four achieved satisfactory continence for their age, but one has had multiple procedures culminating in BN closure, ileocystoplasty, and Mitrofanoff. Among the BN-tightening group, one was in nappies at 4 years, one had residual stress incontinence after two further BN injections, and one proceeded to artificial urinary sphincter after two BN injections. Five patients had significant renal impairment. Patients with satisfactory continence after reimplantation alone and those needing further procedures tended to differ in their preoperative observations of bladder capacity and apparent BN competence. This study suggests preoperative observations of an empty bladder on serial ultrasound and/or a wide-open BN with small or even moderate bladder capacity at cystoscopy to indicate the need for BN surgery. In contrast, children with bladder filling to at least 30% of expected bladder capacity for age on preoperative ultrasound or apposition of the BN at cystoscopy may achieve satisfactory continence after ureteric reimplantation alone. Bladder capacity as an indicator of BN competence can also be correlated to continence outcomes in previously published series. Polyuria associated with renal impairment can exacerbate the challenge for continence. Preoperative bladder capacity appears to be an indicator of inherent BN function and a thorough assessment of the urinary tract by cystoscopy, ultrasound, micturating cystourethrogram, and functional imaging may guide the surgeon on the need for BN surgery at the time of ureteric reimplantation. Where continence remains elusive, patients should be counselled that a further BN injection is occasionally of value although more significant BN procedures are required for most.

Ureter Visualization on Tc-99m DMSA Scintigraphy in Pediatric Patients

Purpose: The aim of this study is to investigate possible reasons of ureter visualization on Tc-99m DMSA scintigraphy. Methods: The planar static renal scintigraphies of pediatric patients (n=2290) who attended for any reason between January 2009 and May 2015 were analyzed retrospectively by the same nuclear medicine physician. In our analysis 15 patients (12 Male (M), 3 Female (F); 0-12, mean: 4 ± 3, 8 years old) were included in the study due to bilateral or unilateral ureter visualization on Tc-99m DMSA scintigraphy. Results: In the visual assessment of scintigraphies, there were 7 patients with bilateral visualization and 8 patients (right in 4 patients, left in 4 patients) with unilateral. Additionally increased background activity was observed in two patients. Cortical defects and/or atrophy of kidneys were observed in 10 (66%) of the patients. The background pathology in these patients were posterior urethral valve (n=3), neurogenic bladder due to meningomyelocele (n=4), vesicoureteral reflux (n=3), urethral atresia (n=2), ureterovesical obstruction (n=1) and unknown (n=2). Conclusion: Ureter visualization on Tc-99m DMSA imaging usually accompanies severe kidney damage and ureteral or bladder pathology. Additionally this finding may point out the patients who could not be corrected completely by the surgical way but this issue has to be evaluated by future studies.

The protective effect of erythropoietin on renal function after releasing of bilateral ureter obstruction in young rat

Objective To investigate the protective effect of erythropoietin (EPO) on renal function after releasing of bilateral ureters obstruction (BUO-R) in young SD rats. Methods From October 2015 to June 2016, forty young SD rats were bought and equally divided into 4 groups randomly (BUO group, BUO-R group, BUO-R+ EPO group and Sham group; n=10) according to random number table. The BUO model was built by bilateral ureteral ligation. EPO (500 U/kg) was given to BUO-R+ EPO rats immediately after releasing of BUO, and then repeated 2d, 4d and 6d thereafter and the same volume of normal saline was simultaneously given to BUO-R rats. The Sham group was prepared in parallel by laparotomy and free dissection of bilateral ureters but not ligated. The urine samples were collected by metabolic cage 24h before death and then blood samples (1 ml) were collected from inferior vena cava. Results The urine osmolarity of Sham group was the highest [(1 794±103)mOsm/kg], BUO-R+ EPO group was (1 257±82)mOsm/kg, and BUO-R group was the lowest [(756±69)mOsm/kg]; Whereas the urine output of Sham group was the lowest [(26±5)μl/(min·kg)], BUO-R+ EPO group was (48±7)μl/(min·kg), and BUO-R group was the highest [(71±9)μl/(min·kg)]; P<0.05. The concentrations of urinary K+ , Na+ and creatinine in BUO-R+ EPO group were [(133.8±5.8)mmol/L, (134.7±4.9)mmol/L and (3 549±482)μmol/L]lower than those in Sham group [(154.7±6.5)mmol/L, (149.3±7.8)mmol/L and (4 537±624)μmol/L], but higher than those in BUO-R group [(112.4±7.2)mmol/L, (106.5±6.3)mmol/L and (2 612±536)μmol/L], P<0.05. The concentrations of hematal K+ , urea and creatinine in three experimental groups were all higher than those in Sham group; of which the hematal K+ , urea and creatinine in BUO group were the highest[(12.1±0.7)mmol/L, (47.6±6.0)mmol/L and (252.8±18.7)μmol/L], the BUO-R group took the second place [(8.5±0.5)mmol/L, (7.8±0.4)mmol/L and (55.2±4.8)μmol/L], and the BUO-R+ EPO group came third [(7.4±0.5)mmol/L, (6.4±0.3)mmol/L and (36.4±3.6)μmol/L], while the Sham group were the lowest [(6.8±0.3)mmol/L, (5.6±0.24)mmol/L and (23.6±2.7)μmol/L]; P<0.05. While the hematal Na+ concentration in BUO group was the lowest [(126.4±5.9)mmol/L], and BUO-R group was the highest [(147.3±4.9)mmol/L], the Sham group was the second lowest [(136.7±4.3)mmol/L], and the BUO-R+ EPO group was the second highest [(141.5±5.7)mmol/L], P<0.05. Conclusion EPO could promote the recovery of renal function and normalize the altered renal water and salt handling function in young BUO-R rats. Key words: Erythropoietin; Ureter obstruction; Renal function

Mini-Laparoscopy for Removal (Partial) of Adnexae at the Time of Hysterectomy

Study ObjectiveTo demonstrate our technique of mini-laparoscopic adnexectomy or salpingectomy at the time of total laparoscopic hysterectomy (TLH). DesignStep-by-step video demonstration of our technique. SettingThe advantages of laparoscopic surgery have been widely recognized, including improved visualization and exposure, reduced operative trauma owing to smaller incisions and gentler tissue handling, and faster postoperative recovery. Continuing technological developments have allowed the use of smaller-caliber instruments while maintaining a high standard of surgical performance. Mini-laparoscopy requires the use of 3-mm or smaller ports. The main advantage of mini-laparoscopy is the reduced incision size, which can translate into a lower incidence of incision-related complications such as postoperative pain, infection, and trocar site herniation, along with superior cosmetic results. Today, in younger patients, prophylactic salpingectomy can be considered instead of adnexectomy, taking into account the well-known benefits of ovarian conservation. Prophylactic salpingectomy involves Fallopian tube removal for primary prevention of epithelial carcinoma of the fallopian tubes, ovaries, and peritoneum in women undergoing pelvic surgery for another indication. Other advantages of this intervention are the avoidance of hydrosalpinx (which affects ∼30% women after hysterectomy), the 7.8% lifetime risk of revision surgery [1], tubal infection, and benign and malignant Fallopian tube tumors. Finally, salpingectomy has no known physiological side effects, is safe and feasible, does not worsen surgical outcomes, does not significantly increase the operative time, and is not related to increased rates of intraoperative and postoperative complications or readmission. InterventionsThe patient is a 44-year-old woman with a history of 2 previous cesarean sections with adenomyosis and endometriosis infiltration of the uterosacral ligaments. After discussion about the risks and benefits of ovarian conservation with prophylactic salpingectomy versus adnexectomy, the patient opted to preserve her ovaries. A TLH with partial removal of the uterosacral ligaments nodules and prophylactic bilateral salpingectomy was performed. To begin, the patient was placed in lithotomy position with Allen stirrups at an angle of approximately 100 degrees. Standard trocar placement was used. A 5- or 10-mm 0° scope was placed at the level of the umbilicus and three 3-mm skin incisions were made for accessory lower quadrant trocar placement: 2 lateral, approximately 3 cm medial to the anterior superior iliac spine, and 1 suprapubic, slightly higher than the line made by the lateral trocars, ensuring that the distance between this port and the camera trocar exceeded 8 cm. This triangulation of the accessory ports allowed for good ergonomics for the surgeon. The procedure continued with abdominopelvic cavity inspection and bilateral transperitoneal ureter identification and eventual adhesiolysis, and then the following steps:1.Coagulation and section of the round ligament bilaterally.2.Opening of the anterior leaf of the broad ligament.3.Fenestration of the posterior leaf of broad ligaments to displace the ureter laterally.4.Bilateral salpingectomy. The tuba-ovarian ligament was first divided at the fimbriae, and then the tube was completely removed from its fimbriated end up to the uterotubal junction, preserving the vascularization of the mesosalpinx as much as possible. The tubes were left attached to the uterus to allow en bloc removal.5.Coagulation and sectioning of the uteroovarian ligaments bilaterally.6.Vesicouterine and posterior dissection.7.Uterine vessel dissection, coagulation, and sectioning.8.Opening of the vagina.9.Uterus extraction by the vaginal route.10.Vaginal closure with laparoscopic figure-eight sutures.The instruments used were a 10-mm scope, a 3-mm bipolar forceps, 3-mm cold scissors, a 3-mm suction-irrigation device and 3-mm grasping forceps. ConclusionMini-laparoscopy is an alternative to classic laparoscopy associated with greater patient satisfaction. Prophylactic salpingectomy has proven to reduce the risk of ovary, peritoneal, and tubal epithelial carcinomas as well as benign tubal diseases, and does not significantly increase the operative time or the incidence of postoperative complications.

Ileal ureteric replacement for bilateral long segment ureteric injuries: a case report and literature review

Objective To report a ileal ureteric replacement surgery for bilateral long segment ureter injury. Methods Data from a patient suffered bilateral long segment uretercic stenosis was reviewed. A 32-year-old female, who underwent radical surgery of cervical cancer and postoperative radiotherapy 1 year ago, complained intermittent low back pain for 11 months and was found renal function abnormality for 3 months. Ultrasound showed bilateral hydronephrosis, and the CT urography showed bilateral middle-lower ureteral stenosis. Preoperative diagnosis was bilateral hydronephrosis with bilateral ureteral obstruction. The patient underwent bilateral ileal ureteric replacement under general anesthesia. Results The surgical procedure was successful and the postoperative recovery was favorable. The operation time was 180 min, and blood loss was 100 ml. The abdominal cavity drainage tube was removed 8 days and the urinary catheter was removed 9 days postoperatively. During 8 months' follow up, the patient showed resolved flank pain with stable serum creatinine. No complication was reported. The CTU 2 months postoperatively showed the hydronephrosis was relieved with normal functioning kidneys. Conclusion Bilateral ileal ureteric replacement surgery might be an effective procedure and viable option for bilateral long segment ureteric injuries. Key words: Ileal ureter replacement; Bilateral; Long segment ureteric injuries

The application experience of 3D laparoscopic operation in the urology

Objectives To explore the application value of 3D (high definition, HD) laparoscopic operation in the urology. Methods 48 cases of operations were completed with the help of Storz 3D HD laparoscopic.Referred to the classic operaions, all the surgeons successfully completed surgery. The operation time, amount of bleeding, postoperative volume of drainage, complications and hospital stays were evaluated. Results The operations were successfully completed with the help of 3D HD laparoscopic except that 1 case was converted to open operation.The operation time was 29-365 min.5 cases were the abdominal cavity after resection of adrenal tumor and radical nephrectomy.The time of simple nephrectomy, subcapsular nephrectomy, renal and ureter full nephrectomy, renal cystdecortication, partial nephrectomy, laparoscopic pyeloplasty was 29~150min, 46~175min, 60~105min, 96~145min, 135~150min, 35~50min, 125min, 105~120min respectively. The time of transperitoneal adrenal tumor resection(1 case), radical nephrectomy(3 cases), ureteral stricture or atresia ureter resection and anastomosis, lysis of adhesions, ureterolithotomy, bilateral ureteral reimplantation, after radical cystectomy and ileal neobladder (bilateral iliac blood vessels lymphadenectomy bladder resection time)and the bladder wall repairing was 175min, 148~164min, 90~140min, 45min, 45~55min, 185min, 246~268min, 30~48min respectively. The time ofrenal pedicle occlusion, anderson hynes anastomosis, end-to-end ureteral anastomosis, ureter suture and bilateral ureter bladder anastomosis was 29min, 90~105min, 40~44min, 10~35min, 82min respectively. The blood loss and postoerative volume of drainage was 10~450mL, 100~500mL. 2 cases were the postoperative bleeding, and postoperative hospital stays were 5~21d. There was no operative death in the group. Conclusions 3D HD laparoscopic operation is suitable for all kinds of operations in the urology, especially for delicate operations.It provides true three-dimensional operative field as well as better using value. Key words: Urologic Surgical Procedures; Laparoscopes

Prevalence of congenital duplication of collecting system in Pakistan

The urogenital system is more likely to have birth defects than any other system. Of all the urinary tract anomalies, Double ureter is the most common one. It may be incomplete (bind ureter) or complete duplication. In order to collect data for this various medical colleges were approached &amp; 120 cadaveric kidney pairs were examined for the presence or absence of double ureters. It was found that 02 out of all examined kidney pairs were showing this anomaly. One pair was having bilateral double ureters while other was showing right sided ureteric duplication.

Serum Neutrophil Gelatinase Associated Lipocalin (NGAL) Outperforms Serum Creatinine in Detecting Sepsis-Induced Acute Kidney Injury, Experiments on Bilateral Nephrectomy and Bilateral Ureter Obstruction Mouse Models.

Serum neutrophil gelatinase associated lipocalin (sNGAL), a promising acute kidney injury (AKI) biomarker produced by renal and non-renal tissues, might be affected by sepsis. We evaluated sNGAL in zero glomerular filtration rate models [bilateral ureter obstruction (BUO) and bilateral nephrectomy (BiNx)] with subsequent cecal ligation and puncture (CLP)-induced sepsis in 6 to 8-week-old ICR mice. We found that sNGAL increased earlier than serum creatinine (Scr) in BiNx/BUO with and without CLP. The earliest time-point of increased sNGAL in BiNx+CLP was 1 h after surgery. Scr, but not sNGAL, was lower at 18 h after BiNx/BUO+CLP compared with BiNx/BUO alone. Compared with BUO, BiNx had higher, and equal sNGAL at 1 to 18 h and 36 h, respectively. Additionally, similar NGAL expression in internal organs (heart, lung, liver, and spleen) and survival rates indicated the comparable severity of BiNx and BUO. Serum interleukin (IL)-6 was increased and correlated with sNGAL in BiNx/BUO with and without sepsis. In summary, we demonstrated: sNGAL is an early AKI biomarker, which is not affected by sepsis; sNGAL is mainly produced by extrarenal sources as demonstrated by the comparable sNGAL in BiNx and BUO; the saturation of renal NGAL re-absorption in BUO is demonstrated by lower sNGAL in BUO at 1 to 18 h, but not at 36 h when compared with BiNx; and a correlation of sNGAL and IL-6 implied sNGAL is a good sepsis prognostic biomarker. Therefore, sNGAL is a more beneficial sepsis-AKI biomarker than Scr.

PD23-09 IS PROLONGED USE OF URETERAL ACCESS SHEATH SAFE?

You have accessJournal of UrologyStone Disease: Surgical Therapy IV1 Apr 2016PD23-09 IS PROLONGED USE OF URETERAL ACCESS SHEATH SAFE? Husain Alenezi, Christopher J. Howlett, Alexander O. El-Warrak, Daniel Olvera-Posada, Marie Dion, Hassan Razvi, and John D. Denstedt Husain AleneziHusain Alenezi More articles by this author , Christopher J. HowlettChristopher J. Howlett More articles by this author , Alexander O. El-WarrakAlexander O. El-Warrak More articles by this author , Daniel Olvera-PosadaDaniel Olvera-Posada More articles by this author , Marie DionMarie Dion More articles by this author , Hassan RazviHassan Razvi More articles by this author , and John D. DenstedtJohn D. Denstedt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1748AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Flexible ureteroscopy (fURS) utilization in the treatment of large and complex upper tract urolithiasis is rising, leading to longer operative times. Ureteral access sheath (UAS) is a widely used ancillary instrument during fURS. UAS can be associated with direct trauma to the ureter together with decreased blood supply due to compression of the ureteral wall. The safety of using UAS for more than 70 minutes is unknown. Our objective is to study the long-term effects of the prolonged use of UAS in an animal model. METHODS Twenty-two female farm pigs (weight 25- 30 kg) with a total of 44 ureters were subjected to an endoscopic procedure under general anesthesia, starting with bilateral retrograde pyelography (RGP) to exclude preexisting ureteral abnormality, followed by insertion of 35 cm 12/14 Fr UAS for 1 hour in one ureter (group 1) then for 3 hours into the contralateral ureter (group 2). Random allocation of the ureters into the groups was performed preoperatively. A single operator performed all procedures and the perceived resistance to UAS insertion was noted. After 4 weeks, bilateral RGP was performed followed by harvesting bilateral ureters, kidneys and bladder and finally euthanasia. Assessment of the RGP and gross pathological appearance of the ureters was performed to identify any ureteral stricture. RESULTS Eighteen animals survived to trial completion (36 ureters). Ureteral stricture was evident in 1 ureter (5.5%) and 5 ureters (27.7%), in groups 1 (1hr) and 2 (3hr) respectively (p= 0.177). However the strictured ureter in group 1 was found to be part of a duplex system on cross-sectioning, thus the difference in stricture rate becomes significant (p= 0.044, OR 1.417, CI 95% 1.042-1.925) when that ureter is excluded. Most of the strictures involved the lower third of ureters (n=5) and the remaining one involved the middle third of the ureter. No resistance was encountered during UAS insertion in 14 ureters (38.9%), while mild and moderate resistance were encountered in 20 ureters (55.6%) and 2 ureters (5.6%), respectively. The likelihood ratio of ureteral stricture was 7.174 with increasing resistance (p=0.028). In univariate analysis, resistance to UAS was the only significant predictor of stricture formation (p=0.049, OR 8.9, CI 95% 1.01-78.47). CONCLUSIONS In this study, the prolonged indwelling time of UAS was associated with increased rate of ureteral strictures, while resistance to UAS insertion was a predictor of increased risk of ureteral strictures. Therefore, we recommend limiting the time of UAS use and avoiding UAS insertion if any resistance is encountered. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e509 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Husain Alenezi More articles by this author Christopher J. Howlett More articles by this author Alexander O. El-Warrak More articles by this author Daniel Olvera-Posada More articles by this author Marie Dion More articles by this author Hassan Razvi More articles by this author John D. Denstedt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of erythropoietin on the expression and function of renal aquaporin-2 after release of bilateral ureter obstruction in young rats

Objective To investigate the effect of erythropoietin (EPO) on the expression of aquaporin-2 (AQP2) in the kidney of young SD rats after release of bilateral ureter obstruction (BUO-R). Methods Thirty-two young SD rats were equally divided into 4 groups randomly (BUO group, BUO-R group, BUO-R+ EPO group and Sham group, 8 rats in each group). The BUO model was built through bilateral ureteral ligation.EPO (500 U/kg) was given to BUO-R+ EPO rats at 2 h after release of BUO, and then repeated 6 h, 12 h, 24 h and 36 h thereafter and the same volume of 9 g/L saline was simultaneously given to BUO-R rats.The Sham group was prepared in parallel by laparotomy and free dissection of bilateral ureters but not ligated.Both side kidneys were harvested 48 h (72 h for Sham group) after release of BUO to examine the effect of EPO on the expression of AQP2 in inner medulla by immunohistochemistry, Real-time PCR and Western blot.The urine samples were collected by using metabolic cage before death. Results The osmotic pressure of BUO-R+ EPO group was higher than that of BUO-R group, but lower than that of Sham group (P<0.05). Immunohistochemistry showed that the collecting duct wall thinned and lumen enlarged.After the pictures were analysized by using Image-Pro Plus software, it showed that the expression of AQP2 in collecting duct in BUO group was significantly down-regulated compared with that in Sham group, whereas, it was slightly weaker in BUO-R group and BUO-R+ EPO group than Sham group(P<0.05). These results were further confirmed by adopting Western blot, and the relative quantity of AQP2 in BUO group was also the lowest of the four groups (P<0.05). Real-time PCR showed that the level of AQP2 mRNA in Sham group was (24.30±1.03) folds of BUO group, (10.60±1.05) folds of BUO-R group and (5.70±1.01) folds of BUO-R+ EPO group, respectively. Conclusion EPO could promote not only the recovery of AQP2 mRNA and protein expression but also the recovery of AQP2 function in young BUO-R rats. Key words: Erythropoietin; Ureter obstruction; Aquaporin-2; Kidney

Bilateral ureteral calcification with left kidney hydronephrosis in systemic lupus erythematosus

A 23-year-old woman with systemic lupus erythematosus (SLE) was admitted for evaluation of anemia. She was diagnosed with SLE 2 years earlier after visiting our hospital with swelling and pain in both proximal interphalangeal joints several years in duration. Although symptoms improved while taking prednisolone and hydroxychloroquine, these medications were discontinued after 10 months because of pregnancy. Eight months before admission, she was treated with prednisolone for SLE flare with thrombocytopenia, elevated liver function, and pulmonary congestion after giving birth. After recovery, hydroxychloroquine and mycophenolate mofetil were added, and she has been stable since then. She was hospitalized because of asymptomatic hemoglobin decrease. However, she complained of left flank pain after admission. Physical examination showed no costovertebral angle tenderness. Urinalysis revealed 2+ albumin, many red blood cells per high power field, and many white blood cells per high power field. Laboratory examination revealed hemoglobin 7.3 mg/dL, creatinine 1.3 mg/dL, total calcium 9.0 mg/dL, inorganic phosphate 2.8 mg/dL, parathyroid hormone 77.8 pg/dL, and C-reactive protein 0.04 mg/dL. Computed tomography of the abdomen showed bilateral ureteral calcification and stones with hydronephrosis of the left kidney (Fig. 1). Figure 1 Abdominal CT. (A) Curved multiplanar reconstruction imaging shows bilateral ureter calcification (arrows) with hydronephrosis of the left kidney. (B) Precontrast axial imaging shows left ureter calcification with central lucency (arrow). SLE is a chronic systemic inflammatory autoimmune disease affecting various organ systems. Calcinosis occurs in damaged tissues, and calcification has been reported primarily in the musculoskeletal, cerebral, and vascular systems of SLE patients. Bilateral calcification of the ureters is quite rare; however, when flank pain, hematuria, or azotemia develops in SLE patients, ureteral calcification and obstruction should be considered.

A Case of Acute Renal Failure Associated with IgG4-Related Disease Presenting Both Tubulointerstitial Nephritis and Retroperitoneal Fibrosis

We report a case of IgG4-related disease presenting both tubulointerstitial nephritis and retroperitoneal fibrosis causing acute renal failure in a 63-year-old male. He was admitted to our hospital because of acute renal failure requiring emergent hemodialysis. Computed tomography showed a soft-tissue density mass with an irregular border in the retroperitoneum. The mass involved bilateral ureters and had caused acute renal failure by bilateral hydronephrosis. Because of a history of uveitis and high IgG4 levels, we considered a diagnosis of retroperitoneal fibrosis, IgG4-related disease. Kidney biopsy revealed IgG4-related kidney disease with interstitial nephritis. After relief of urinary obstruction by inserting ureteral catheters into the bilateral ureters, renal function recovered.