Left Ureter Research Articles

Ultrasound Frequency Of KUB Stones In Patients With Flank Pain

Aims and objectives: To find out the frequency of kUB stones in patients with flank pain. Methods: This prospective cross-sectional study was done at the Radiology Department of DHQ Hospital, Gujrat. It includes a total 61 patients who presented with flank pain. The age range of patients was between 21 to 75 years and included 35 males and 26 females. SPSS was then used for Statistical analysis. Frequency of renal tract stones was calculated. Results: - Out of 61 patients who presented with flank pain, stones were present in 45 (73.7%) patients. 17( 27.9%) stones were seen in right kidney, 12(19.7%) stones were seen in left kidney,13(21.3%) in right ureter and 3(4.91%) in left ureter. 
 Conclusion: - Sonography is an excellent modality with many benefits for diagnosing kidney stones it is non-ionizing radiation free, relatively inexpensive, widely available, and simple to use, with a high diagnostic effectiveness. It is concluded patients that are reported with flank pain have kidney stones.

Surgical resection of a massive residual retroperitoneal mass after chemotherapy for a paratesticular rhabdomyosarcoma: a case report

IntroductionParatesticular rhabdomyosarcoma is a rare and aggressive mesenchymal tumor, accounting for only 7% of all rhabdomyosarcomas. It is mainly encountered in children and adolescents. The standard treatment consists of radical orchidectomy with negative surgical margins. However, chemotherapy is recommended to control retroperitoneal micrometastasis. The place of surgery for progressive retroperitoneal lymph node metastases remains controversial. We present a case of paratesticular rhabdomyosarcoma with progressive retroperitoneal lymph node metastases treated with surgery.Case reportWe report a case of a 17-year-old North African male with no particular medical history who presented with a left scrotal mass that had been evolving for several months. Beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase were normal. Scrotal ultrasonography revealed the presence of a 6 cm heterogeneous hypoechogenic tissular mass with cystic areas adherent to the left scrotal wall, which was thickened in some places and vascularized by color Doppler. It exerted a mass effect on the homolateral testicle, which was of average volume. The thoracic–abdominal–pelvic computed tomography scan showed the presence of suspicious paraaortic lymph nodes. The most voluminous one measured 16 × 23 mm2. A left orchidectomy was performed. The final pathology report revealed an 8 cm paratesticular rhabdomyosarcoma of the embryonic type that displaced the testicle without invading it. Without going beyond it, it infiltrated the epididymis, the rete testis, and the albuginea. The surgical margin at the level of the spermatic cord was free. The patient had adjuvant chemotherapy (ifosfamide, vincristine, and dactinomycin). The patient had a challenging paraaortic lymph node dissection since the mass enlaced the left ureter and renal vessels. On histological examination, the paraaortic lymph nodes were metastatic.ConclusionRhabdomyosarcoma is an aggressive malignancy with high metastatic potential. Therefore, only an accurate diagnosis and early treatment can ensure better survival. Surgery in expert hands seems to be a good option for progressive retroperitoneal nodes. However, further studies are needed to determine the place of surgery in this setting.

Diagnosis of Upper Urinary Tract Urothelial Cell Carcinoma by Urine Cytology in a Patient with Valvular Heart Disease: A Case Report

A 58-year-old male was admitted to the hospital with severe gross hematuria and many comorbidities such as rheumatic heart disease and severe mitral valve stenosis. Because of atrial fibrillation, the patient took anticoagulant drug for stroke prevention. The patient was requested to stop anticoagulant agents and received blood replacement therapy for blood loss after hospitalization. Ureterorenoscopy was unable to visualize or biopsy the mass due to a massive blood clot. Urine cytology of left and right ureter showed high-grade urothelial carcinoma (HGUC) and few suspicious cells, respectively. Computed tomography angiography (CTA) of the whole abdomen revealed blood clot in the upper pole calyx and renal pelvis of the left kidney as well as the urinary bladder, but no abnormal enhancing lesion. The patient underwent the standard treatment for upper tract urothelial carcinoma (UTUC) with laparoscopic radical nephroureterectomy (RNU) with bladder cuff excision because the consulted cardiologist suggested to start anticoagulant agents as soon as possible. Surgical pathology analysis revealed high-risk tumors with multiple low grade papillary urothelial carcinoma. The patient required long term follow-up. Here, the authors reported a case of UTUC with valvular heart disease, earlier diagnosed by using only positive urinary cytology, rather than by radiological examinations and/or related symptoms before definite treatment. Keywords: Urine Cytology; Upper tract; Ureter; Ureteroscopy; Urothelial carcinoma; False positive; Nephroureterectomy

Primary ovarian endometrioid stromal sarcoma presenting with reno-ureteral colic

BackgroundEndometrioid Stromal Sarcomas are an infrequent group of mesenchymal tumors that we must take into account in the differential diagnosis despite representing only 0.2% of tumors of the female genital tract, as they can go unnoticed until advanced stages.Case presentationFifty-fourth year-old woman referred from the Urology department due to incidental finding of adnexal mass in MRI during examination after renoureteral colic, in the case of a 50 mm solid cystic mass in LE. MT were within the normal range, and the CT scan observed this mass in contact with the left ureter. The surgery was completed with hysterectomy and contralateral adnexectomy without incident and chemotherapy treatment was not added. The pathological result was ovarian tissue with low-grade endometrial sarcoma. Currently, after two years of follow-up, the patient remains stable without any recurrence of disease.ConclusionsEndometrioid stromal sarcomas are rare tumors that originate in the endometrial stroma, the ovarian location being rare. Management lies in surgical treatment, and adjuvant therapy is sometimes necessary in advanced stages.

A Rare Case in Urology: Inflammatory Myofibroblastic Tumour.

Inflammatory myofibroblastic tumour (IMT) is a soft tissue malignancy with a mixture of myofibroblastic spindle cells with hyalinised stroma and inflammatory infiltrates. We report a case of a 35-year male patient with a 100×90 mm mass located at the posterior wall of the urinary bladder just adjacent to the prostate and rectum. The mass caused grade 3 hydronephrosis in the left kidney and grade 1 hydronephrosis in the right kidney. The patient was operated and the mass lesion was excised completely. Because the left ureter was adherent to the mass, it was excised at the most distal part and uretero-neo-cystostomy was performed as the bladder and the prostate were preserved. Morphology and immunohistochemistry were consistent with IMT. With surgical excision of the tumour, no recurrence or metastases were seen up to 3 years postoperatively. Key Words: Inflammatory myofibroblastic tumour, Bladder, Urinary system, Hydronephrosis.

Malignant Glomus Tumor of the Ureter.

Although glomus tumour is usually seen in the subungual region of the extremities, it may rarely occur in visceral organs. Approximately 1% of all glomus tumours are malignant. Malignant glomus tumours of the urinary system are extremely rare. This paper presents a case of malignant glomus tumour of the left ureter in a 41-year male patient who had undergone a simple left nephrectomy 4 years ago and presented with recurrent macroscopic haematuria. Uretectomy and mass excision were performed. No progression was observed during the 6-month post-operative follow-up. The tumour can be differentiated from other tumours by pathological and immunohistochemical examination following surgical excision. Because there are very few cases, the treatment protocol is not entirely clear. However, complete removal of the tumour is an effective treatment and can prevent local recurrence. Key Words: Malignant glomus tumour, Ureter, Treatment, Urogenital system.

Description of the technique for laparoscopic radical prostatectomy in canine cadavers: 2D vs. 3D camera.

To describe the technique of laparoscopic radical prostatectomy in canine cadavers. Cadaveric study. 8 canine cadavers. Specimens were randomly divided into a 2D or 3D group. The vesicourethral anastomosis (VUA) was performed with 5 mm laparoscopic needle holders. A unidirectional barbed suture was used to complete the VUA with two simple continuous suture patterns. The number of stitches placed, the patency of the anastomosis, and the distance between the VUA and the ureters were recorded. Four dogs were entered into each group. The prostatectomy was completed in each dog following the same technique. VUA were completed with nine stitches (range: 8-10 stitches) for the 2D group and ten stitches (range: 9-11 stitches) for the 3D group (p<0.176). All the stitches were placed full thickness. The VUA was patent in each case. The left ureter was 1.05 cm (range: 0.5 to 1.1cm) from the VUA in the 2D group and 1.8 cm (range: 1.3-1.8 cm) for the 3D group (p< 0.025). The right ureter was 1.5 cm (range: 1 to 2 cm) from the VUA in the 2D group and 1.75 cm (range: 1.3-2 cm) for the 3D group (p< 0.55). Laparoscopic radical prostatectomy can be performed with a 2D or a 3D camera in canine cadavers. The 3D camera results in more accurate placement of the sutures since they were placed further away from the left ureter. Radical prostatectomy with laparoscopy should be considered for dogs.

A misplacement of a ureteral stent into the abdominal aorta: a case report of a rare retrograde ureteral stenting complication

BackgroundCervical cancer is often associated with malignant ureteral obstruction and consequent hydronephrosis. Hydronephrosis caused in this way can be resolved by placing ureteral stents or performing a percutaneous nephrostomy. Complications that may occur during the retrograde ureteral stent placement are usually mild, but serious complications such as stent migration into the cardiovascular system are also possible. Here we present an unusual case where a ureteral stent entered the abdominal aorta during the cystoscopic ureteral stenting, which was resolved by a cystoscopic stent removal kept in check by endovascular catheters.Case presentationsThe 48-year-old female patient was treated in the regional secondary healthcare facility due to bilateral hydronephrosis caused by cervical cancer. The patient had bilateral percutaneous nephrostomies and ureteral stents. Due to the calcification of the left ureteral stent, an urethrorenoscopy with lithotripsy of the calculus in the left ureter was performed in the regional secondary healthcare facility, and the ureteral stent was cystoscopically replaced. The control radiography of the urinary tract showed a misplacement of the left ureteral stent, and a computed tomography showed that the stent was located in the abdominal aorta. The patient was referred to the University Clinical Center of Serbia, where a ureteral stent was cystoscopically removed from the abdominal aorta under the control of endovascular catheters. The patient was in good general condition at all times, with no signs of bleeding, and she was discharged from the hospital on the fourth postoperative day.ConclusionsThe migration of a ureteral stent into the abdominal aorta and the cardiovascular system in general is a rare type of ureteral stenting complication whose treatment requires a multidisciplinary approach. In order to prevent such complications, it is necessary to strictly adhere to the indications for the ureteral stent placement in the case of malignant ureteral obstruction. Also, this procedure should be performed according to the current guidelines and controlled by an X-ray or ultrasound.

Case report on:- A case report on management and outcomes of vesicle calculi with right ureteric calculi

Stone diseases that affect the urinary system include urinary tract stones. One common disorder of the urinary system is stones in the urinary tract. According to where they occur, the four different types of stones are categorized as well as urethra, bladder, kidney, and ureteral stones. The patient healed fast and was released after receiving a series of systematic and successful treatments, including completing the one-stage operation. Whole urinary calculi can be eliminated after a single therapy, and urolithiasis persisting over the entire term is uncommon. After seven days of treatment, the clinical improvement response was outstanding and considerable. After receiving Unani therapy for a month without surgical intervention, a U.S.G. finding was suggestive of the absence of any calculi in the left kidney and ureter. The formulations prevented urinary supersaturation of lithogenic chemicals and proved safe and efficient. Clinical findings: For the past four years, problems included abdomen ache, frequency, hesitation, and a burning sensation while passing pee. There was a history of blood in the urine on several occasions. He then proceeded to Rural hospital Wardha. Diagnostic evaluation: After being admitted, the patient had an abdominal computed tomography (C.T.) scan.The findings revealed right ureteric calculi and vesicle calculi. The results of a routine urinalysis indicate that the blood's WBC count is 4,578/L and that the creatinine (Cr) level is 140 mmol/L. Therapeutic intervention: Catheterization and bilateral nephrostomy were our first treatments, which resulted in grey pyuria. Simultaneously, piperacillin-tazobactam was widely utilized as an anti-inflammatory agent. Outcome: The patient's health has improved once all interventions have been completed. The patient's lower abdomen pain and burning when urinating have subsided, and she is now stable. Conclusion: Rarely occurs urolithiasis with an entire challenging course.

Cancer Arising from Endometriosis

Study Objective Presentation of unique case of postmenopausal patient with previous total hysterectomy, salpingo-oophorectomy and excision of endometriosis who developed cancer originating from endometriosis. Design Case report Setting Endometriosis Referral center Patients or Participants This video presents a 78-year-old G1P1 female with a history of endometriosis who presented with post-coital vaginal bleeding. She had a history of a total abdominal hysterectomy at the age of 46 due to pelvic pain, and later underwent bilateral salpingo-oophorectomy and excision of endometriosis at the age of 56 due to continued pain. She was on hormonal supplementation with transdermal estrogen. Preoperative examination and imaging revealed a 5 cm friable mass at the vaginal cuff and a smaller pelvic mass in the left pelvic sidewall. Interventions The patient underwent multi puncture video laparoscopy. The left pelvic sidewall mass near the left ureter was carefully resected and found to be endometriosis on final pathology. The vaginal cuff mass was also resected. Measurements and Main Results Pathology reported endometriosis juxtaposed with well-differentiated endometrioid adenocarcinoma. Immunohistochemical tumor staining further confirmed gynecological origin. Conclusion The relationship between endometriosis and ovarian cancer has been established, although not fully elucidated. Therefore, among patients with a history of endometriosis, continued regular gynecologic follow up is recommended not only for recurrence but also for possible malignant transformation. Presentation of unique case of postmenopausal patient with previous total hysterectomy, salpingo-oophorectomy and excision of endometriosis who developed cancer originating from endometriosis. Case report Endometriosis Referral center This video presents a 78-year-old G1P1 female with a history of endometriosis who presented with post-coital vaginal bleeding. She had a history of a total abdominal hysterectomy at the age of 46 due to pelvic pain, and later underwent bilateral salpingo-oophorectomy and excision of endometriosis at the age of 56 due to continued pain. She was on hormonal supplementation with transdermal estrogen. Preoperative examination and imaging revealed a 5 cm friable mass at the vaginal cuff and a smaller pelvic mass in the left pelvic sidewall. The patient underwent multi puncture video laparoscopy. The left pelvic sidewall mass near the left ureter was carefully resected and found to be endometriosis on final pathology. The vaginal cuff mass was also resected. Pathology reported endometriosis juxtaposed with well-differentiated endometrioid adenocarcinoma. Immunohistochemical tumor staining further confirmed gynecological origin. The relationship between endometriosis and ovarian cancer has been established, although not fully elucidated. Therefore, among patients with a history of endometriosis, continued regular gynecologic follow up is recommended not only for recurrence but also for possible malignant transformation.

Robotic-Assisted Laparoscopic Excision of Deep Infiltrating Endometriosis with Concomitant Left Ureteroneocystostomy

<h3>Study Objective</h3> To describe the surgical techniques employed to effectively excise deep infiltrating endometriosis involving the ureters and to highlight the successful re-implantation of the left ureter. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is the case of a 45-year-old G1P1001 patient with a history of chronic pelvic pain and endometriosis. She underwent previous exploratory laparotomy due to endometriosis. Her symptoms however recurred and worsened to the point where she started experiencing left flank pain. A CT scan revealed moderate left hydroureteronephrosis to the level of the left adnexa. MRI findings confirmed the left ureter to be encased by pelvic endometriosis causing significant extrinsic compression. <h3>Interventions</h3> Intra-operatively, deep infiltrating endometriosis was noted involving the posterior cul-de-sac, bilateral uterosacral ligaments, with retroperitoneal fibrosis involving bilateral ureters. Retroperitoneal dissection was performed using a medial approach thus identifying the ureters bilaterally. Careful and extensive dissection was then carried out, excising the fibrotic endometriotic nodule from the ureters. The left hydroureter was transected at its most distal and narrowed portion by the urology team. The proximal end for re-implantation was then spatulated. The bladder was mobilized, and a tension free re-implantation was successfully completed after placing a double pig-tail stent in a retrograde fashion. A water-tight re-anastomosis was confirmed. <h3>Measurements and Main Results</h3> The patient recovered well from her procedure and had significant improvement in her pain symptoms when she was reviewed at her postoperative visit. <h3>Conclusion</h3> Despite its incessant, recalcitrant nature, endometriosis affecting the ureters can be effectively resected. Laparoscopic ureteroneocystostomy for ureteral endometriosis is safe, feasible, and can achieve good surgical outcomes leading to effective control of patient's symptoms as was noted in this case.

8103 Extensive Bladder Endometriosis between Ureters

<h3>Study Objective</h3> To present a case of extensive bladder endometriosis located between the two ureters, with complete lesion's resection after bilateral double J stent insertion. <h3>Design</h3> Case report illustrated with video. <h3>Setting</h3> Under general anesthesia the patient was placed in supine position, arms alongside the body and legs 80 grades abducted. Four laparoscopic accesses were performed: one for optics in the umbilical scar and three accessories: both iliac fossa and suprapubic region. <h3>Patients or Participants</h3> 35 years- old patient, with no comorbidities and no previous pregnancy, complained of intense dysmenorrhea and dysuria related to the menstrual period. Physical examination showed vesicouterine thickening and painful retrocervical nodule. The ultrasonography with bowel preparation showed a focal thickening at the bladder wall measuring 3.8 × 3.2cm, involving detrusor and bladder mucosa and in intimate contact with the left ureter. There were also signs of intestinal, uterine, and adnexal endometriosis lesions. <h3>Interventions</h3> The patient was eligible for an endometriosis treatment laparoscopy. It was performed an intraoperative planned cystoscopy to locate the nodule and its relationship with the vesical trigone. As the lesion presented a big extension and was located in the middle of the ureters, two double J stents were inserted. The lesion was excisioned in its integrity and a continuous two layers bladder suture was performed. <h3>Measurements and Main Results</h3> Surgical duration was three hours, with minimal blood loss and no complications. Patient was discharged ninety-six hours after surgery. Pathology report confirmed endometriosis. <h3>Conclusion</h3> Bladder endometriosis may significantly interfere with patients' quality of life. Preoperative cystoscopy and double J stent insertion are fundamental for surgical planning and safety of large endometriotic lesions' resection. A multidisciplinary approach is essential to provide a proper endometriosis treatment.

PO35 Presentation Time: 10:30 AM: Initial Outcomes for Utilization of the Venezia Hybrid High-Dose Rate Brachytherapy Applicator in Definitive Treatment of Locally-Advanced Cervical and Endometrial Cancer

<h3>Purpose</h3> The Venezia gynecological applicator (Elekta) is a hybrid interstitial/intracavitary brachytherapy applicator used to treat cervical cancers. Previous data supporting the use of hybrid brachytherapy comes mainly from the EMBRACE cohort showing increased coverage of the high-risk CTV (HR-CTV) with decreased toxicity. Single-institution data, further supports this technique. We undertook this study to report our initial experience with the Venezia applicator for treatment of locally advanced cervical and endometrial cancers. <h3>Materials/Methods</h3> We retrospectively reviewed 21 patients who received brachytherapy using the Venezia applicator for definitive treatment of cervical or endometrial cancer, treated from June, 2021 to March, 2022. All patients completed chemoradiotherapy followed by brachytherapy boost. For each brachytherapy fraction, patients received sedation and the Venezia applicator was placed. Radiation treatment planning was performed on CT imaging fused to daily MRI, using the Oncentra® treatment planning system. If needles were required for hybrid interstitial brachytherapy, the plan was optimized first without utilizing the needles, to meet constraint to organs at risk (OARs). Subsequently, planning was performed considering the interstitial needles with a focus on optimizing the balance of target coverage and dose to organs at risk. Radiation dose to target volumes and organs at risk were recorded as equivalent dose in 2Gy fractions (EQD2). <h3>Results</h3> Median age was 54 years. Ninety percent of patients were treated for a primary cervical cancer and 10% for primary endometrial cancer. Twenty-nine percent of patients had T1 primary tumor, 48% had a primary T2 tumor and 24% had a primary T3 tumor. The most common histology was squamous cell carcinoma (SCC) in 76% of patients, with adenocarcinoma in 10% and the remaining being undifferentiated or endometrioid. Median follow up was 4.3 months. Thirty-three percent of patients experienced acute toxicity with brachytherapy, all of which were grade 1-2. Twenty-nine percent experienced acute GI toxicity, 10% experienced acute GU toxicity and 10% experienced bleeding. Median brachytherapy dose and fractionation was 28Gy delivered over 4 fractions. Sixty-two percent of patients required hybrid interstitial brachytherapy and the median number of interstitial needles placed was 4. Median volume of the Gross Tumor Volume (GTV) and HR-CTV at first fraction were respectively 5.22cm³(IQR 4.26cm³-10.28cm³) and 27.84cm³(IQR 24.71cm³-40.36cm³⁾. Median HR-CTV D90 and D98 were respectively 85.3Gy(IQR 83.1Gy-88.8Gy) and 76.8Gy (IQR 74.2Gy-79.6Gy). Median GTV D98 was 98.4Gy (IQR 94.3Gy-116.3Gy). Regarding OARs, median D2cc dose to the rectum, sigmoid and bladder were respectively 56.9Gy (IQR 53.7Gy-59.1Gy), 60Gy (IQR 55.9Gy-63.7Gy) and 75.3Gy (IQR 72.3Gy-77.6Gy). Median D1cc dose to the bowel was 50Gy (IQR 46.6Gy-56.8Gy). Median D0.1cc dose to the left and right ureter were respectively 71.8Gy (IQR 62.6Gy-85Gy) and 67.5Gy (IQR 61.6Gy-89.1Gy). <h3>Conclusions</h3> Brachytherapy using the Venezia hybrid applicator was implemented with good dosimetry and sparing of organs at risk. Procedure related complications were mild.

Can AAGL 2021 Endometriosis Classification be Adopted at Preoperative Ultrasound for Reliably Predicting Surgical Complexity?

<h3>Study Objective</h3> to evaluate the use of new AAGL2021 Endometriosis classification (AAGL2021-EC) for staging at ultrasound (ULS) women undergoing surgical approach for deep endometriosis (DE). <h3>Design</h3> single-center retrospective analysis of a prospectively collected database (NCT05291624). <h3>Setting</h3> referral center for endometriosis. <h3>Patients or Participants</h3> consecutive women undergoing surgical approach for DE. <h3>Interventions</h3> at preoperative ULS, the presence of endometriosis was staged by using the AAGL2021-EC (ULS score). Laparoscopic surgical approach was performed within 15 days from the ultrasonographic evaluation. During surgery, the presence of endometriosis was staged by using the AAGL2021-EC (surgical score); the surgeons were blinded to the results of the preoperative ULS staging. All the women were treated by full radical resection of all visible endometriotic lesions. <h3>Measurements and Main Results</h3> 198 patients were enrolled. The mean ULS score was significantly lower than the surgical score (24.6 ± 12.3 vs 35.9 ± 19.6; p<0.001). In 53.5% (n=106) of patients, the severity stage predicted by ULS score coincided exactly with that described at surgery; in 32.8% (n=65) cases, ULS predicted a higher surgical severity stage; in 13.7% (n=27) cases, ULS predicted a lower severity stage. There was a moderate agreement between ULS severity stage and surgical procedures performed according to the distinguished severity stages expected by the AAGL2021-EC (V=0.520; p=0.0003); in particular, the agreement was worse when predicting surgical procedures related to lower (V=0.172; p=0.327) than higher (V=0.412; p=0.005) severity stages (p<0.001). The maximum percentages of exact concordances between ULS and surgical specific localization scores were observed for bladder (83.1%) and vagina (77.2%); the minimum percentage for peritoneum (41.2%). The most relevant underestimation and overestimation in specific localization scores were reported, respectively, for left ureter (46.5%) and right ovary (31.5%). <h3>Conclusion</h3> the ultrasonographic use of AAGL2021-EC moderately predicts surgical complexity; in particular, it tends to be worse when predicting easier surgical procedures expected by AAGL2021-EC severity stages.

Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion.

Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.

S2042 Hydronephrosis: An Unusual Complication of Diverticular Abscess

Introduction: Acute diverticulitis is inflammation due to microperforation of diverticulum in the colon. Ureteral complications from inflammatory bowel disease and colon cancer have been extensively documented, however, hydronephrosis as a complication of diverticulitis is rarely reported. We present a case of a patient with a diverticular abscess who developed left-sided hydronephrosis. Case Description/Methods: A 40-year-old man with a past medical history of laparoscopic cholecystectomy presented with left lower quadrant cramping abdominal pain for 2 weeks. He endorsed constipation for 3 months but denied other symptoms. His physical examination was significant for a palpable phlegmon in the left lower quadrant with mild tenderness to palpation. Laboratory values revealed hemoglobin of 11.4 g/dl, platelet count of 499 k/ul and unremarkable basic metabolic panel. Computed tomography (CT) scan of the abdomen with contrast revealed severe sigmoid diverticulitis and perisigmoid abscess measuring 6 x 2.6 cm (Figure A). It further revealed moderate left hydronephrosis with narrowing of the ureter, concerning for external ureteral compression by the diverticular abscess (Figure B). After multidisciplinary discussion with interventional radiology, urology, and surgery, recommendation was made to undergo surgical intervention after the resolution of acute diverticulitis. The patient was treated with intravenous antibiotics with symptomatic relief and discharged with plan for outpatient surgery. The patient was unfortunately lost to follow-up. He presented 3 months later with perforated diverticulitis, persistent hydronephrosis, colovesical and colocutaneous fistula requiring exploratory laparotomy and repair. His surgical pathology was negative for malignancy and revealed severe diverticulitis. Patient was discharged home in stable condition. Discussion: Ureteral complications in diverticulitis can occur due to the close anatomical location of the left ureter to the descending and sigmoid colon. Common urologic complications include the development of enterovesical fistulas and urinary calculi and obstruction. Physicians should be aware of this association to ensure a repeat CT scan is performed 4-6 weeks after acute diverticulitis to document resolution. Figure 1.: A. CT scan of the abdomen revealing 60.1 x 26.3 mm diverticular abscess. B. CT scan of the abdomen showing left hydronephrosis and dilation of the ureter.

Emphysematous Pyelonephritis, Emphysematous Cystitis, and Emphysematous Ureteritis: A Case Report

Emphysematous urinary tract infections (EUTIs) are rare, severe, and suppurative infections affecting various parts of the urinary tract. We report a case of a 75-year-old male presenting with hematuria and generalized weakness withuncontrolled diabetes mellitus (DM) and hypertension. He tested positive for COVID-19on the second day of hospital admission. A non-contrast-enhanced CT of the abdomen and pelvis revealed gas within the left renal parenchyma, walls of the left ureter, and urinary bladder, establishing the diagnosis of EUTIs. The patient was treated using intravenous antibiotics without any surgical intervention, and four weeks later was stable and transported tolong-term acute care (LTAC) facility. DM is the most common risk factor for the development of EUTIs and Escherichia coli is the most common causative pathogen.

Diagnosis and treatment of left ureteral injury as a rare complication of oblique lumbar interbody fusion surgery: a case report and literature review

BackgroundOblique lumbar interbody fusion (OLIF) surgery has been performed as a minimally invasive lateral lumbar fusion technique in recent years. Reports of operative complications of OLIF are limited, and there are fewer reports of ureteral injuries.Case presentationA 62-year-old Chinese woman diagnosed with "lumbar spondylolisthesis (L4 forward slip, I degree)" underwent OLIF treatment. The surgical decompression process was smooth, and the cage was successfully placed. After the expansion sleeve of OLIF was removed, clear liquid continuous outflow from the peritoneum was found. The patient was diagnosed with a ureteral injury. The urological surgeon expanded the original incision, and left ureteral injury anastomosis and ureteral stent implantation were performed. The patient was changed to the prone position and a percutaneous pedicle screw was placed in the corresponding vertebral body. The patient was indwelled with a catheter for 2 weeks, and regular oral administration of levofloxacin to prevent urinary tract infection. After 2 months, the double J tube was removed using a cystoscope. One year after surgery, the symptoms of lumbar back were significantly improved, and there were no urinary system symptoms. However, the patient needed an annual left ureter and kidney B-ultrasound.ConclusionUreteral injury is a rare complication and is easily missed in OLIF surgery. If the diagnosis is missed, the consequences can be serious. Patients should undergo catheterization before the operation and hematuria should be observed during the operation. We emphasize the careful use of surgical instruments to prevent intraoperative complications. In addition, after withdrawing the leaf in the operation, it is necessary to carefully observe whether a clear liquid continues to leak. If ureteral injury is found, one-stage ureteral injury repair operation should be performed to prevent ureteral stricture.

Novel ureteral navigation with a fluorescent catheter during hemi-hysterectomy in cloacal exstrophy

We used a near-infrared ray catheter (NIRC) in a child with cloacal exstrophy presenting with hematometra and assessed whether the NIRC could help with complicated adhesiolysis during hemi-hysterectomy in children. A 6-French pig tail-type NIRC was inserted into the left ureter with guidance from a cystoscope. Laparoscopic hemi-hysterectomy with fluorescence observation was performed using the VISERA ELITE 2 system. NIRC insertion into the left ureter was not as difficult as expected despite the eccentric position of the left ureter orifice. When we found an enlarged left uterus and fallopian tube, adhesion was extremely severe around them due to chronic inflammation caused by hematometra. When near-infrared rays were applied, a fluorescent ureteral catheter that emitted bright green excitation light was observed on the dorsal side of the enlarged left uterus and fallopian tube. Under ureteral navigation with an NIRC, dissection of the adhesions was performed safely and smoothly. Hemi-hysterectomy and adnexectomy were performed successfully. The patient was doing well 2 years postoperatively without any complications. An NIRC can provide useful real-time visualization of the ureter course and reduce the risk of ureteral damage in children with advanced adhesions.

P13.06: Valve Bladder Diversion, Making Possible a Kidney Transplant

Introduction: The late diagnosis in a patient with posterior urethral valve (PUV) and end-stage kidney disease is a challenging scenario which may need renal replacement therapy and reconstruction of the urinary tract. Reducing recurrent urinary tract infections (UTI) is the main urologic objective in these patients in order to offer them a kidney transplantation (KT). Many factors must be considered to define the best moment to perform the reconstruction, that could be done prior, during or after kidney transplantation. Patient and Method: This is a 5-year-old boy who was admitted for febrile urinary tract infection. During the admission end-stage kidney disease and PUV were diagnosed. The first step was to perform a cystoscopy and valvular ablation. Videourodynamyc studies after surgery showed a bladder’s capacity of 50 ml, low compliance, incomplete emptying associated with high grade bilateral vesicoureteral reflux. Hemodialysis began as renal replacement therapy, antibiotic prophylaxis and anticholinergics were indicated. Four months later, an open vesicostomy was performed due to persistent febrile urinary tract infections. Eleven months after diagnosis, the patient was transplanted using a graft from a deceased donor. At the same time of transplant surgery, the right kidney and ureter were resected through a right hockey stick incision. Two months after transplantation another endoscopic residual valve ablation was done. After seventeen months from kidney transplant, the left kidney and ureter were resected by laparoscopy. Urodynamic studies continued showing high voiding detrusor pressure. While patient kept his bladder diverted, incontinence was managed with five diapers a day and maintained scholar and physical activities. At two years of follow-up, a third valvular endoscopic revision and ablation was performed associated with circumcision and replacing the open vesicostomy with a suprapubic tube. Intermittent opening was indicated and after three months, the tube was removed. Six months after the last surgery, bladder’s capacity improved from 100 ml to 250 ml, bladder emptying has no residual volume and no incontinence. Kidney ultrasonography did not present hydronephrosis and cystography showed no VUR. Twenty nine months after KT the patient remained urinary tract infections free, creatinine level was 0.68 mg/dL and clearance 102 ml/min/1.73 m2. Conclusion: Open vesicostomy is a simple and safe procedure to manage UTI and allows kidney transplant in PUV valve bladders. Urological surveillance after transplant involves clinical assessment, urodynamic studies, endoscopic and reconstructive surgeries. Bladder cycling after transplant improves storage and augmentation procedures may not be needed.