Left Ureteroscopy Research Articles

Immunotherapy Combined with Chemotherapy in Neoadjuvant Therapy for Locally Advanced Renal Pelvis Carcinoma: A Case Report and Literature Review

ABSTRACT Introduction and importance: Upper tract urothelial carcinoma (UTUC), including renal pelvis cancer and ureteral cancer, is highly prevalent in people aged 70 ˜ 90 years. Immune checkpoint inhibitor therapy is a major breakthrough in the field of oncology and is an emerging anti-tumor treatment modality after chemotherapy, targeted therapy and anti-angiogenic therapy. Here we presented a UTUC case who benefited from treatment of immunotherapy combined with chemotherapy in neoadjuvant therapy. Case presentation: A 66-year-old male patient presented on July 2, 2021, with a 3-month history of left-sided abdominal pain and a 2-month history of gross hematuria. To confirm the diagnosis, the treatment of left ureteroscopy was performed under general anesthesia on July 7, 2021. Biopsy pathology revealed urothelial carcinoma, clinical stage cT3-4N1M0, high-risk. Four cycles of neoadjuvant therapy were preoperatively administered with immunotherapy combined with chemotherapy every 21 days. Partial response (PR) was confirmed via imaging after the 4th cycle. The patient underwent radical surgery on November 11, 2021. Postoperative diagnosis: left renal pelvis cancer, pT3N0M0, high risk. Adjuvant therapy was continued after surgery with 4 cycles of GC chemotherapy. After chemotherapy, CTU reexamination and cystoscopy was performed and show no signs of the carcinoma returning. Discussion: Immune checkpoint inhibitors have become first-line therapy for patients with metastatic UC who are not candidates for cisplatin chemotherapy. However, the current literature is inconclusive on the efficacy of neoadjuvant therapy with preoperative immunotherapy combined with chemotherapy. We discuss clinical outcomes and literature reviews for these patients. Conclusion: It’s feasible and safe in PD-L1-positive locally advanced UTUC patients that preoperative neoadjuvant PD-1 inhibitor immunotherapy combined with GC chemotherapy was selected for 4 cycles, after neoadjuvant therapy, further radical surgery was performed, and adjuvant chemotherapy was performed after surgery. Highlight

Symptomatic renal papillary varicosities and medullary nephrocalcinosis

BackgroundNephrocalcinosis is often asymptomatic but can manifest with renal colic or hematuria. There is no reported association between nephrocalcinosis and renal vascular malformations, which may also be a source of hematuria. We herein present a case of a patient with hematuria related to nephrocalcinosis and renal papillary varicosities. These varicosities were diagnosed and successfully treated with flexible ureteroscopy and laser fulguration.Case presentationA 24-year-old female with a history of epilepsy (on zonisamide), recent uncomplicated pregnancy, and new diagnosis of nephrocalcinosis presented with right flank pain and intermittent gross hematuria. Imaging revealed intermittent right sided hydronephrosis. A cystoscopy identified hematuria from the right ureteral orifice. Diagnostic flexible ureteroscopy revealed numerous intrapapillary renal stones and varicose veins of several renal papillae. A 200 μm holmium laser fiber was used to unroof these stones and fulgurate the varicosities with resolution of her symptoms for several months. She later presented with left-sided symptoms and underwent left ureteroscopy with similar findings and identical successful treatment.ConclusionUnilateral hematuria from discrete vascular lesions of the renal collecting system may be obscured by other benign co-existing conditions, such as nephrocalcinosis and nephrolithiasis. Although a simultaneous presentation is rare, flexible ureteroscopy with laser fulguration offers an ideal diagnostic and therapeutic modality for these concurrent conditions if symptoms arise.

V09-08 ROBOT ASSISTED ILEAL INTERPOSITION

You have accessJournal of UrologyUpper Tract Reconstruction (V09)1 Sep 2021V09-08 ROBOT ASSISTED ILEAL INTERPOSITION Tarek Ajami, Raul Martos, Joan Sureda, Agustin Franco, and Antonio Alcaraz Tarek AjamiTarek Ajami More articles by this author , Raul MartosRaul Martos More articles by this author , Joan SuredaJoan Sureda More articles by this author , Agustin FrancoAgustin Franco More articles by this author , and Antonio AlcarazAntonio Alcaraz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002052.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The use of robot assisted techniques is progressively competing with standard approaches in reconstructive surgeries. In this video we present a case of robotic intracorporeal ileal substitution and describe the technique for this minimally invasive procedure. METHODS: The patient was derived to our center due to sepsis after a left ureteroscopy. Imaging revealed total ureteral avulsion that required nephrostomy tube placement. We patient was scheduled months later por robotic ileal interposition. RESULTS: The surgery was done in two phases. The first one included the ileal selection with reconstruction of bowel transit, transposition to the retroperitoneal space below the sigmoid colon, stenting with double J catheter and distal anastomosis to the bladder. The second phase is done in lateral decubitus position. The remnant of the ureter is dissected and sutured to the proximal intestinal end. Total surgical time was 6 hours. The patient had an uneventful postoperative recovery. Both stents were removed at the first month. In the CT scan there was no hydronephrosis and MAG-3 renal scintigraphy showed symmetric radiotracer uptake. CONCLUSIONS: A totally intracorporeal robot assisted ileal interposition is a feasible technique that permits a minimally invasive approach for two different fields. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e689-e689 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tarek Ajami More articles by this author Raul Martos More articles by this author Joan Sureda More articles by this author Agustin Franco More articles by this author Antonio Alcaraz More articles by this author Expand All Advertisement Loading ...

V03-07 TECHNICAL CAVEATS IN ROBOT-ASSISTED RADICAL NEPHROURETERECTOMY WITH RETROPERITONEAL LYMPHADENECTOMY FOR POST CHEMOTHERAPY UPPER TRACT UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVE: Upper tract urothelial carcinoma (UTUC) forms 5% of all urothelial cancers.Urothelial carcinoma has been known for tumors developing lymphatic metastases at a relatively high incidence of 20–30%. Post chemotherapy UTUC with residual lymph nodes represents a distinct surgical challenge because of severe desmoplastic reactions. Radical nephroureterectomy with retroperitoneal lymphadenectomy provides a technically feasible and safe option in such patients. A robotic approach is being increasingly used to perform this complex oncologic procedure in view of its distinct advantages. We hereby present a video of robot assisted radical nephroureterectomy with retroperitoneal lymph node dissection for post chemotherapy UTUC and discuss a few points of technique related to it. METHODS: A 64 year female was incidentally found to have left renal pelvis urothelial carcinoma. CECT KUB revealed a poorly defined mildly enhancing lesion distending the left renal pelvis and left upper ureter. Multiple retrocaval lymph nodes was present. Left ureteroscopy showed upper ureteric and pelvis wall thickening with 2-3 cm sized protruding mass in the left renal pelvis. Biopsy was taken which came out as high grade urothelial carcinoma. Chemotherapy (Gemcitabine + Cisplatin) x 3 cycles was given after which FDG avidity and number of lymph nodes decreased. Transperitoneal robot assisted radical nephroureterectomy with retroperitoneal lymphadenectomy was then performed. Patient was first placed in standard left lateral position. Pneumoperitoneum created using Veress needle. Standard right kidney 7 ports made, 4 of 8 mm, 1 of 5 mm and 2 of 12 mm. Da Vinci Xi docked. Right colon reflected along the white line of Toldt, duodenum kocherized. Right gonadal vein identified, traced up, clipped and divided. IVC dissected, pre caval, para caval and inter aortic caval lymph node dissection done till proximal right common iliac vein (crossing of ureter). Right renal vein dissected gently and lymph node tissue behind renal vein removed. Large lymphatic vessels clipped before cutting.Hemostatsis confirmed. Robot undocked, ports removed and closed, keeping 2, 12 mm assitant port in situ. Patients position changed to right lateral decubitus. Standard left kidney 4 robotic ports inserted. Left ureter and gonadal vein identified and lifted. Pre and para aortic lymph node dissection done till left proximal common iliac artery (crossing of ureter) with the combination of sharp and blunt dissection. Renal vein identified and Hilar dissection done. Gonadal vein along with adjacent lymph nodes traced proximaly upto the renal vein where they were ligated and divided. Lumbar veins draining to renal vein clipped and divided. Stapling of renal hilum with endo GIA stapler was done. Ureteric clipping was done before mobilization of kidney. Kidney mobilized from all its attachements. Ureter mobilized as inferiorly as possible. Camera and right robotic arm instruments switched. Left lower ureter dissected. Left ueretrovesical junction identified. Bladder dissected distally and Stay V - loc 3.0 suture taken. Lower end of left ureter removed along with cuff of bladder wall. Bladder closed in one layer with V loc. Haemostasis ensured & drain placed. Robot undocked & Specimen retrieved through a pfannensteil incision. Abdomen closed in layers and ports removed under vision. Port site closed. RESULTS: Total console time was 425 minutes and blood loss was 50ml. Per urethral catheter and drain were removed on POD 5 and 1 respectively. Patient was discharged in stable condition on POD 2. Histopathology revealed urothelial carcinoma-pT3N0M0. CONCLUSIONS: In post chemotherapy UTUC, severe desmoplastic reaction as well as larger-volume residual disease requires more extensive retroperitoneal dissection. This increase the technical demands of the surgery and make it one of the most difficult and dangerous operations. Robot assisted RNU with RPLND remains a technical feasible and safe option in such patients. Source of Funding: None

Exceptional intrarenal pseudomembranous.

We report the case of a 51-year-old patient, known as hypertensive and type 2 diabetic, admitted to emergency for acute pyelonephritis. She suffered from low back pain in a feverish context. A Uro-scanner showed the presence of a 12mm pyelic renal calculus and a calycal calculus of 6mm diameter responsible for a moderate dilation of left pyelocalictic cavities. First, we performed drainage with a double J probe. Then, in a second step, the left ureteroscopy allowed partial laser fragmentation. The presence of a suspect soft magma prompted us to stop the procedure. After performing a hydatid serology that has returned negative, a laparoscopic left pyelotomy allowed the progressive externalization of the suspect magma. It presented with a greenish, fibrinous, semi-solid shell completely molding the pyelon and the pyelocalicielles cavities. The introduction of the flexible cystoscope through a trocar at the end of the procedure allowed us to check the complete cleaning of the excretory cavities. The anatomopathological study is back in favor of a weakly eosinophilic acellular material with some polyhedral crystals and some inflammatory elements. There were no signs of malignancy. The patient did not present any postoperative complication and did not present a recurrence.

Radiation Dosimetry for Ureteroscopy Patients: A Phantom Study Comparing the Standard and Obese Patient Models.

To determine the effect of obesity on radiation exposure during simulated ureteroscopy. A validated anthropomorphic adult male phantom with a body mass index (BMI) of approximately 24 kg/m(2), was positioned to simulate ureteroscopy. Padding with radiographic characteristics of human fat was placed around the phantom to create an obese model with BMI of 30 kg/m(2). Metal oxide semiconductor field effect transistor (MOSFET) dosimeters were placed at 20 organ locations in both models to measure organ dosages. A portable C-arm was used to provide fluoroscopic x-ray radiation to simulate ureteroscopy. Organ dose rates were calculated by dividing organ dose by fluoroscopy time. Effective dose rate (EDR, mSv/sec) was calculated as the sum of organ dose rates multiplied by corresponding ICRP 103 tissue weighting factors. The mean EDR was significantly increased during left ureteroscopy in the obese model at 0.0092 ± 0.0004 mSv/sec compared with 0.0041 ± 0.0003 mSv/sec in the nonobese model (P < 0.01), as well as during right ureteroscopy at 0.0061 ± 0.0002 and 0.0036 ± 0.0007 mSv/sec in the obese and nonobese model, respectively (P < 0.01). EDR during left ureteroscopy was significantly greater than right ureteroscopy in the obese model (P = 0.02). Fluoroscopy during ureteroscopy contributes to the overall radiation dose for patients being treated for nephrolithiasis. Obese patients are at even higher risk because of increased exposure rates during fluoroscopy. Every effort should be made to minimize the amount of fluoroscopy used during ureteroscopy, especially with obese patients.

A Novel Use of Near-Infrared Fluorescence Imaging During Robotic Surgery Without Indocyanine Green

Abstract Introduction: In addition to enhanced magnification, the da Vinci® Surgical System offers the ability to display near-infrared fluorescence (NIRF) imaging. NIRF imaging has previously been described in conjunction with the administration of the fluorophore indocyanine green (ICG). The principle urologic application of NIRF imaging has been to distinguish normal parenchyma from tumor during partial nephrectomy with intravenous ICG. We describe a novel use of NIRF imaging without ICG to identify intraluminal areas of interest during robotic-assisted laparoscopic (RAL) surgery marked by the white light (WL) of endoscopes. Materials and Methods: A single surgeon performed RAL surgery on six patients aided by NIRF imaging to visualize the areas of interest marked by the WL of endoscopic instruments. Patient 1 underwent RAL partial ureterectomy with a psoas hitch and Boari flap with left ureteroscopy for ureteral stricture. Patients 2 and 3 underwent RAL diverticulectomies with cystoscopy for urothelia...

Endoscopic Management of Submucosal Renal Stones

Introduction: The prevalence of kidney stones in the United States is estimated at 5%–10% and increasing. Stone disease can lead to pain, renal obstruction, and renal injury. Papillary calcifications may also cause chronic flank pain, which can be relieved in up to 85% of cases, with durable outcomes in 60% of cases, by ureteroscopic laser papillotomy. In this study, we aim to describe the endoscopic technique to treat submucosal renal stones. Patients and Methods: A 57-year-old man presented with intermittent left flank pain. Otherwise healthy, his only medical issue has been nephrolithiasis. One previous left ureteroscopy documented the presence of submucosal stones. The patient was first evaluated with a noncontrast computed tomography. Imaging revealed multiple calcifications in the upper, middle, and lower pole, with the largest being 1.0 cm, located on the lower pole. Blood work showed normal serum creatinine and electrolytes, and 24-hour urine collections had high urinary sodium, calcium, oxalate, and uric acid. After an initial consultation, a decision was made to treat the stone burden through flexible ureteroscopy. Results: Several visible papillary calcifications were fragmented with a 200-μm laser fiber set at 800 Hz and 0.8 J until they were released from the papilla. Once free, stones were basketed and removed. When no more papillary calcifications or submucosal stones were identified through endoscopy, fluoroscopy was used to find which renal papilla contained submucosal stones and the procedure was repeated to treat all radiopaque stones. At the end of the surgery, a Double-J stent was placed. The operative time was 2 hours, blood loss was minimal, and there were no intra/postoperative complications. The stent was removed after 1 week and the patient remained asymptomatic at a 2-month follow-up. Stone composition analysis revealed pure calcium stone. Conclusion: Endoscopic management of submucosal renal stones is feasible and safe, it may improve stone-related symptoms, and can provide a stone-free status. No competing financial interests exist. Runtime of video: 6 mins 35 secs

MP73-05 INCREASED RADIATION EXPOSURE DURING URETEROSCOPY IN THE OBESE PATIENT.

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2014MP73-05 INCREASED RADIATION EXPOSURE DURING URETEROSCOPY IN THE OBESE PATIENT. Fernando Cabrera, Richard Shin, Giao Nguyen, Chu Wang, Yi Hsuan Chung, Ramy Youssef, Charles Scales, Michael Ferrandino, Glenn Preminger, Terry Yoshizumi, and Michael Lipkin Fernando CabreraFernando Cabrera More articles by this author , Richard ShinRichard Shin More articles by this author , Giao NguyenGiao Nguyen More articles by this author , Chu WangChu Wang More articles by this author , Yi Hsuan ChungYi Hsuan Chung More articles by this author , Ramy YoussefRamy Youssef More articles by this author , Charles ScalesCharles Scales More articles by this author , Michael FerrandinoMichael Ferrandino More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , Terry YoshizumiTerry Yoshizumi More articles by this author , and Michael LipkinMichael Lipkin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2358AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with urolithiasis are at increased risk of significant radiation exposure. We determined the effect of obesity on radiation exposure during ureteroscopy (URS). Effective dose rates were calculated using an obese and non-obese validated phantom model during right and left URS. METHODS A validated anthropomorphic adult male phantom was positioned to simulate URS. Padding with radiographic characteristics of human fat was placed around the phantom to create an obese model. The phantom represents a male with a Body Mass Index (BMI) of approximately 24 kg/m2 and the obese model represents a male with a BMI of 30 kg/m2. Metal oxide semiconductor field effect transistor dosimeters were placed at 20 organ locations in the obese and non-obese model to measure organ dosages. A portable C-arm was used to provide continuous fluoroscopy to simulate a left and right URS for three 5-6 minute runs each. Organ dose rates were calculated by dividing organ dose by fluoroscopy time. Effective dose rate (EDR, mSv/sec) was calculated as the sum of organ dose rates multiplied by a tissue weighting factor (International Commission on Radiological Protection Publication). Values are reported as mean ± SD. RESULTS The mean effective dose rates were higher for the obese model compared with the non-obese model. The mean EDR during left URS was significantly increased in the obese model at 0.0092 ± .0004 mSv/sec compared to 0.0041 ± 0.0003 mSv/sec in the non-obese model (p = 0.006). The mean EDR during right sided URS was 0.0087 ± 0.0044 and 0.0036 ± 0.0003 mSv/sec in the obese and non-obese model, respectively (p = 0.180). The mean organ doses are listed in the table. CONCLUSIONS Fluoroscopy during URS contributes to overall radiation dose. Obese patients are at even higher risk due to increased exposure during fluoroscopy. Efforts should be made to minimize the amount of fluoroscopy used during URS, especially in obese patients. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e866 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Fernando Cabrera More articles by this author Richard Shin More articles by this author Giao Nguyen More articles by this author Chu Wang More articles by this author Yi Hsuan Chung More articles by this author Ramy Youssef More articles by this author Charles Scales More articles by this author Michael Ferrandino More articles by this author Glenn Preminger More articles by this author Terry Yoshizumi More articles by this author Michael Lipkin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urothelial Carcinoma of the Native Ureter in a Kidney Transplant Recipient

A 56-year-old woman who underwent cadaveric kidney transplantation 44 months earlier had hydronephrosis of the left native kidney diagnosed on routine sonography. She also had chronic urinary tract infection but not gross microscopic hematuria. History included diabetes mellitus, gout, hypertension and hyperlipidemia. Left retrograde pyelography (RP) showed complete obstruction of the left native proximal ureter (part A of figure, arrow). Multidetector computerized tomography urography (MDCTU) revealed a fork sign at the left proximal ureter (part B of figure, arrow) and a spindle sign at the left middle ureter (part B of figure, arrowheads), suggesting urothelial carcinoma (UC). Although urine cytology was negative for malignancy, left ureteroscopy revealed a proximal ureteral mass subsequently proved on biopsy to be UC. The patient underwent bilateral nephroureterectomy with bladder cuff excision. Histological examination confirmed UC in the left native proximal and middle ureter with periureteral fat invasion. The patient died of brain and bone metastases 8 months after surgery, although there was no clinical or radiological evidence of metastasis at surgery. In Taiwan kidney transplant recipients have a reported 4.1% incidence of UC involving greater than 90% of the native upper urinary tract. 1 The most common presentation is gross hematuria followed by chronic urinary tract infection or microscopic hematuria. Mean SD time from transplantation to UC diagnosis is 48.2 49.6 months. UC is usually diagnosed at cystoscopy or on RP. Approximately 50% of patients have hydronephrosis on sonography, of whom 23% have positive urine cytology. MDCTU accurately diagnosed UC in patients with gross hematuria and detected more UC of the native upper urinary tract in kidney transplant recipients than RP. 2 Nonetheless, a careful search for imaging signs suggestive of UC throughout the entire native upper urinary tract is necessary and important on MDCTU to achieve a correct diagnosis because these native upper tracts are small and poorly functioning.

Fluoroscopic Organ and Tissue-Specific Radiation Exposure by Sex and Body Mass Index During Ureteroscopy

Although radiation exposure from CT and plain film imaging has been characterized, the radiation received by patients during modern-era fluoroscopy has not been well described. The purposes of this study were to measure absolute organ and tissue-specific radiation doses during ureteroscopy and to determine the influence of body mass index (BMI) and sex on these doses. Eight cadavers underwent a simulated left ureteroscopy. Using a modern C-arm with automatic exposure control settings, thermoluminescent dosimeters were exposed for a fluoroscopy time of 145 seconds (mean time of clinical ureteroscopies from 2006 to 2008). Total tissue exposures were compared by BMI and between sexes using the Wilcoxon signed ranks test and the Mann-Whitney test with p < 0.05 considered significant. Among all cadavers, radiation doses were significantly lower in all contralateral organs excluding the gonad (p < 0.012). Doses were similar bilaterally in the gonad in cadavers with BMI <30, and in all organs in cadavers with BMI >30 (p > 0.05). There were significantly higher mean bilateral gonadal doses in female cadavers (3.4 mGy left and 1.9 mGy right) compared with male cadavers (0.36 mGy left and 0.39 mGy right). The highest cancer risk increase was seen at the posterior skin equivalent to 104 additional cancers per 100,000 patients. Contralateral doses were lower for all organs except the gonad when the BMI was <30. In contrast, when the BMI was >30, there was no difference in radiation dose delivered to the ipsilateral and contralateral organs. Gonadal doses were significantly higher in female cadavers. Modern-era fluoroscopy remains a significant source of radiation exposure and steps should be taken to minimize exposure during ureteroscopy.