Length Of Ureter Research Articles

Technique of Tubularized Bladder Mucosa Method for Treating Recurrent Vesicoureteral Reflux.

Technique of Tubularized Bladder Mucosa Method for Treating Recurrent Vesicoureteral Reflux.

Verification of relationships between anthropometric variables among ureteral stents recipients and ureteric lengths: a challenge for Vitruvian-da Vinci theory.

ObjectiveTo determine and verify how anthropometric variables correlate to ureteric lengths and how well statistical models approximate the actual ureteric lengths.Materials and methodsIn this work, 129 charts of endourological patients (71 females and 58 males) were studied retrospectively. Data were gathered from various research centers from North and South America. Continuous data were studied using descriptive statistics. Anthropometric variables (age, body surface area, body weight, obesity, and stature) were utilized as predictors of ureteric lengths. Linear regressions and correlations were used for studying relationships between the predictors and the outcome variables (ureteric lengths); P-value was set at 0.05. To assess how well statistical models were capable of predicting the actual ureteric lengths, percentages (or ratios of matched to mismatched results) were employed.ResultsThe results of the study show that anthropometric variables do not correlate well to ureteric lengths. Statistical models can partially estimate ureteric lengths. Out of the five anthropometric variables studied, three of them: body frame, stature, and weight, each with a P<0.0001, were significant. Two of the variables: age (R2=0.01; P=0.20) and obesity (R2=0.03; P=0.06), were found to be poor estimators of ureteric lengths. None of the predictors reached the expected (match:above:below) ratio of 1:0:0 to qualify as reliable predictors of ureteric lengths.ConclusionThere is not sufficient evidence to conclude that anthropometric variables can reliably predict ureteric lengths. These variables appear to lack adequate specificity as they failed to reach the expected (match:above:below) ratio of 1:0:0. Consequently, selections of ureteral stents continue to remain a challenge. However, height (R2=0.68) with the (match:above:below) ratio of 3:3:4 appears suited for use as estimator, but on the basis of decision rule. Additional research is recommended for stent improvements and ureteric length determinations.

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.

MP5-11 THE IMPACT OF LENGTH OF URETERAL RESECTION ON BENIGN URETERO-INTESTINAL STRICTURE RATE IN ILEAL CONDUIT OR ILEAL NEOBLADDER URINARY DIVERSION FOLLOWING CYSTECTOMY

Objectives: To assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. Methods and materials: We identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. Results: A total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P ¼ 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication ZIII (hazard ratio ¼ 2.11, 1.01–4.40) and urine leak (hazard ratio ¼ 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. Conclusions: The etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not

Technique Selection of Bricker or Wallace Ureteroileal Anastomosis in Ileal Conduit Urinary Diversion: A Strategy Based on Patient Characteristics

This study was designed to establish an individualized selection strategy for the two most common types of ureteroenteric anastomotic techniques (Bricker and Wallace anastomosis) used in ileal conduit (IC) diversion. Patients who underwent IC diversion after radical cystectomy for transitional cell carcinoma between January 2009 and December 2011 were prospectively collected. The choice of anastomosis type (Bricker vs. Wallace) was successively based on tumor characteristics, ureteral anomalies, and ureteral length after retrosigmoidal tunneling. Ninety-nine patients were enrolled in the final study. Fifty-three patients underwent Bricker anastomosis, and 46 underwent Wallace anastomosis. Ureteral stricture developed in 6 (6.1%) patients and the overall stricture rate for all ureters was 3.1% (6/196). Strictures occurred at an average of 13.3 months after surgery and were predominately located in the left ureter (66.7%, 4/6). The difference in the ureter stricture rates between the two groups was not statistically significant: 3.8% (4/104) and 2.2% (2/92) for Bricker and Wallace, respectively (p=0.686). There were no significant differences in age, sex, body mass index (BMI), prevalence of pelvic radiation therapy, length of stay, follow-up time, or time to stricture between the two techniques. Patients in whom stricture developed had a significantly higher mean BMI compared with those without stricture (25.2 vs. 23.3 kg/m(2), respectively; p=0.008). Our preliminary outcomes demonstrate that this selection strategy of Bricker vs. Wallace anastomosis seems to be clinically reliable, providing an acceptable low ureteral stricture rate of 3.1%. However, the potential advantage for oncologic control of this strategy is needed to further confirm.

Predicting female ureteral length: a mathematical model

Aim: Ureteral double J stent placement is a common urological procedure. A stent placement is performed for multiple conditions but some of them are contraindicated, mainly in pregnant female patients, because of X-rays. This work aims to suggest a mathematical model to predict female ureteral length by finding a link among different physical data. Materials and methods: Between June 2007 and July 2009, 100 female patients who had undergone ureteral stent placement were enrolled in the present study with the exception of those with septic conditions, history or evidence of TCC, congenital and acquired kidney or ureteral malformations, and previous ureteral surgery. The physical data of each patient were collected (mean age 55.8 years, range 18–89 SD 15.27, mean height 173 cm, range 160–182 SD 6.31, mean weight 75.33 kg, range 62–94 SD 8.81). A previous ureteral retrograde pyelography was performed during the procedure to individualise the pyeloureteral junction. Ureteral length was estimated through a graduated ureteral catheter with a final result between 24 and 27 cm. The length was read in cystoscopy examining the ureteral orifice while the catheter tip reached the pyeloureteral junction. The collected data were then analysed. Results: A link between the female patients’ ureteral length and height was observed. The following mathematical model can predict female ureteral length starting from the patient’s height: Result: y = 0.151712487 (height expressed in cm) ± 0.12; correlation coefficient: r = 0,973, residual sum of squares: rss = 5.285. No link was found between ureteral length and patients’ age and weight. Conclusions: A good estimation of the length of the ureter to be cannulated enables us to choose in advance the proper one to use. Female patient height correlates with ureteral length. A cost reduction can also be obtained, avoiding an intra-operative X-ray control. An X-ray-free ureteral stenting procedure can be described simply through an ultrasound control mainly in pregnant women. Further studies are needed to obtain a similar mathematical model for male patients.

Study on Staging and Grading of Urinary Bladder Tumour with Histopathological Correlation

A cross sectional observational study was done to see the staging and grading of urinary bladder tumor along with their histopathological correlation at the Department of Pathology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. The study was done during the period of July 2006 to June 2007 and total 150 cases were included those were clinically suggestive and cystoscopically or sonographically suspected cases of bladder tumor. Size of bladder, length of ureters, other organs present; tumor characteristics: size (including thickness), location extent of invasion, shape (papillary, ulcerated), multifocal lesion and appearance of non-neoplastic mucosa, thickness of bladder wall away from tumor were observed. Total 145 samples were collected by TURBT and 5 were by cystectomy. Mean age of the study patients was 58.5 years and 95.33% of them were male. Histopathologically 95.33% were papillary urothelial carcinoma, 2.66% were adenocarcinoma, 1.33% was squamous cell carcinoma and 0.66% were carcinosarcoma. Among 150 cases 72 (50.34%) bladder tumour were of high grade and 71 (49.65%) were low grade. In 7 (4.66%) cases grading were not done because they were other than papillary urothelial carcinoma. Staging were done in 93 cases and in remaining 57 cases staging was not possible due to absence of muscularis propria. 32 (21.33%) cases were stage T2, 31 (20.66%) cases T1 and 4 (2.66%) were in stage Ta. Overall findings of the cross sectional Bangladeshi population was almost similar to other developing and developed countries.

Comparative Urologic Complications of Ureteroneocystostomy in Kidney Transplantation: Transvesical Leadbetter-Politano Versus Extravesical Lich-Gregoir Technique

BackgroundThe incidence of urologic complications after kidney transplantation remains high despite improvements in diagnosis and operative techniques. Urinary tract reconstruction is usually done by ureteroneocystostomy (UCNS), and several techniques are available. In this study, we evaluated the outcomes of 2 different UCNS techniques performed in our department, the transvesical Leadbetter-Politano (L-P) and the extravesical Lich-Gregoire (L-G) technique. Material and MethodsWe evaluated the outcomes of 2 different UCNS techniques, L-P versus L-G, performed in our department between July 1, 2006, and December 31, 2011. During this period, we performed 524 consecutive renal transplantations—264 cases using the L-P technique (50.3%) and 260 cases with L-G technique (49.7%). Renal grafts were obtained from cadaveric donors in 146 cases (27.86%) and from living-related donors in 378 cases (72.14%). Recipient mean age was 35.64 years and the male to female ratio was 1.63:1. ResultsUrologic complications after kidney transplantation occurred in 22 cases in the L-P UCNS group (8.33%). The most common complications were ureteral stenosis (3.41%) and leakage (2.65%). Other complications recorded were lymphoceles (1.89%) and hematoma with secondary ureteral obstruction (0.38%). Compared with the L-P UCNS technique, the L-G technique was associated with fewer overall complications (6.15% vs 8.33%; P = .06), a lesser rate of ureteral stenosis (2.31% vs 3.41%; P = .08), and a similar rate of leakage. However, statistical analysis revealed no differences between the 2 techniques (P = .06). In addition, we did not note any differences in graft and patient survival between the 2 groups. ConclusionsIn our study, the extravesical L-G technique has a lower complication rate compared with transvesical L-P procedure, but without statistical differences. Furthermore, the L-G technique is easier and faster to perform, it avoids a separate cystotomy, and requires a shorter ureteral length. In conclusion, we recommend L-G technique as technique of choice in kidney transplantation.

Impact of Ureteral Length on Urological Complications and Patient Survival After Kidney Transplantation

BackgroundUrologic complications are of the most important complications after kidney transplantation which increases mortality and morbidity significantly.ObjectivesWe designed this study to evaluate the association between ureteral length and postoperative complications.Patients and MethodsWe recorded the length of the transplanted ureter during the operation. Ureter-to-bladder anastomosis was performed using modified Lich-Gregoir method on the ureteral stent. Complications like urine leakage and increased creatinine were evaluated. We used both univariate and multivariate analyses and survival analysis according lengths of ureter. It means that the main variable is ureteral length and other variables are studied based on it.ResultA total of 395 patients with the mean age of 37 years (range, 18 to 68 years) were enrolled in the study, twenty six graft lost during the follow-up period. The Mean age of recipients was 37 ± 13 years. Urinary stenosis was seen in 6 patients (1.5%) and urinary leakage in 4 (1%) patients. The complication rate was not significantly different between these groups (P = 0.67). We found that there were no significant difference among complication (P = 0.25), hospitalization (P = 0.31) and survival (P = 0.84) at 5.5 cm length cut off.ConclusionsThe length of transplanted ureter does not affect the postoperative urologic complications (including urinary fistula and ureter-to-bladder anastomosis stricture), and it seems that decreased rate of complication frequency during the recent years is due to technical improvement, surgeon’s skillfulness and development in use of immunosuppressant’s postoperatively.

Report of New Technique: Transvesicoscopic Politano-Leadbetter Ureteral Reimplantation

Introduction: Advancements in endoscopic treatment and laparoscopic correction as minimally invasive surgical procedures have allowed them to increasingly replace open ureteral reimplantation in the management of high-grade vesicoureteral reflux (VUR). Most transvesicoscopic ureteroneocystostomies have been performed via the transtrigonal Cohen procedure, which lengthens the ureter across the bladder base to the opposite side. However, the Cohen procedure has the distinct disadvantage of making future transurethral endourological cannulation and stone operation practically impossible.1–3 We report our initial experience with transvesicoscopic ureteroneocystostomy through the Politano-Leadbetter technique, which uses a more orthotopic ureteral location. Materials and Methods: A 21-year-old man underwent bilateral laparoscopic transvesicoscopic Politano-Leadbetter ureteral reimplantation. The refluxing ureters were grade IV on the left and grade II on the right according to voiding cystourethrography (VCUG). Dissection and mobilization of the ureters is the same as in conventional transvesicoscopic reimplantation. In the extended supine position, we created a pneumovesical space and used three 5-mm working ports. We placed a tagging suture on the bladder mucosa at the inferior edge of the right ureteral orifice with a 5-0 monofilament. The ureters were mobilized with hook electrocautery. Mobilization of the ureters was continued until an adequate ureteral length of 2.5–3 cm was obtained, and the terminal part of the ureter was resected. The location of the new hiatus was selected in a straight line superior to the original orifice. The new hiatus was created blindly by passing a Diamond-Flex® laparoscopic articulating circular retractor (Snowden-Pencer, CareFusion, Waukegan, IL) from the original hiatus behind the bladder to perforate through the posterior wall of the bladder at the new hiatal orifice. The right ureter was extracted through the neohiatus, and the ureter was brought through the new tunnel to the original hiatus. Ureterovesical anastomosis was performed with intracorporeal suturing using 5-0 monofilament sutures at four points per ureteral orifice. The mucosal defect was closed with 5-0 absorbable interrupted sutures. Results and Conclusion: The whole procedure was accomplished without intraoperative or postoperative complication. The operative time was 175 minutes, and blood loss was minimal. Left ureteral stents were indwelled, but no drain was used. The patient was discharged 5 days after the operation. After 3 months, the bilateral reflux disappeared on the VCUG. The results from this case indicate that transvesicoscopic Politano-Leadbetter ureteral reimplantation appears to be an effective and safe treatment for high-grade VUR. The Politano-Leadbetter procedure creates a new ureteric orifice in a normal anatomical position, allowing ureteroscopic procedures. We used a laparoscopic circular retractor to create a neohiatus close to the bladder wall above the old orifice incision of the bladder mucosa. After preparation of a neohiatus by this unique method, a free suture was used to guide the ureter. The passage of the extravesically mobilized ureter through the neohiatus was achieved by pulling the free suture end intravesically. In the end, a submucosal tunnel preparation from the old to the new hiatus. The cross-trigonal technique is popular among pediatric urologists. In this technique, the ureter is detached from its attachments and moved across the trigone. This achieves a longer tunnel, while using the initial hiatus. The primary limitation of the technique is ureteral access following the procedure. In the proposed Politano-Leadbetter technique, the ureter is brought outside the bladder through a new orifice. The operator must be very careful not to trap the ureter or other tissue or to perforate the peritoneal space and its organs when the ureter is rerouted outside the bladder. The ureter is then brought into the neohiatus and down the new tunnel. This laparoscopic Politano-Leadbetter reimplantation technique is technically more complex and requires sufficient bladder capacity. Our new technique is an optional treatment to replace the open reimplantation approach. No competing financial interests exist. Runtime of video: 4 mins 25 secs

A +20% Adjustment in the Computed Tomography Measured Ureteral Length Is an Accurate Predictor of True Ureteral Length Before Ureteral Stent Placement

The correct length of a ureteral stent is important in minimizing postplacement discomfort and stent migration. We describe and validate a method to accurately measure the ureteral length. The ureteral length in 48 patients undergoing ureteral stent placement for urolithiasis was measured by computed tomography (CT) (total thickness of axial slices between the ureteropelvic junction and ureterovesical junction) and adjusted up by 20%. The adjusted CT measurement of ureteral length was compared with direct intraoperative measurement using scatter plot and Pearson correlation coefficient. Correlation coefficients were also calculated between intraoperative ureteral length and various body habitus measurements such as the height, weight, and waist circumference. Median patient age was 62 years. The median stone diameter was 7.5 mm (1-20). The ratio of left- to right-sided stones was 2:1. The stone location was in the proximal ureter in 45.8%, distal ureter in 37.5%, kidney in 10.4%, and midureter in 6.3%. Symptoms included adnominal/flank pain (93.8%) followed by nausea/vomiting (39.6%) and gross hematuria (16.7%). Median creatinine was 1.4 (0.8-3.6 mg/dl) and median WBC was 8.6 (2.8-17.6). The median ureteral length was 25.8 cm (19.2-29.4) on the CT scan and 25.5 cm (19.0-29.0) on the intraoperative measurement (p=0.57). The Pearson correlation coefficient between the two measurements was 0.979. In contrast, the height, weight, and waist circumference correlated poorly with intraoperative ureteral length measurements (r=0.34, 0.19, and 0.40, respectively). CT-measured ureteral length adjusted up by 20% is a reliable method to accurately measure the true ureteral length. This method is superior to traditional indirect methods that rely on body habitus measurements.

A new operative technique – Extra renal ureterocalycostomy for correction of PUJ obstruction in a horseshoe kidney

The authors describe a novel operative technique in a child with PUJ obstruction in a horseshoe kidney, where a pyeloplasty was clinically indicated but unsafe because of insufficient length of ureter and predicted technical difficulty in transposing large renal vessels coursing to the renal hilum. During the operation, there was a favourably positioned extra renal lower pole calyceal infundibulum identified, of similar dimensions to the spatulated ureter and this was chosen for an end to side tension free anastomosis. As far as the authors are aware this technique of extra renal ureterocalycostomy has not been described before.

Analysis of ureteral length in adult cadavers

Introduction In some occasions, correlations between human structures can help planning surgical intra-abdominal interventions. The previous determination of ureteral length helps pre-operatory planning of surgeries, reduces costs of auxiliary exams, the correct choice of double-J catheter with low morbidity and fewer symptoms, and an adequate adhesion to treatment. Objective To evaluate ureteral length in adult cadavers and to analyze its correlation with anthropometric measures. Materials and Methods: From April 2009 to January 2012 we determined ureteral length of adult cadavers submitted to necropsy and obtained the following measures: height, distance from shoulder to wrist, elbow-wrist, xiphoid appendix-umbilicus, umbilicus-pubis, xiphoid appendix-pubis and between iliac spines. We analyzed the correlations between ureteral length and those anthropometric measures. Results We dissected 115 ureters from 115 adult corpses from April 2009 to January 2012. Median ureteral length didn't vary between sexes or according to height. It was observed no correlation among ureteral length and all considered anthropometric measures in all analyzed subgroups and in general population. There were no significant differences between right and left ureteral measures. Conclusions There is no difference of ureteral length in relation to height or gender (male or female). There is no significant correlation among ureteral length and the considered anthropometric measures.

Predicting Female Ureteral Length: A Mathematical Model

Aim: Ureteral double J stent placement is a common urological procedure. There are many conditions that lead to a stent placement and some of them, mainly in pregnant female patients, have the contraindications of using X-ray. This study has the aim of proposing a mathematical model able to predict ureteral length finding a correlation between different physical data. Materials and methods: Between June 2007 and July 2009, 100 female patients who underwent ureteral stent placement were enrolled in this study. Patients with septic conditions, history or evidence of TCC, congenital and acquired kidney or ureteral malformations, and previous ureteral surgery were not enrolled. Physical data for each patient were obtained (age mean 55.8 yrs range 18-89 SD 15.27, height mean 173 cm. range 160-182 SD 6.31, weight mean 75.33 kg range 62-94 SD 8.81). During the procedure, a previous ureteral retrograde pyelography was performed to individualize the pyeloureteral junction. Ureteral length was calculated using a graduated ureteral catheter (ureteral length obtained between 24 and 27 cm). The length was read in cystoscopy looking at the ureteral orifice while the catheter tip reached the pyeloureteral junction. The collected data were analyzed. Results: A correlation between ureteral length and height of the patients was found. The following mathematical model is able to predict ureteral length starting from the patient’s height: Result: y=0.151712487 (height expressed in cm) ± 0.12; Correlation Coeff: r = 0.973, Residual Sum of Squares: rss=5.285. No correlation was found with patient’s age and weight. Discussion and conclusion: Knowing with a good approximation the length of the ureter to be cannulated gives the possibility to choose in advance the proper one to be used. Patient’s height correlates with her ureteral length. A cost reduction can be obtained avoiding an intraoperative X-ray control. An X-ray free ureteral stentingprocedure can be described (using just ultrasound control) mainly in pregnant women.

Comparison of Transumbilical and Conventional (Pfannenstiel) Laparoscopic Donor Nephrectomy

Forty-eight healthy voluntary renal donors between 18 and 60 years of age with BMI less than 30 who were planned for laparoscopic left side donor nephrectomy were enrolled in the study. After randomization 25 donors (group A) underwent a conventional laparoscopic donor nephrectomy with a Pfannenstiel incision used for kidney extraction whereas in 23 donors (group B) the kidney was extracted via a midline extension of the transumbilical port. Both groups of recipients were comparable in terms of basic disease leading to end stage renal disease and were given triple drug immunosuppression comprising of calcineurin inhibitor, mycophenolate and steroid. Mean age of donors in group A was 41.72 yrs and 38.04 yrs in group B. Mean duration of surgery and warm ischemia time were comparable (227.12 min/ 263 seconds in group A versus 228.91 min/ 283 seconds in group B). Estimated blood loss was similar in both groups (165.6 ml in group A versus 151.3 ml in group B). There were no intraoperative or postoperative complications in both groups. Weight of the kidneys (128.2 gm in group A vs. 120.4 gm in group B), length of renal artery (2.37 cm in group A vs. 2.30 cm in group B) and length of renal vein (2.58 cm in group A vs. 2.67 cm in group B) were statistically similar in both groups. Length of ureter (8.7 cm in group A vs. 10.17 cm in group B) and length of extraction site incision (7.95 cm in group A vs. 10.17 cm in group B) showed statistically significant difference. Pain scores noted by numerical rating scale on day 1 (8 in group A vs. 6 in group B) and 3 (6 in group A vs. 3 in group B) after surgery and at time of discharge (5 in group A vs. 3 in group B) showed statistically significant difference. Both groups of donors rated pain at 0 at 1 month following surgery. Day of discharge was similar in both groups with median 3 days post operative stay. Serum creatinine of recipients on day 1 (2.57 vs. 2.99 mg/dl in groups A and B respectively) and 3 (1.74 vs. 2.15 mg/dl in groups A and B respectively) after surgery were comparable while mean serum creatinine on post operative day 7 (1.74 vs. 2.15 mg/dl in groups A and B respectively) was significantly higher in recipients of group B. Serum creatinine of recipients at 1 month post transplantation was similar in both groups (1.11 vs. 1.18 mg/dl in groups A and B respectively). The higher creatinine at day 7 may be explained by two patients in group B who had delayed graft function due to calcineurin inhibitor toxicity. In conclusion the lower pain scores and shorter incision length with similar outcomes suggests that a transumbilical route may be a better approach for kidney retrieval.

Urological Complications after Renal Transplantation - Therapeutical Management

Aims: Urological complications can affect the outcome of kidney transplantations by increasing the morbidity and mortality, including the lost of the graft. The aim of this study is to determine the incidence of urological complications, occurring after renal transplantation, in our centre. Methods: A series of 796 consecutive renal transplantations were performed between 1st of January 2004 and 31st of December 2011 in our Institute with a male to female ratio of 1.77/1. The mean age of the recipients was 35.16 years old. Renal grafts were obtained in 594 cases (74.62%) from living-related and in 202 cases (25.38%) from cadaveric donors. In 494 cases (62.1%) we performed a modified Leadbetter-Politano technique and, in another 302 cases (37.9%) a Lich-Gregoire ureterocystoneostomy. The follow-up of these patients ranged from 1 to 78 months, with none lost to follow-up. In 683 (85.8%) cases transplantation was carried out into the right iliac fossa, and only 113 (14.2%) cases in left iliac fossa. A double J ureteral stent was occasionally placed. Indwelling Foley catheters were removed seven to nine days post transplant and ureteral stents at four weeks post transplantation. Results: The overall incidence of urological complications was 7.78% (62 cases). Ureteral leakage and ureteral stenosis, located at the site of the ureterovesical anastomosis were the most common. We recorded 25 ureteral stenosis (3.14%), 16 ureteral fistulas (2.01%), 13 lymphoceles (1.63%), three hematoma with ureteral obstruction (0.37%),two cases of renal lithiasis(0.25%) and three cases of obstruction due to clot formation (0.37%). For the patients with ureteral stenosis (25 cases) the most common method of surgical treatment was vesicoureteral re-anastomosis 17 cases (2.13%). In the other eight cases (1.01%), with short and distal stenosis were treated effectively by anterograde (via NST) or retrograde endourological approach, with double pigtail stenting. Ureteral leakage was the second major urological complication (16 cases). Ureteral stenting was performed in eight cases (1.01%) (patients with vesicoureteral anastomosis leakage, marginal ureteral necrosis), seven vesicoureteral re-anastomosis (0.87%) (vesicoureteral anastomosis leakage, ureteral necrosis) and one ureteropyelostomy (0.13%) using the ipsilateral native ureter (inadequate length of ureter). Peri-graft collection with extramural obstruction of the ureter was diagnosed by ultrasonography in 13 cases. Percutaneous drainage was successful in six cases (0.75%) and open surgical peritoneal fenestration was performed in the other seven cases (0.88%). Two patients (0.25%) developed renal lithiasis. The treatment was retrograde double pigtail ureteral stent insertion followed by ESWL. Three patients (0.37%) developed hematoma with secondary ureteral obstruction, solved by percutaneous drainage in one case (0.12%) and open surgical evacuation and drainage in other two cases (0.25%). For the cases of ureteral clot obstruction (3 cases, 0.37%), a double pigtail ureteral stent insertion after endourological clot removal was successful. Conclusions: Urological complications related to leakage or stenosis can be treated minimally invasive by ureteral stent insertion or by surgical vesicoureteral reimplantation. Early diagnosis and treatment will help maintain renal graft function. In our study, graft survival after successful treatment has been similar for all the patients.

Changing to a loop-type ureteral stent decreases patients’ stent-related symptoms

The first indwelling ureteral splint was described in 1967. A ureteral stent can cause unpleasant side effects, such as urinary frequency, urgency, incontinence, hematuria, bladder pain and flank pain, which have a negative impact on a patient's quality of life. It is necessary to minimize the amount of material in the bladder in order to decrease stent-related symptoms. This study investigated the stent-related symptoms after changing from a double pigtail to a loop-type ureteral stent in the same patient group. This study followed 25 patients who underwent ureteral stent exchange from double pigtail to loop-type ureteral stent between September 2009 and February 2010. Ureteral stents were exchanged using topical, conscious sedation and general anesthesia for the various procedures including stent exchange, before/after shock wave lithotripsy and before/after ureteroscopy. The stent length was selected to be the same as whole ureteral length and the caliber based on the previous stent. A self-administered stent-related symptom questionnaire was used to assess stent-related symptoms in comparison to the previous double-pigtail stents. A total of 25 patients with a median age of 56.5years underwent ureteral stent exchange. All patients had stone disease except two patients who had ureteral stricture. Almost all of stent-related symptoms without nocturia showed a significantly lower score with the loop-type ureteral stent than in double-pigtail stent. None of the patients experienced urinary tract infection either before or after undergoing ureteral stent exchange. Changing to loop-type ureteral stent significantly decreased ureteral stent-related symptoms.

Which is the best method to estimate the actual ureteral length in patients undergoing ureteral stent placement?

To define the best modality for estimating ureteral length in patients undergoing ureteral stent placement. This study enrolled 151 patients (169 ureters) undergoing stent insertion. In all of them, an intravenous urography and non-contrast computed tomography were carried out. The actual ureteral length was determined by direct measurement using a 5-Fr ureteral catheter. A multivariate analysis evaluated the association between the ureteral length and each of the following parameters: body height, body surface area, ureteral trace by intravenous urography, linear distance (liner distance 1) from the ureteropelvic junction to the ureterovesical junction by intravenous urography, linear distance (liner distance 2) from the mid kidney to the ureterovesical junction by intravenous urography, and the distance from the level of the renal vein to the ureterovesical junction by axial computed tomography (axial computed tomography distance). The mean actual ureteral length was 23.2 cm (median 24 cm, range 16-29 cm). The Spearman correlation coefficients for body height, body surface area, ureteral trace, liner distance 1, liner distance 2 and axial computed tomography distance were 0.3126, 0.3076, 0.4541, 0.5230, 0.4796 and 0.6168, respectively. Axial computed tomography distance showed the best correlation with the actual ureteral length. The axial computed tomography distance as calculated by the axial computed tomography can more reliably predict the actual ureteral length than other parameters. Further studies are required to show the best method for estimating the actual ureteral length in patients undergoing ureteral stent placement.

Choosing an Appropriate Length of Loop Type Ureteral Stent Using Direct Ureteral Length Measurement

Purpose: The ureteral stent is now a fundamental part of many urological procedures. To decrease ureteral stent-related symptoms, loop type ureteral stent was developed. However the most important factor to decrease urinary symptoms is choosing the optimal length of a ureteral stent. We investigated the relationship between the actual ureteral length and the loop type ureteral stent position. Materials and Methods: A total of 226 loop type polyurethane ureteral stents (156 patients) were inserted with four options for stent length (20, 22, 24 and 26 cm). The ureteral length was measured using a ruled 5-Fr ureteral catheter. The appropriateness of stent position was defined into three groups based on kidney-ureter-bladder films. Results: Nine stents (3.9%) migrated, 171 stents (75.7%) were in the appropriate position and 46 stents (19.5%) were overlong. The rate of migration rate and overlong stents closely correlated with the ureteral length when the proximal end of the stent was in the renal pelvis. Conclusions: It is appropriate to choose a loop type ureteral stent that is the same or 1 cm less than the length of the ureter when the proximal end of the stent will be in the renal pelvis.

Distal Ureteral Calculi: US Follow-up

To assess accuracy of ultrasonographic (US) follow-up of distal ureteral calculi by using computed tomography (CT) and conventional radiography (kidneys, ureters, and bladder) as reference standards. The study was approved by the Regional Ethics Committee, and written informed consent was obtained. One hundred fifty-eight patients with CT-diagnosed symptomatic ureteral calculi, for whom follow-up imaging was ordered, were enrolled from February 2006 to December 2008. Six were excluded, having not met study entry criteria, with 121 men (mean age, 49 years; range, 20-91 years) and 31 women (mean age, 44 years; range, 34-77 years) completing the protocol with adequate reference standard imaging. Targeted transabdominal US occurred coincidently with follow-up CT (n = 92) or radiography (n = 60), with US evaluation prospectively compared considering sensitivity and specificity. Statistical analysis was performed with a χ(2) test, t test, or paired t test, as appropriate. Results of nine US examinations were nondiagnostic because of inadequate ureteral visualization, and among these, two cases showed residual distal calculi. Of the remaining 143 patients, 33 had residual distal calculi, all visualized with US. There was a single false-positive study, giving sensitivity, including nondiagnostic US examinations, of 94.3% (95% confidence interval [CI]: 80.8%, 99.3%) and specificity of 99.1% (95% CI: 95.3%, 100%). All calculi appeared hyperechoic with posterior acoustic shadowing. Additional diagnostic features included presence of a hypoechoic rim and Doppler twinkle artifact. Mean stone length was 7.2 mm ± 2.6 (standard deviation) (range, 4-18 mm). Mean ureteral length visualized was 36.4 mm (range, 12-77 mm), with calculi positioned at a mean of 13.1 mm ± 11.2 (range, 0-40 mm) from the ureterovesical junction (UVJ). Nondiagnostic results were more likely with bladder volume of 110 mL or less (eight [16%] of 50 vs one [1%] of 102, P = .0009). Ureteral calculi within 35 mm of the UVJ can be accurately followed-up by using transabdominal US, which substantially reduces patient radiation burden.