Lower Ureter Research Articles

Peadiatric transvesicoscopic dismembered ureteric reimplantation for ectopic upper ureter in duplication anomalies

Ectopic upper pole ureters in duplex kidneys can be managed surgically by ipsilateral distal ureteroureterostomy or reimplantation of both ipsilateral ureters when upper pole shows reasonable function. This study aimed to evaluate the clinical outcomes of transvesicoscopic dismembered upper ureteric reimplantation for patients with ectopic upper pole ureters in duplication anomalies. Between July 2015 and January 2019, laparoscopic transvesicoscopic ureteral reimplantation was performed in 20 patients with ectopic upper pole ureters. An incision was made in the bladder wall at 1.0cm proximal to the lower ureteral orifice of affected side. The upper pole ureter was recognized, and the terminal portion of the upper ureter was ligated and cut. Then the proximal portion of the upper ureter was mobilized, a transverse submucosal tunnel was created and upper ureteric reimplantation was performed with 6/0 absorbable sutures. Patients were followed up with renal ultrasonography and voiding cystourethrogram for clinical outcomes and hydronephrosis trends. Median (range) age at surgery was 22.5 (10-53) months. All of the 20 operations were successful, and none required conversion to an extravesical approach or open surgery. Four patients presented with worsening upper pole hydroureteronephrosis but recovered three to six months postoperatively. Resolution of symptoms and improving hydroureteronephrosis were achieved in all patients and VUR of the upper and lower ureters was not detected at postoperative follow-up. To our knowledge, dismembered reimplantation of upper pole ureters has been reported only in a small series through extravesical technique. In our study, we performed intravesicoscopic upper ureter Cohen reimplantation for duplex system ureteral ectopia. Compared with the extravesical approach, the transvesicoscopic approach leave most of the pelvic structures intact and the creation of a submucosal tunnel for prevention of ureteral reflux is more reliable; in addition, this approach avoids any manipulation of the lower pole ureter compared to ipsilateral ureteroureterostomy. But this method does not seem applicable to children under 6 months of age because of the small bladder capacity. The laparoscopic intravesical technique of dismembered ureteral reimplantation was safe and feasible in our cases and may be an alternative surgical treatment for ectopic upper pole ureters in duplication anomalies.

Робот-ассистированная радикальная цистэктомия с ортотопической деривацией мочи

Introduction Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder formation is a complex surgical procedure. Aim To describe the main stages of RARC and to analyze its short-term results. Materials and methods RARC with ileocystoplasty was performed in 16 patients, most of whom were men (n=14). In 15 patients, the indication for surgery was bladder cancer (BCa), while one patient has radiation-induced sigmoid fistula with a formation of small, contracted bladder. During radical cystectomy (RC), the lower ureters were dissected, followed by posterior dissection of the bladder with mobilization from both sides to the pelvic fascia, clipping and transection of the vesical pedicles, and suturing of the dorsal venous complex with urethral dissection. After pelvic lymph node dissection, 40 cm of the ileum was resected, after that two distal segments of 15 cm were U-shaped, and a 1.5 cm incision was made in the lower part of the bowel, followed by a formation of the urethral anastomosis. Then bowel segments were detubularized, and continuous suture on the posterior and anterior walls of the neobladder was done. Ureters were implanted in the proximal tubular part of the resected colon according to the Nesbit technique. Results The mean operation time was 380 minutes. The blood loss ranged from 80 to 200 ml; however, blood transfusion was not performed. Complications during 30-days after RARC were observed in 7 (43.7%) patients, including 4 (25%) of class I-II according to Clavien - Dindo, and 3 (18.7%) of class III-IV. In patients with leakage at the uretero- intestinal anastomosis (n=2) and urethro-neobladder anastomosis (n=1), percutaneous drainage was performed, which allowed to resolve these complications. There were no cases of bowel obstruction. One patient with gastrointestinal bleeding required blood transfusion. The 90-day late complications occurred in 6 (37.5%) patients, including 2 cases of upper urinary tract infection. One patient died of acute myocardial infarction. Conclusion RARC is a contemporary minimally invasive method for muscle-invasive BCa. Stepwise approach to RARC with intracorporeal neobladder formation may reduce the operation time and the rate of complications.

Pseudodiverticulum: A rare late complication of the Boari flap procedure for lower ureteric repair

The Boari bladder flap is a vital tool in the armamentarium of the urologist. It is used to maintain continuity of the urinary system when dealing with diseased segments of the mid and lower ureter. It is, however, associated with long-term complications. We present the case of a 46-year-old woman who developed a rare pseudodiverticulum as a consequence of the procedure. This patient had undergone a right-sided laparoscopic Boari bladder flap for a right distal ureteric stricture secondary to pelvic endometriosis, and presented 10 years later at our urology department with long-standing irritative voiding symptoms and a feeling of incomplete voiding. Radiological and endoscopic investigation revealed the presence of a capacious pseudodiverticulum which was seen on ultrasound to retain a significant amount of urine post micturition and then to empty back into her bladder, strongly suggesting that this was the cause of her sensation of incomplete bladder emptying. She had minimal symptom bother and no recurrent urinary tract infections, calculi or tumour, and it was decided that no further operative management was necessary and that her condition could be managed her conservatively. To the best of our knowledge, this is only the second case describing this rare, long-term complication of a Boari flap. Level of evidence: Level 5.

Duplicated Collecting System

Study Objective The objective of this video is to discuss the presentation, evaluation, and treatment of duplicated urinary collecting systems, and to present a case of duplicated ureters with ectopic ureteral implantation at the vaginal introitus. Design N/A Setting N/A Patients or Participants We present the case of a 56 year-old presenting with a history of recurrent urinary tract infections starting in adolescence. She reported symptoms of urinary urgency, frequency, and incontinence. She additionally reported an unclear history of an incidental diagnosis of ureteral anomaly in childhood. Interventions For evaluation of this patient, a computed tomography urogram was performed which revealed a right duplicated kidney with upper ureter inserting into the bladder neck, and lower ureter with unclear course. A voiding cystogram was performed to evaluate for ureteral reflux which was not demonstrated. A renal MAG3 scan was performed and demonstrated differential function between the two right renal moieties but no evidence of obstruction to the outflow tract to either renal moiety. Exam under anesthesia, cystoscopy, and right retrograde pyelogram revealed an ectopic ureteral orifice at the vaginal introitus and mild hydroureter leading to the upper renal moiety. Measurements and Main Results Complete mapping of this patient's right collecting system revealed complete ureteral duplication with the lower renal moiety drained by a normal ureter leading to an orthotopic ureteral orifice and the upper renal moiety draining into a mildly dilated ureter leading to an ectopic ureteral orifice at the vaginal introitus. The patient will subsequently undergo robotic-assisted right ureteroureterostomy and excision of distal ectopic ureter in a combined laparoscopic and vaginal approach. Conclusion Duplicated urinary collecting systems are the most common birth defect related to the urinary tract and can be frequently encountered by the pelvic surgeon. Knowledge of the presentation and workup of these anomalies is important in determining appropriate treatment.

Medical expulsive therapy: a cost effective evidence-based definitive treatment for ureteric stones

Background: The lifetime risk of kidney stones is between 5% and 10% and rates of recurrence are as high as 50%. Majority of the ureteric stones (70%) are found in the lower third of the ureter. Available setup, type, size of the stone, and expertise of the surgeon are the major factors affecting the treatment modality. Medical expulsive therapy has shown promising results in previous studies. Aim of the study was to assess the efficacy of tamsulosin and deflazacort combination therapy for stone expulsion in relation with site and size of stones.Methods: A total of 97 patients with ureteric calculi of size 10 mm or less attending the urology out-patient department were included. Received medical expulsive therapy using tamsulosin (0.4 mg) and deflazacort (30 mg) for 7 days. Patients were evaluated for stone expulsion on 7th day by non-contrast computed tomography of kidney ureter bladder. Site, side and size of stones were noted.Results: Ureteric calculi was more prevalent in the age group of 21-30 years 38 (39.2%). Male preponderance was observed (76.28%) with male female ratio being 3.2:1. Lower site 64 (65.97%) ureteric calculi were most common. The majority had a stone size of 4-6 mm (42%). Stones were expelled on 7th day in 69 (71.13%) patients. Expulsion rates were highest for the stone size of 2-4 mm (94.4%) followed by 4-6 mm (88.1%). The highest expulsion rates were observed for Lower ureteric stones (84.4%).Conclusions: Medical expulsive therapy using tamsulosin and deflazacort is an effective treatment modality for the management of ureteric stones, especially those present in lower ureter and those ≤8 mm in size.

MP22-13 DOUBLE URETERAL STENT PLACEMENT REDUCES RESTENOSIS AFTER INCISION AND DILATATION FOR URETERAL STENOSIS

INTRODUCTION AND OBJECTIVE: Laser incision (laser endoureterotomy: LE) and balloon dilatation (BD) are the treatments for ureteral strictures measuring ≤20 mm; however, these treatments are associated with a high risk of postoperative restenosis. Endoscopic management of benign ureteral strictures has been described in the adult literature with failure rates of 12% to 38%. Therefore, this study aimed to investigate the effectiveness of a novel method to place double ureteral stents after LE and BD. METHODS: In total, 10 patients who underwent endoscopic surgery for ureteral stenosis from January 2016 to March 2019 were included. All stenoses were iatrogenic rather than congenital. In LE, the stenosis site, including 2 mm before and after the site, was incised using a laser until the fat tissue outside the ureter was visible. A flexible ureteroscope was used for upper ureteral stenosis and a semi-rigid ureteroscope was used for middle or lower ureteral stenosis. In BD, the stenosis site was dilated with a balloon up to 15 Fr. In all cases, two 4.7-Fr ureteral stents were placed and removed 4–8 weeks after surgery. The improvement of hydronephrosis, surgical parameters, and complications were evaluated. RESULTS: The stenosis site was confirmed in the upper ureter in six patients; in the middle ureter in three patients; and in the lower ureter in one patient, with an average distance of 9.7 ± 5.6 mm. Preoperative hydronephrosis was grade G1 in one patient, grade G2 in one patient, grade G3 in four patients, grade G4 in four patients, and improved in nine patients (90%) 3 months after surgery. The average duration of surgery was 111 ± 21 minutes, and no surgical complications over grade 3 were observed. The average duration of hospital stay was 4.1 ± 0.5 days. The mean follow-up period was 661 ± 405 days, and no restenosis was observed in any of the eight patients. CONCLUSIONS: Placement of double ureteral stents after surgery for ureteral stenosis was effective. Source of Funding: none

Clinical study on the treatment of small calculi in the middle and lower segment of ureter by extracorporeal physical vibrating lithotomy

Objective To compare the clinical effects of active lithotripsy(extracorporeal physical vibration lithotripsy combined with drugs) and passive lithotripsy(drug therapy alone) in the treatment of small stones in the middle and lower ureter. Methods All the included subjects were patients with primary small ureteral calculi in the middle and lower segment(<6 mm) admitted to our hospital from January 2018 to September 2018 outpatient department. Patients in the two groups were randomly divided into the active stone drainage group (in vitro physical vibration stone drainage combined with drug therapy) and the passive stone drainage group(purely drug therapy). Urinary CT was reexamined 1, 2 and 4 weeks after treatment. Comparison indexes: the rate of ureteral calculi excretion and net excretion at 1, 2 and 4 weeks after treatment, and the incidence of complications in the two groups were compared.Logistic regression analysis was performed on related parameters. Results A total of 138 patients were included in the study, among which 76 were males and 62 were females. There was no statistical difference in gender composition, age, stone size, CT value and stone distribution between the two groups(P>0.05). The stone removal rate of active rock discharging group on 1, 2 and 4 weeks was 52.6%, 63.2% and 78.9% respectively, while the corresponding passive stone discharging group was 33.9%, 40.3% and 61.3% respectively(P 0.05). Conclusions Physical vibration stone drainage is a safe and effective auxiliary treatment of stone drainage, compared with conservative treatment, can improve the ureteral stone drainage rate. Key words: Ureteral Calculi; Lithotripsy; Drug Therapy

Ureterosciatic Hernia Treated with Laparoscopic Intraperitonization of the Ureter.

Background: Ureterosciatic hernia (USH) is a rare benign disease. We report a case of USH treated with laparoscopic intraperitonization of the ureter. Case Presentation: A 70-year-old woman was admitted to our hospital with right abdominal pain lasting for 2 months. CT showed right hydronephrosis and invagination of the right ureter into the right sciatic foramen. She underwent retrograde ureterography, which revealed abnormal tortuosity of the right lower ureter, and was found to have USH. We performed laparoscopic intraperitonization of the ureter and she presented good postoperative course. Conclusion: Laparoscopic intraperitonization of the ureter can be a useful treatment for USH.

Efficacy of Tamsulosin plus Tadalafil versus Tamsulosin as Medical Expulsive Therapy for Lower Ureteric Stones: A Randomized Controlled Trial.

Introduction Urolithiasis is one of the common disorder with which about 1/5th is found in the ureter, of which 2/3rd is seen in the lower ureter. Medical expulsive therapy is one of the routine modalities of treatment which uses various drugs acting on the ureter smooth muscle by different mechanism. We aim to compare the efficacy of combination vs. single drug. Methods This randomized controlled trial was done in 176 consecutive patients over a period of six months (March 2019 to August 2019) in Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching. Participants were divided into two groups (Group A, tamsulosin plus tadalafil, and Group B, tamsulosin) from computer-generated random numbers. Therapy was continued for a maximum of 3 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of colic and emergency room visits for pain, early intervention, and adverse effects of drugs were recorded. Results Among 176 patients who were enrolled in study, 7 were lost to follow-up, and 5 people required immediate intervention. There was a significant higher stone passage rate in group A than group B (64 vs. 50; P=0.025) and shorter expulsion time (1.66 vs. 2.32 weeks P=0.001) and less number of emergency room visits and colic episodes. No significant side effects were noted during study. Conclusion Tamsulosin plus Tadalafil is more effective than tamsulosin with early passage of stone and decreased number of colic episodes and emergency visits without significant side effects for lower ureteric calculi of 5 mm to 10 mm.

Diabetic ketoacidosis complicated by emphysematous pyelonephritis: a case report and literature review

BackgroundThe management of emphysematous pyelonephritis (EPN) includes conservative medical treatment, percutaneous drainage, and surgical resection of the involved kidney. EPN with diabetic ketoacidosis(DKA) is very rare, in which the clinical management of refusing surgical drainage is inexperienced.Case presentationA 34-year-old woman presented with abdominal pain, chills, fever, nausea, vomiting, chest tightness, and shortness of breath. Blood test results were consistent with diabetic ketoacidosis. Urinary computed tomography scan showed multiple stones in the right kidney and lower ureter, with right hydronephrosis. Blood culture demonstrated Escherichia coli bacteremia, and EPN was diagnosed. Considering the need for a second percutaneous nephrolithotomy, the patient refused percutaneous drainage. After continuous intravenous infusion of small doses of insulin and antibiotic treatment, the ketoacidosis resolved. The patient’s temperature returned to normal and abdominal pain was alleviated, and liver and kidney functions were also back to normal. After hospital discharge, the patient underwent two percutaneous nephrolithotomy in the department of urology.ConclusionsEPN with diabetic ketoacidosis should be diagnosed as soon as possible. For patients with Class 1 and Class 2 EPN with diabetic ketoacidosis and urinary tract obstruction, if surgical drainage is refused, it is particularly important to rapidly correct diabetic ketoacidosis and intravenous use of sensitive antibiotics, so as to create conditions for follow-up percutaneous nephrolithotomy.

A new and easy technique of double-J stenting after retroperitoneal laparoscopic ureterolithotomy: A discussion of other techniques

Aim:To summarize a new and easy technique of double-J stent (DJ stent) placement after retroperitoneal laparoscopic ureterolithotomy (RLU).Materials and Methods:RLU for upper and upper half of mid ureteric stones was performed successfully in 172 patients during the 8-year period between March 2011 and February 2019. In all the cases, a ureteric DJ stent was successfully placed by this new technique. A small-bore antral puncture needle is inserted into the retroperitoneal space to push down a DJ stent with a guidewire into the lower ureter. The tip of the antral puncture needle is manipulated to bring it near the ureterotomy site for easy insertion of the stent. The whole stent is pushed down leaving only the upper end in the ureterotomy area. Then, the guidewire is removed and the upper end is pushed up slowly into the renal pelvis.Results:DJ stents were successfully inserted by this technique in all the 172 cases. In most cases, the stent could be placed in <3 min (range between 2 and 8 min). In two patients, the upper end failed to fully coil in the renal pelvis, but as the stent was passed beyond the ureterotomy site, it served its purpose of an internal drain. None of our cases had any urinary leak. Stents were removed cystoscopically after 6–12 weeks.Conclusion:This technique provides an easy, fast, and safe antegrade method of inserting a DJ stent after RLU.

Paediatric transvesicoscopic Cohen ureteric reimplantation for ectopic upper ureter in duplication anomalies

To evaluate the clinical outcomes of transvesicoscopic Cohen ureteric reimplantation for patients with ectopic upper pole ureters in duplication anomalies. Between July 2015 and January 2019, laparoscopic transvesicoscopic ureteral reimplantation was performed in 20 patients with ectopic upper pole ureters. An incision was made in the superior bladder wall at 1.0cm proximal to the lower ureteral orifice of affected side with an electric hook. The upper pole ureter has been recognized, and the terminal portion of the upper ureter was ligated and cut. Then the proximal portion of the upper ureter was mobilized, a transverse submucosal tunnel is created and ureteric reimplantation performed with 6/0 absorbable sutures. Patients were followed up with renal ultrasonography and voiding cystourethrogram. All of the 20 operations were successful, and none required conversion to an extravesical approach or open surgery. The operation time ranged from 90 to 155 minutes. Resolution of symptoms was achieved in all patients and VUR of the upper and lower ureters was not detected at postoperative follow-up. Four patients presented with temporary ureteric dilatation on follow-up renal ultrasound but recovered three months after operation. The laparoscopic intravesical technique of ureteral reimplantation was safe and feasible in our cases and may be an alternative surgical treatment for ectopic upper pole ureters in duplication anomalies.

Expect the unexpected

To describe our experience with a series of 3 children with the most common congenital uropathy, pelviureteric junction obstruction (PUJO), presenting with uncommon or life-threatening complications from the PUJO itself, or complications of pyeloplasty surgery. The first case (5 year old) presented obtunded with malignant hypertension and PRES (posterior reversible encephalopathy syndrome). She was found to have a severe PUJO with a ruptured renal calyx and large compressive sub capsular urinoma. This Page-kidney type phenomenon was driving the severe hypertension. She was managed with a drain for the sub-capsular urinoma, medical hypertension control and emergency retrograde JJ stent insertion across the PUJO. The second case (infant) presented in acute renal failure and was found to have bilateral PUJO on imaging. She underwent emergency retrograde JJ stenting of the more severely hydronephrotic kidney. The third case (infant) presented with recurrent PUJO and underwent Redo Pyeloplasty. Post-operatively, the distal end of the JJ stent was coiled in the lower ureter, causing a complete obstruction at the VUJ, with perinephric leak from the pyeloplasty wound. The lower end of the stent was negotiated into the bladder with the help of a ureteroscope and without disturbing the pelvic end of the JJ stent. Case1-Recovered well, hypertension resolved and pyeloplasty done electively. Case2-Renal parameters normalised after JJ stent placement, followed by elective pyeloplasty. Case 3-Perinephric leak settled, JJ stent removed after 8 weeks. PUJO, a common uropathy, can be associated with uncommon and severe complications: requiring awareness, prompt diagnosis and astute timely management to tide over the threatening scenarios.

Incidence of Stone Retropulsion in Ureteroscopic Pneumatic Lithotripsy for lower ureteric stones by using stone cone.

Objectives: To measure the incidence of stone Retropulsion and its complication in ureteroscopic pneumatic lithotripsy for lower ureteric stones by using stone cone. Study Design: Observational cross sectional study. Setting: Gujranwala Medical College, Gujranwala. Period: January 2017 to December 2018. Material &amp; Methods: Consecutive simple random sampling technique was used. Total 120 patients were treated with URS pneumatic lithotripsy for single ureteric stone were enrolled in study. The diagnosis was established by plain spiral CT scan in all patients. The incidence of stone Retropulsion and complications of procedure were noted. Data was analyzed using SPSS 22.0, chi square test was used to check stratification of data, p value less than 0.05 was taken significant. Results: The stone was in lower ureter in all patients who were included in study regardless of side. The mean age of patients was 46±2.6 years and 65% (78) patients were male while 35% (42) patients were females. Success rate of 97.5% (116) achieved in patients in which stone cone was used. Conclusion: Use of stone cone gives high success rate in preventing stone Retropulsion by using pneumatic lithotripsy.

A Case of Recurrent Uterine Leiomyosarcoma Treated with Complete Laparoscopic Resection

Video Objective Uterine leiomyosarcoma (uLMS) is aggressive mesenchymal neoplasm and is associated with a high risk of recurrence and poor prognosis. The 5year overall survival rate is about 60% even in FIGO stage I disease. There is no firm evidence of chemotherapy, so surgical resection should be considered to control the disease in case of localized recurrence. We will report a case underwent total laparoscopic complete resection for recurrent mass involved sigmoid colon and right ureter. Setting Gynecology and Obstetrics department of a general hospital. Interventions The patient was a 56-year-old woman underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy for enlarged 9cm cervical leiomyoma. The pathological examination of the uterus resected showed cytologic atypia,nuclear mitoses and coagulative necrosis, she was diagnosed as primary uLMS, stageⅠB. She rejected to receive adjuvant chemotherapy. After 7months, the isolated metastasis in pelvic and lung was suspected. Magnetic resonance imaging revealed that the 4cm tumor possibly be involved sigmoid colon and right lower ureter. Resection of the recurrent mass with segmental bowel resection and partial resection of ureter with ureteroneocystotomy was performed laparoscopically without any complications. Complete tumor resection with histologic negative margins was achieved. She had postoperative adjuvant chemotherapy with doxorubicinfor 6 cycles and additional surgery for lung meta is scheduled. Also, we experienced another three salvage cases with successful resection in combination with laparoscope and thoracoscope. Conclusion The surgical indications for recurrent uLMS should be selected, but the complete resection of localized recurrence may lead to control the disease. Minimally invasive approach may be one of the feasibleoption.

Minimally Invasive UV Fistula Repair with the Aid of Laparoscopic Ureteroneocystostomy

Video Objective We will present two cases which suffered from ureteral vaginal fistula after hysterectomy and underwent repair at our institute. Setting Urban general hospital Japan. Interventions Case 1 complained of fluid leakage two days after laparoscopic hysterectomy. CT showed leakage of urine from the lower ureter. Case 2 was referred to us from another institute after suffering from vaginal fluid leakage for four years. This case underwent abdominal hysterectomy four years ago and two weeks later the patient complained of fluid leakage. Six months later, an urologist made an attempt to repair the fistula but was unsuccessful due to the amount of adhesion the patient was suffering. For Case 1, we performed a laparoscopic uteroneocystostomy with a psoas hitch, which facilitated a tension-free anastomosis for this patient. The most important point of this surgery is meticulous dissection without impairing blood perfusion. This was extremely difficult in Case 2 due to extensive and severe adhesion. Laparoscopic skills for this reconstruction such as laparoscopic suturing and knowledge of fundamentals like tension and torsion free anastomosis are vital for the success of the surgery. No patients experienced stenosis or leaks and no other complications occurred and no blood transfusions were required. The fistulas were repaired without sequel. The patients were able to ambulate and take a normal diet the day after the surgery and could be discharged 4 days after surgery. Conclusion Although knowledge of reconstruction and laparoscopic skills such as intracorporeal suturing and ligation are difficult to master, this technique is valuable in its feasibility and patient friendliness.

Thermal effect of holmium laser lithotripsy under ureteroscopy.

Thermal effect of holmium laser lithotripsy under ureteroscopy.

Factors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic: results from the Multi-centre cohort study evaluating the role of Inflammatory Markers In patients presenting with acute ureteric Colic (MIMIC) study.

To assess the relationship of white blood cell count (WBC) and other routinely collected inflammatory and clinical markers including stone size, stone position, and medical expulsive therapy use (MET), with spontaneous stone passage (SSP) in a large contemporary cohort of patients with acute ureteric colic, as there are conflicting data on the role of WBC and other inflammatory markers in SSP in patients with acute ureteric colic. Multicentre retrospective cohort study coordinated by the British Urology Researchers in Surgical Training (BURST) Research Collaborative at 71 secondary care hospitals across four countries (UK, Republic of Ireland, Australia, and New Zealand). In all, 4170 patients presented with acute ureteric colic and a computed tomography confirmed single ureteric stone. Our primary outcome measure was SSP, as defined by the absence of need for intervention to assist stone passage (SP). Multivariable mixed effects logistic regression was used to explore the relationship between key patient factors and SSP. In all, 2518 patients were discharged with conservative management and had further follow-up with a SSP rate of 74% (n=1874/2518). Sepsis after discharge with conservative management was reported in 0.6% (n=16/2518). On multivariable analysis neither WBC, neutrophils count, nor C-reactive protein (CRP) predicted SSP, with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.91-1.04, P=0.38), 1.06 (95% CI 0.99-1.13, P=0.1) and 1.00 (95% CI 0.99-1.00, P=0.17), respectively. MET also did not predict SSP (adjusted OR 1.11, 95% CI 0.76-1.61). However, stone size and stone position were significant predictors. SSP for stones <5mm was 89% (95% CI 87-90) compared to 49% (95% CI 44-53) for stones ≥5-7mm, and 29% (95% CI 23-36) for stones >7mm. For stones in the upper ureter the SSP rate was 52% (95% CI 48-56), middle ureter was 70% (95% CI 64-76), and lower ureter was 83% (95% CI 81-85). In contrast to the previously published literature, we found that in patients with acute ureteric colic who are discharged with initial conservative management neither WBC, neutrophil count, nor CRP, helps determine the likelihood of SSP. We also found no overall benefit from the use of MET. Stone size and position are important predictors and our present findings represent the most comprehensive SP rates for each millimetre increase in stone size from a large contemporary cohort adjusting for key potential confounders. We anticipate that these data will aid clinicians managing patients with acute ureteric colic and help guide management decisions and the need for intervention.

A Case of Localized Amyloidosis of the Right Ureter Treated Effectively by Occulusive Dressing Technique Therapy Using Dimethyl Sulfoxide : Long-Term Follow-Up of Eight Years

The patient was a 56-year-old female. She was referred to our department for further examination of right hydronephrosis in 2010. Computed tomography (CT) showed right hydronephrosis, and retrograde pyelography (RP) revealed stenosis of the right lower ureter. Urine cytology was negative. Transurethral biopsy of the right ureter was performed using ureteroscopic cup forceps and the histopathlogical diagnosis was ureteral amyloidosis. A whole-body search was performed, including rectal biopsy, but no evidence of amyloidosis was obtained. She was diagnosed with localized amyloidosis of the right ureter. A ureteral stent was indwelled and the patient was given occulusive dressing technique (ODT) therapy using dimethyl sulfoxide (DMSO) for 1 year. After ODT therapy, right hydronephrosis improved. After a 2-year followup, it worsened. ODT therapy was restarted and continued for 2 years. She consulted our department because of fever and right lumbago in April 2017 after a 4-month interruption of ODT therapy. CT revealed progression of the right hydronephrosis. A ureteral stent was indwelled and ODT therapy was restarted. The right hydronephrosis improved after 1 year. ODT therapy using DMSO was effective for localized ureteral amyloidosis, but periodic follow-up was necessary and ODT therapy was also effective when it recurred after the interruption of treatment.

In vitro study of age-related changes in human ureteral failure properties according to region, direction, and layer.

Knowledge of the capacity of the ureteral wall to withstand urodynamic or external stresses is essential to understand ureteral injury and rupture that mostly occur following trauma, but may also be secondary to obstructive uropathy. It has clinical significance as well in the prevention of iatrogenic injury, for example, during ureteroscopy, but no information is available with regard to the age-related failure properties and regional differences have not been systematically described. Uniaxial tensile testing was performed on 166 ureteral rings and strips from 21 humans free of overt urologic disease; histological evaluation was performed. The degree of layer participation to the intact wall failure stress (=tissue strength), peak elastic modulus (=stiffness), and failure stretch (=extensibility) was assessed by examining layer-specific ruptures in the stress-stretch data. Failure stress at and peak elastic modulus before the first (muscle/adventitial) rupture correlated inversely less with age ( p < 0.05 in few regions/directions) than failure stress at the second (mucosal) rupture ( p < 0.05 in the middle and lower ureter), consistent with the decreased mucosal thickness in ≥50-year-old subjects. Failure stretch at both ruptures did not correlate with age ( p > 0.05 in most regions/directions), paralleling elastin content. Correlations with age were more significant in females than males. Failure stress at the second rupture point was higher ( p < 0.05) distally in <50-year-old but not in ≥50-year-old subjects, justified by the increased collagen distally in the former. Directional differences in failure stretches ( p < 0.05 at all ages/regions/genders) were justified by preferentially axial collagen reinforcement. The presented results may establish the foundation for computational models of iatrogenic/accidental ureteral trauma.