Lower Ureter Research Articles

Efficacy of Low-Dose Deflazacort with Tamsulosin in the Medical Expulsive Therapy of Distal Ureterolithiasis: A Randomized Controlled Trial

Introduction: Distal ureterolithiasis, characterized by stones in the lower ureter, poses significant challenges in clinical management. Medical expulsive therapy (MET) using Tamsulosin is a common non-invasive treatment, but its efficacy can be limited, especially for stones larger than 5 mm. Deflazacort, a corticosteroid with anti-inflammatory properties, may enhance the effectiveness of Tamsulosin by reducing ureteral inflammation and facilitating stone passage. Methods: This prospective, randomized controlled trial enrolled 80 patients with distal ureteral stones <8 mm. Participants were randomly assigned to receive either Tamsulosin alone or Tamsulosin with Deflazacort for 28 days. Primary outcomes included stone expulsion rate and time, while secondary outcomes were pain reduction, analgesic use, and adverse effects. Results: The combination therapy group showed a higher expulsion rate (85% vs. 70%) and significantly faster expulsion time (10.1 days vs. 13.9 days, p=0.006). Pain reduction was greater in the Deflazacort group, with fewer colic episodes and reduced analgesic requirements. Adverse effects were comparable between the groups, with no significant increase in major side effects in the combination therapy group. Conclusion: The addition of low-dose Deflazacort to Tamsulosin significantly improves stone expulsion rates, reduces expulsion time, and lowers pain levels in patients with distal ureterolithiasis, without increasing major adverse effects. This combination may represent a superior treatment option in MET for distal ureteral stones.

ESWL EFFICACY FOR VARIOUS DENSITY STONES (HU) ON PLAIN CT SCAN

Extracorporeal Shock Wave Lithotripsy (ESWL) is a keystone in the harmless management of urinary tract stones, offering a viable alternative to surgical mediation for patients pained by urolithiasis. Objectives: The study aims to find the ESWL efficacy for various density stones (HU) on plain CT scans. Methods: This observational study was conducted at CMH Lahore from February 17, 2024, to May 16, 2024. Data were collected from 180 patients suffering from renal stones. Males represented 60% (108 patients), while females 40% (72 patients). Predominantly, stones were located in the renal pelvis (45%), followed by the upper ureter (30%) and lower ureter (25%). The mean stone size was 10 mm, ranging from 5 to 20 mm, with a corresponding mean stone density of 900 Hounsfield Units (HU) as measured on Plain CT Scan. Results: Data were collected from 180 patients. The mean age of the patients was 50.98±2.34 years. There were 60% male and 40% female patients. According to stone location, 45% are located at the renal pelvis, 30 at the upper ureter and 25% at the lower ureter. A mean reduction in the stone size of 65% post-treatment underscores the procedure's ability to facilitate stone disintegration. Stone-free rates varied based on stone density, with higher rates observed for stones with lower densities: 85% for stones ≤ 700 HU, 75% for stones > 700 HU and ≤ 1000 HU, and 65% for stones > 1000 HU. Conclusion: It is concluded that an accurate assessment of stone density and ESWL score is vital in directing treatment decisions and upgrading outcomes for patients going through ESWL for urinary stones. These findings highlight the importance of personalised treatment approaches and the potential of the ESWL score as an essential tool in clinical practice.

Hypothesis Explaining Development of Squamous Cell Carcinoma During Infection with Schistosoma Haematobium

Schistosome worms are blood-dwelling flukes that cause chronic infection in more than 200 million people and are thought to be responsible for 500,000 deaths annually. During infection with Schistosoma haematobium, eggs are deposited in the mucosa and submucosa of the bladder and lower ureters. Squamous cell carcinoma (SCC) of the bladder is a long-term sequela of chronic infection. The mechanisms underlying the association between S. haematobium and SCC of the bladder are largely unknown, with all reports to date exclusively demonstrating epidemiological evidence linking S. haematobium infection with SCC of the bladder. Scientists hypothesised that the parasite antigens might induce alterations in epithelial cells towards cancer. Scientists used Chinese Hamster Ovary (CHO) cells and treated the cells in culture with S. haematobium total antigen (Sh). Results showed increased proliferation, increased S-phase and decreased apoptosis, as well as down-regulation of tumor suppressor p27 and up-regulation of anti-apoptotic molecule Bcl-2 (Botelho et al., 2009). Angiogenesis is defined as the formation of new blood vessels from preexisting ones and is recognized as a key event in cell proliferation and carcinogenesis and spread of malignant lesions (Dematei et al., 2017). S. haematobium is classified as a Group 1 carcinogen by the World Health Organization’s International Agency for Research on Cancer (Hodderet al., 2000). Another factor that may play a major role in bladder carcinogenesis in schistosomiasis patients is the presence of continuous physical irritation and inflammation produced by Schistosoma eggs in the bladder mucosa. The adult S. haematobium worms inhabit the veins of the perivesical plexus, where the female lays eggs. Some eggs pass through the bladder mucosa and are excreted in the urine. Other eggs are trapped in the tissue. A chronic inflammatory reaction is initiated, with the invasion of histiocytes and other inflammatory cells into the bladder, the formation of granulomas and eventually fibrosis. In addition, the eruption of the eggs through the mucosa stimulates reparative urothelial hyperplasia and cell turnover (Rosin et al., 1994). In our article we try to explain possible mechanism of conversion normal cells into tumor cells from the position of karyogamic theory.

The impact of routine frozen section analysis during nephroureterectomy or segmental ureterectomy for urothelial carcinoma on final surgical margin status and long-term oncologic outcome.

The utility of intraoperative frozen section analysis (FSA) at the surgical margins (SMs) in patients with upper urinary tract cancer has not been established. We herein assessed the clinical significance of routine FSA of ureteral SMs during nephroureterectomy (NU) or segmental ureterectomy (SU). A retrospective review of our Surgical Pathology database identified consecutive patients undergoing NU (n=246) or SU (n=42) for urothelial carcinoma from 2004 to 2018. FSA (n=54) was correlated with the diagnosis of frozen section controls, the status of final SMs, and the prognosis of patients. During NU, FSA was performed in 19 (7.7%) patients and was significantly more often requested in cases with ureteral tumor (13.1%) than in those with renal pelvis/calyx tumor (3.5%). Final SMs at the distal ureter/bladder cuff were positive only in non-FSA cases in the entire NU cohort (8.4%; P=0.375) or those with tumor at the lower ureter (57.6%; P=0.046), but not in any of FSA patients (0%). During SU, FSA was performed in 35 (83.3%) cases, including 19 at either proximal or distal SM and 16 at both SMs (SU-FSA2). Final positive SMs were significantly more often detected in non-FSA patients (42.9%) than in all FSA (8.6%; P=0.048) or SU-FSA2 (0%; P=0.020) patients. Overall, FSAs were reported as positive or high-grade carcinoma (n=7), atypical or dysplasia (n=13), and negative (n=34), and all these diagnoses were confirmed accurate on the frozen section controls, except one with a revision from atypical to carcinoma in situ. Meanwhile, 16 (80.0%) of 20 cases with initial positive/atypical FSA achieved negative conversion by excision of additional tissue. Kaplan-Meier analysis revealed that SU-FSA did not significantly reduce the risk of tumor recurrence in the bladder, disease progression, or cancer-specific mortality. Nonetheless, NU-FSA was strongly associated with reduced progression-free (P=0.023) and cancer-specific (P=0.007) survival rates, compared with non-FSA, which may imply a selection bias (e.g., FSA for clinically more aggressive tumors). Performing FSA during NU for lower ureteral tumor, as well as during SU, significantly reduced the risk of positive SMs. However, routine FSA for upper urinary tract cancer failed to considerably improve long-term oncologic outcome.

Comparison of reduced lead sets in detection of common ECG abnormalities

The utility of intraoperative frozen section analysis (FSA) at the surgical margins (SMs) in patients with upper urinary tract cancer has not been established. We herein assessed the clinical significance of routine FSA of ureteral SMs during nephroureterectomy (NU) or segmental ureterectomy (SU).A retrospective review of our Surgical Pathology database identified consecutive patients undergoing NU (n=246) or SU (n=42) for urothelial carcinoma from 2004 to 2018. FSA (n=54) was correlated with the diagnosis of frozen section controls, the status of final SMs, and the prognosis of patients.During NU, FSA was performed in 19 (7.7%) patients and was significantly more often requested in cases with ureteral tumor (13.1%) than in those with renal pelvis/calyx tumor (3.5%). Final SMs at the distal ureter/bladder cuff were positive only in non-FSA cases in the entire NU cohort (8.4%; P=0.375) or those with tumor at the lower ureter (57.6%; P=0.046), but not in any of FSA patients (0%). During SU, FSA was performed in 35 (83.3%) cases, including 19 at either proximal or distal SM and 16 at both SMs (SU-FSA2). Final positive SMs were significantly more often detected in non-FSA patients (42.9%) than in all FSA (8.6%; P=0.048) or SU-FSA2 (0%; P=0.020) patients. Overall, FSAs were reported as positive or high-grade carcinoma (n=7), atypical or dysplasia (n=13), and negative (n=34), and all these diagnoses were confirmed accurate on the frozen section controls, except one with a revision from atypical to carcinoma in situ. Meanwhile, 16 (80.0%) of 20 cases with initial positive/atypical FSA achieved negative conversion by excision of additional tissue. Kaplan-Meier analysis revealed that SU-FSA did not significantly reduce the risk of tumor recurrence in the bladder, disease progression, or cancer-specific mortality. Nonetheless, NU-FSA was strongly associated with reduced progression-free (P=0.023) and cancer-specific (P=0.007) survival rates, compared with non-FSA, which may imply a selection bias (e.g., FSA for clinically more aggressive tumors).Performing FSA during NU for lower ureteral tumor, as well as during SU, significantly reduced the risk of positive SMs. However, routine FSA for upper urinary tract cancer failed to considerably improve long-term oncologic outcome.

COMPARATIVE STUDY OF MULTIDETECTOR COMPUTED TOMOGRAPHY (MDCT) WITH ULTRASONOGRAPHY IN ACCURATE DIAGNOSIS OF URETERIC CALCULUS SIZE.

Background The trend of imaging modalities used in the evaluation of urinary system stones had been changed recently due to the developments in computed tomography (CT) technology. The present study was Objective undertaken to nd the accuracy of multi-detector computerized tomography in comparison with ultrasonography for an accurate diagnosis of ureteric calculus size. Methodology Single centre hospital-based comparative cross-sectional study was conducted at Department of Radio-diagnosis, Sri Venkateshwara Medical College Hospital, and Research Centre, a tertiary care teaching hospital located in Ariyur, Puducherry. A total of 118 patients from February 2021 to September 2022 underwent unenhanced multidetector CT and ultrasound for the diagnosis of ureteric calculus size. The mean age was 38.8 ± 14.8 years and 74.5% were males and female to Results male ratio was 1.0:2.9. On CT scans stones were found in the vesicoureteric junction among 12.7% of patients. Ureteric calculi in the upper ureter, mid ureter, and lower ureter were found in 9%, 7%, and 32.2% of patients respectively. Other CT scan ndings included hydronephrosis in 6% of patients, hydroureteronephrosis in 60%, and perinephric fat stranding in 3.4% of patients. In ultrasound, 6% of patients had hydronephrosis and 60% of patients had hydroureteronephrosis. Among the 79 cases with ureteric calculi in CT, 35 cases were found on ultrasound. The sensitivity of diagnosing ureteric calculi using ultrasound is compared with CT and was found to be 44.30% with 100% specicity and 100% PPV, and 46.99% NPV This study concludes that Conclusion multidetector computerized tomography (MDCT) is more accurate when compared to Ultrasonography in the case of ureteric calculus. However, in positive cases of ureteric calculus in ultrasonography, there is no signicant difference in size noted in comparison with computed tomography.

Analysis of the Efficacy and Risk Factors for Failure of Balloon Dilation for Benign Ureteral Stricture

This study aimed to investigate the efficacy of balloon dilation in ureteral stricture and to analyze the risk factors for the failure of balloon dilation, which will hopefully provide some reference for clinicians to develop treatment plans. We retrospectively analyzed 196 patients who underwent balloon dilation between January 2012 and August 2022, 127 of whom had complete baseline and follow-up data. General clinical data, perioperative data, balloon parameters at the time of surgery, and follow-up results were collected from the patients. Univariate and multivariate logistic regression analyses were performed for the risk factors for surgical failure in patients undergoing balloon dilatation. The success rates of balloon dilatation (n = 30) and balloon dilatation combined with endoureterotomy (n = 37) for lower ureteral stricture at 3 months, 6 months, and 1 year were 81.08%, 78.38%, and 78.38% and 90%, 90%, and 86.67%, respectively. The success rates of balloon dilation at 3 months, 6 months, and 1 year in patients with recurrent upper ureteral stricture after pyeloplasty (n = 15) and primary treatment (n = 30) were 73.33%, 60%, and 53.33% and 80%, 80%, and 73.33%, respectively. The success rates of surgery at 3 months, 6 months, and 1 year for patients with recurrence of lower ureteral stricture after ureteral reimplantation or endoureterotomy (n = 4) and primary treatment with balloon dilatation (n = 34) were 75%, 75%, and 75% and 85.29%, 79.41%, and 79.41%, respectively. Multivariate analysis of the failure of balloon dilation showed that balloon circumference and multiple ureteral strictures were risk factors for balloon dilation failure (OR = 0.143, 95% CI: 0.023-0.895, p = 0.038; OR = 1.221, 95% CI: 1.002-1.491, p = 0.05). Balloon dilation combined with endoureterotomy in lower ureteral stricture had a higher success rate than balloon dilation alone. The success rate of balloon dilation in the primary treatment of the upper and lower ureter was higher than that of balloon dilation in the secondary treatment after failed repair surgery. Balloon circumference and multiple ureteral strictures are risk factors for balloon dilation failure.

Value of preoperative ureteral wall thickness in prediction of impaction of ureteric stones stratified by size in laser ureteroscopic lithotripsy

ObjectivesTo evaluate the role of preoperative UWT in the prediction of impaction of ureteral stones stratified according to stone size in ureteroscopic laser lithotripsy.Patient and methodsThis study included 154 patients submitted to URSL for ureteral stones. Radiological data comprised the presence of hydronephrosis, anteroposterior pelvic diameter (PAPD), proximal ureteric diameter (PUD), and maximum UWT at the stone site. Collected stone characteristics were stone size, side, number, site, and density.ResultsThe study included 154 patients subjected to URSL. They comprised 74 patients (48.1%) with impacted stones and 80 (51.9%) with non-impacted stones. Patients were stratified into those with stone size ≤ 10 mm and others with stone size > 10 mm. In the former group, we found that stone impaction was significantly associated with higher PAPD, PUD, and UWT. In patients with stone size > 10 mm, stone impaction was related to higher UWT, more stone number, and higher frequency of stones located in the lower ureter. ROC curve analysis revealed good power of UWT in discrimination of stone impaction in all patients [AUC (95% CI) 0.65 (0.55–0.74)] at a cut-off of 3.8 mm, in patients with stone size ≤ 10 mm [AUC (95% CI) 0.76 (0.61–0.91)] at a cut-off of 4.1 mm and in patients with stone size > 10 mm [AUC (95% CI) 0.72 (0.62–0.83)] at a cut-off of 3.0 mm.ConclusionsStratifying ureteric stones according to size would render UWT a more practical and clinically-oriented approach for the preoperative prediction of stone impaction.

Role of Patient Age and Stone Density in Predicting Outcomes of Shockwave Lithotripsy in Lower Ureteral Stones.

Shockwave lithotripsy (SWL) is an important tool for treating ureteral stones, especially when ureteroscoy (URS) is not readily available. The aim of the study was to identify factors associated with the success of shockwave lithotripsy (SWL) in the treatment of lower ureteral stones. Total of 105 consecutive patients with single lower ureteral stones treated with SWL between January 2021 and February 2022 were reviewed retrospectively. Clinical and stone parameters including age, gender, and body mass index (BMI), stone length, and stone density were analyzed. SWL procedures were done using electro-conductive lithotripter Sonolith i-sys (EDAP TMS, Vaulx-en-Velin, France). We evaluated available clinical and radiologic features that might have been related to successful SWL treatment. Treatment was successful in 67/105 patients (63.8%). Multivariate logistic regression revealed that a successful outcome was significantly related to mean stone density (MSD) (95% CI: 1.004- 1.009) and the patients age (95% CI: 1.022- 1.13). Gender, BMI, and stone length were not an independent predicting factors. Stone density and patient age were independent predictors of successful outcome after two SWLs in the lower ureter. However, gender, BMI, and stone length did not independently predict treatment success.

Emergency extracorporeal shock wave lithotripsy: A study on feasibility and efficacy in stone clearance and reducing morbidity in ureteric and renal stones with colic.

Evaluation of safety, efficacy, and feasibility of emergency extracorporeal shockwave lithotripsy (eESWL) in combating obstructing stones with colic on emergency basis. From November 2019 to November 2021, 102 subjects underwent emergency ESWL for obstructing ureteric and renal stones with colic within 24 h of presentation. Patients in this study belonged to age group of 18-67 years with mean being 39 years consisting of 85 males and 22 females (M:F = 85:22). Mean stone dimensions were 8.26 mm in length and 7.65 mm in width. A total of 42 patients had their stone in kidney or upper ureter while 24 patients had stone in mid ureter and remaining patients (n = 36) had stone in lower ureter. About 65 patients had their stone completely cleared after single ESWL session while 20 patients required multiple sessions to achieve complete clearance. Of these 17 patients (16.67%) were not rendered stone free even after three sessions and had to undergo ureteroscopic lithotripsy (URSL). Overall Stone Free Rate (SFR) was 83.33%. For stone attenuation of ⩽900 HU, SFR was 97.18% while for >900 HU it was only 51.61%. eESWL is safe, feasible, and efficacious noninvasive alternative for definitive management of obstructing ureteral and renal stones with colic as far as stone clearance and rapid and definitive pain relief are concerned and that too with very minimal morbidity without the need for admission and hence can reduce the prolonged waiting period for endoscopic stone surgery in any high-volume tertiary care hospital. Length, width, and attenuation of stone were found to be the main factors dictating the success of eESWL.

Diagnostic value ultrasound signs of stones less than or equal to 10 mm and clinico-radiological variants of ureteric colic

ObjectiveTo determine the diagnostic value of ultrasound signs of urinary stones less than or equal to 10 mm and to determine clinico-radiological variants of ureteric colic. MethodsA total of 455 ultrasound investigations were performed in patients referring to emergency department with urolithiasis and symptoms suspected of ureteric colic between January 2021 and May 2021. In addition to microscopic evaluation of urine sediment to detect different crystals and non-contrast spiral computed tomography to detect stones, B-mode and color Doppler sonography was performed to assess the presence of acoustic shadow (AS) and twinkle artifacts (TA) as possible signs of stone(s) in ureter. ResultsWhile the sensitivity and specificity of AS and TA were higher than 90% in patients with stones greater than 5 mm; positive prognostic values of these parameters were found to be extremely low for stones with sizes of 1–3 mm with specificity and sensitivity values not exceeding 53%. The sensitivity and specificity of AS and TA in the upper and lower ureters were higher for stones greater than or equal to 5 than for compared to those less than 5 mm. At the same time, the diagnostic values of TA and AS for middle ureter stones were very limited. The most prevalent clinico-radiological variants of ureteric colic were types I, III, and V being observed in 39%, 28% and 21% cases, respectively. ConclusionOur results demonstrate that TA and AS parameters seem to have a very low sensitivity and specificity in the diagnosis of urinary stones less than 5 mm. The diagnostic value of TA and AS increase significantly in stones greater than or equal to 5 mm. Therefore, clinicians need to be very careful for overestimating the diagnostic values of TA and AS for stones less than 5 mm and non-contrast spiral computed tomography must be the method of choice for patients presenting to emergency department with ureteric colic.

Efficacy of Pneumatic Lithoclast in Management of Different Metabolic Stones in Lower Ureter

Background: Management of ureteral calculi represents one of the complex problems in urological practice. Aim: To study the efficacy of pneumatic lithoclast as a management option for different metabolic ureteric stones. Study design: Descriptive study. Methodology: Study enrolled both male and female patients (n=60) above 12 years of age. Stone size and metabolic type was determined with determining the Hounsfield units of the stone on plain abdominal CT scan and matching them with the predetermined ranges for specific stone types. Renal transplant and cancer patients were excluded. SPSS v.26 analyzed the data. Mean±SD presented quantitative variables. Results: Calcium oxalate stones were most frequent and were observed in 32 (53.3%) patients followed by Struvite (18.3%). Almost 96.7% ureteric stones were cleared with pneumatic lithoclast. Conclusion: It was concluded that pneumatic lithoclast is an efficacious procedure in urology in clearing different metabolic stones in lower ureter thus advocates its routine use. Keywords: Pneumatic Lithotripsy, Metabolic Stones and Ureteric Stone.

571 Evaluating the Effectiveness of Extracorporeal Shockwave Lithotripsy (ESWL) for Ureteric Stones During COVID-19 Pandemic - A Single Centre Experience

AimReliance on ESWL for treating ureteric stone has increased during the COVID-19 pandemic. We examined the outcomes for ureteric stones treated with our on-site lithotripter to assess the success rate and determine the variables that could affect the outcome results.MethodA retrospective review using electronic records and images of patients who underwent ESWL for ureteric stones (January to December 2020). Univariate and multivariate analysis used to determine stone-free rate predictors (Stone Free rate/SFR: No residual stones on post-ESWL imagining).ResultsA total of 36 patients underwent ESWL for ureteric stones. Mean age was 58 years (21–90), and mean stone size was 8 mm (5–20). Stones were located in the proximal (67%) or lower ureter (33%). Overall SFR was 64% (67% proximal, 33% distal). 64% of patients required only one session to be stone free, with 60% stone free after two sessions. Stones <10mm had a SFR of 67%, compared to 58% for stone >10 mm. The only statistically significant predictor was stone size (longest dimension, p=0.04). No statistical significance with stone location (P=0.09), skin-to-stone distance (SSD) (P=0.7), stone density (P=0.3) or stone volume (P=0.3). In treatment failure, time to definitive ureteroscopy was 4 weeks.ConclusionOur overall SFR was slightly lower than expected but comparable to available literature. This data highlights the importance of patient selection for ESWL and would be useful in counselling about local success rate. More than half of the patients required only one session for stone clearance and stone size was the only significant predictor for successful ESWL.

Removal of a Foley catheter misplaced into the ureter by percutaneous puncture: a rare case report

BackgroundThe incidence of aberrant catheterization into a ureter is extremely low, and there is a 20% chance that the balloon cannot be deflated. Regrettably, the mechanism underlying this complication remains unknown. There has been no reported case of a Foley catheter successfully removed from the ureter via percutaneous puncture.Case presentationA 86-year-old man complained of increasing abdominal pain after an 18F Foley catheter was inserted into his urethra. His attending physician attempted but failed to deflate the balloon. A bedside ultrasound and CT scan revealed that the catheter tip was in the right lower ureter. Several measures, including cutting the catheter and inserting a rigid guidewire, were then attempted but failed to deflate the balloon. Finally, the inflated balloon was punctured with a PTC needle under ultrasound-guidance, and the misplaced Foley catheter was removed. Two days after the pelvic drainage tube was removed, the patient was discharged.ConclusionThis is the first reported case of a Foley catheter being removed from the ureter via percutaneous puncture. The mechanism by which the balloon is unable to deflate may be related to the passive twist of the catheter. In such a case, an overall assessment of the patient's condition should be performed, and non-invasive to invasive interventions should be phased in.

Laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures: our experience.

This study was designed to evaluate the feasibility of laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures of the middle and lower ureters. By observing its curative effect and prognosis, we can provide a safer and reliable treatment option for patients with middle and lower ureteral injury. In this study, of the eight cases under study, five were diagnosed with long-segment ureteric strictures, one had long-segment ureteric avulsion, one was diagnosed with ureteral rupture caused by surgical injury of appendicitis, and the remaining one underwent ureterostomy after ureteralinjury. The location of ureteral injury was in the middle lower segment. All eight patients underwent laparoscopic ureteral reimplantation with a Boari flap from January 2018 to October 2021. In this study, two patients were treated with a Boari bladder flap with psoas hitching. All procedures were performed by the same surgeon with over 20years of experience in urological surgery. The mean length of ureteric avulsion or ureteric strictures was 7.94cm (range, 4-15cm). Laparoscopic ureteral reimplantation with a Boari flap was performed successfully between 120 and 240min. The mean duration of postoperative hospital stay was 6days, and no major complications related to the procedure in the perioperative period occurred. Postoperative follow-up showed no obvious hydronephrosis on computed tomography urography or urinary ultrasound in all eight patients. Postoperative reexamination did not reveal any significant hydronephrosis, urinary tract infection, or ureteral reflux, and none of the postoperative renal functions were abnormal. Laparoscopic ureteral reimplantation with a Boari flap is safe and feasible for experienced physicians. In our case, the length/width ratio of bladder flap is more than 4:1, with good blood supply and no obvious complications, it provides a longer alternative length.

Initial experience of transurethral-assisted laparoendoscopic single-site nephroureterectomy

PurposeWe describe a new transurethral technique for distal ureter management and the improvement of intraoperative exposure during LESS-NU. MethodsA total of 20 transurethral assisted LESS-NU were performed between May 2018 and December 2020 in our institution. The access route for the operation was via a single-port, with four channels placed through a transumbilical incision. After the lower ureter was separated from the bladder wall, a 1470 laser working channel was placed through the urethra to precisely cut the ureteral orifice. Following this, a self-made urethra auxiliary port was inserted through the bladder cuff opening to facilitate a resection of the ureter and kidney. The peri-operative and postoperative data were then retrospectively collected and analysed. ResultsAll procedures were completed successfully and one patient needed an additional port. The mean operative time was 196.8 ± 45.8 min and the mean estimated blood loss was 58.9 ± 32.0 ml. The days required for the surgical drain removal and the hospital stay were 4.6 ± 4.6 and 11.1 ± 6.4 days, respectively. One patient developed a fever following surgery but there were no major complications. During the average follow-up period, which lasted 25.5 months, one patient developed spinal cord metastasis and died 8 months after surgery. No obvious abnormalities were found in any of the other patients. ConclusionThe tansurethral approach of the distal ureter for LESS-NU is deemed safe and efficient. The technique used offers accurate control of the distal ureter and good exposure of LESS.

Reducing the rate of negative ureteroscopy: predictive factors and the role of preoperative imaging.

The aim of this study was to investigate factors that may predict a negative ureteroscopy (URS) performed for ureteric calculi in prestented patients and to assess preoperative imaging in reducing the rate of negative URS. Data were collected on emergency stent placement for a ureteric calculus from April 2011 to February 2016 (Group A) and October 2016 to October 2019 (Group B). Data included patient demographics, indication for a stent, stone characteristics, baseline bloods, urine culture, readmission, negative URS rate and the use of pre-URS imaging. Multivariate logistic regression was used for statistical analysis. Of 257 patients who underwent emergency stent insertion, 251 underwent deferred URS for a ureteric calculus and 6 avoided URS due to pre-URS imaging. Indications for stent were pain (42%), sepsis (39%) and acute kidney injury (19%). Mean stone size was 7.8mm, mean stone density was 699 Hounsfield units (HU) and the stone locations were upper (62%), mid (13%) and lower ureter (25%). The overall negative URS rate was 12%. The negative URS rate was lower in patients with pre-URS imaging compared with those with none, 6% and 14%, respectively (OR=2.33, 95% CI: 0.69-7.56, p=0.2214). Logistic regression analysis indicated stone size as the only significant predictor of a negative URS, where the greater the size of the stone the less likely URS would be negative (β=0.75, 95% CI: 0.60-0.94 p=0.011). Utilising pre-URS imaging can lead to a reduction in negative URS rate. Stone size <5mm appears to be the subgroup most likely to benefit from imaging.

The Fate of Double J Stent Used in Pyelolithotomy and Uretero Lithotomy

Background: In Bangladesh there is no complete data which would reflect the idea about the fate of double J stent used in pyelolithotomy and ureterolithotomy. Methods: This was a prospective observational study, conducted at the Department of Surgery, Comilla Medical College Hospital, Comilla, during the 6-month period of June 2013 to November 2013. Fifty patients diagnosed with Nephrolithiasis &amp; ureterolithiasis admitted at the respective hospital were selected as the study sample. Proper informed consent was taken before the data collection from the concerns. Statistical analysis of the results was obtained by using window-based computer software devised with Statistical Packages for Social Sciences (SPSS-22). Result: Among the 50 patients studied, &gt;50% of the patients were distributed among the age group of 31-40 years and next was 21-30 years. 35 patients of the series were male (70%) and 15 were female (30%). In this series, male to female ratio was 2.33:1. Among the 50 stented patients, stone was located in kidney in 30 pts (60%), in upper ureter in 10 pts (20%), in mid and lower ureter in 4(8%) and 6(12%) patients respectively. In this study, the commonest indications of D J stenting were after pyelolithotomy, following ureteroscopy for obstructive uropathy due to ureteric stone. In this study, irritative voiding symptoms like dysuria, frequency/urgency occurred in 20% and 24% respectively, and haematuria in 10% of patients. Stent encrustation in 1 (2%), stent migration in 3 (6%), stent fracture in 1 (2%), urinary infection in 2(4%) and stent colic in 1(2%) were the complications noted. Conclusion: Ureteral stents are a convenient means of drainage for the upper urinary tract. However, their use is not devoid of side effects. Stent placement results in considerable morbidity in the form of irritative lower urinary tract symptoms. The side effects associated with ureteral stents must be kept in mind when deciding on stent placement and dwell time. ............

Использование нейронных алгоритмов при выборе метода оперативного лечения мочекаменной болезни

AIM to assess the possibility of using neural network algorithms in choosing a method for surgical treatment of urolithiasis. MATERIALS AND METHODS treatment results of 625 patients with kidney stones were analyzed in the study. Information about each patient was presented in the form of a multidimensional vector characterized by following preoperative investigations: questionnaires, clinical examination, instrumental and laboratory studies. A register was created where information on more than 50 parameters for each patient was added. Each example has an output parameter representing a predefined treatment strategy (extracorporeal shock-wave lithotripsy [ESWL] - 1, percutaneous nephrolithotomy [PCNL] - 2, pyelolithotomy or nephrolithotomy - 3). The initial database served as the basis for training the neural network estimation technique. RESULTS A prospective trial was conducted to assess the clinical efficiency of the recommendations of neural network. A cohort of 150 patients admitted to the urology department was divided into two groups of 75 people. In the group 1, patients received treatment according to the standard recommendations. In group 2, treatment strategy was chosen based on the results of neural network analysis. In the group 1, ESWL was performed in 40 (53.3%) patients. The average number of sessions was 1.8. At the discharge, residual fragments were diagnosed in 12 (30%) cases. In 4 patients, acute pyelonephritis developed, which required performing ureteral catheterization and subsequent treatment. In group 1, the efficiency of ESWL was 75%. In the group 2, where the neural network assessment technique was used, the average number of sessions was 1.4. At the discharge, 7 (15.6%) patients had residual fragments: 4 in the kidney, in 3 in the lower ureter (steinstrasse). In 4 cases, a conversion for PCNL was performed. ESWL efficiency was 91.1%. Stone-free rate for ESWL in the second group was significantly higher due to the greater number of stone fragmentation. In addition, number of shock waves was lower (the average number of sessions was 0.4 less). Improvement of treatment tactics through the use of neural network algorithms led to a decrease in hospitalization times, as well as to an improvement in the quality of treatment. The low efficiency of ESWL, as the first-line method, led to a change in treatment tactics in 25% of patients in group 1 and only in 8.9% of patients in group 2. Using these algorithms, it was possible to reduce hospitalization time, need for changing treatment strategy, number of auxiliary procedures, readmission rates, the incidence of inflammatory complications, and the number of residual fragments after ESWL. CONCLUSIONS The possibility of using the neural network prediction technique at the preoperative stage in patients with kidney stones has been shown. This technique allows practicing urologist to make a decision on the choice of the optimal treatment method on an individual basis, thereby minimizing the risk of early postoperative complications.

Prediction of the ureteric stone outcome by CT scan

Background and objective: Urolithiasis is prevalent in both developed and developing countries, which is attributed to changes in lifestyles. Management of ureteric stones is highly dependent on their characteristics such as volume, size, and density which can be determined based on the images obtained from CT scan. The present study was carried out to examine the association between the final outcomes of the stones and different stone parameters specified by CT scan. Methods: The present prospective cross-sectional study consisted of 100 patients who had been referred to the Radiology Department of Rizgary and Erbil Teaching Hospitals in Erbil, Kurdistan Region, Iraq, over six months in 2019 to undergo abdominal CT scan with clinical suspicion of ureteric stones. All patients underwent non-contrast MDCT scan, and the CT images were evaluated for the presence of ureteric stone, site of the stone, side, diameter in three planes, volume, and density. The outcome of the stone was correlated with each above variables. Results: Ureteric stones were more prevalent among the young and middle age group (25-64 years) with an approximate male-to-female ratio of 3.34:1. There were significant associations between stone outcomes (i.e. spontaneous passage or need for intervention) and the stone characteristics including volume (P &lt;0.001), density (P &lt;0.001)site (upper, mid and lower ureter) (P = 0.02), anteroposterior diameter (P &lt;0.001), transverse diameter (P = 0.006), and superior inferior diameter (P &lt;0.001). Conclusion: Upon the significant correlation between the spontaneous passage of ureteric stones and their characteristics (i.e., volume, density, site, anteroposterior diameter, transverse diameter, and superior inferior diameter), it is highly recommended that all patients with urolithiasis undergo CT scan examination in order to make the proper decision regarding stone management. Keywords: Ureteric stones; CT scan; Stone characteristics; Spontaneous passage.