Lower Ureter Research Articles

Palliative Care of Malignant Ureteral Obstruction with Polytetrafluoroethylene Membrane-Covered Self-Expandable Metallic Stents: Initial Experience

PurposeWe assessed the efficacy and safety of insertion of a polytetrafluoroethylene membrane-covered self-expandable metallic stent (UVENTA stent) for palliation of malignant ureteral obstruction on the basis of our early results.Materials and MethodsEighteen patients underwent UVENTA stent insertion for extrinsic malignant ureteral obstructions of 20 ureters. The UVENTA stents were deployed retrogradely under cystoscopy and fluoroscopy. Candidates for the procedure had preexisting double-J stents that were nonfunctional or caused excessive bladder irritation. We recorded the success and patency rate in addition to any complications associated with the procedure.ResultsThe mean length of obstruction was 10.6 cm (range, 2 to 20 cm). Two ureters were obstructed in the upper ureter, 9 in the lower ureter, and 9 in multiple levels of ureter. Simultaneous balloon dilation was performed in 12 ureters. UVENTA stents were successfully inserted in all patients. No obstruction of the UVENTA stents occurred during the mean follow-up period of 7.3 months (patency rate 100%), but de novo ureteral obstruction developed in 4 ureters. There were no instances of stone formation, hyperplastic reaction, encrustation, or migration. Abnormally elevated serum creatinine decreased to normal levels and hydronephrosis gradually resolved during the 4 weeks after UVENTA insertion. No significant complications developed except for transient and self-limiting hematuria and mild lower abdominal pain.ConclusionsUVENTA stents may relieve malignant ureteral obstruction safely and easily. Long-term follow-up is necessary to assess the role of this stent in the treatment of malignant ureteral obstruction.

Forgotten double J stent in the urinary bladder with calculus formation

Received: 23 March 2011 Accepted: 22 August 2011 Published: 30 Apri l 201 2 CASE REPORT A 40­year­old male patient came with complaints of frequency of micturition, dysuria and intermittency for six months. He underwent left uretero­renoscopic lithotripsy one year back for one cm calculus in the lower ureter. His general physical examination was unremarkable excepting for mild suprapubic pain. On investigation his complete urine examination showed many RBCs but rest of the urine examination was unremarkable. His urine culture was sterile. Plain radiograph of the abdomen revealed a radio­opaque shadow encasing a retained DJ stent which slipped into the bladder (Figure 1). The patient underwent open cystolithotomy and removal of the calculus along with the stent (Figure 2). He is asymptomatic and doing well on follow up. DISCUSSION Since its description by Finney et al. Double J ureteral stents are widely used in urological practice [1]. These stents are used to establish or improve drainage in cases of extrinsic or intrinsic obstruction of urinary passage. They are also placed after iatrogenic injuries to the ureter and prophlactically in complex abdominal CLINICAL IMAGES OPEN ACCESS Kusuma 45

An Unusual Case of Right Retrocaval Ureter Associated With Ipsilateral Ureterocele

A 36-year-old man with right flank pain presented to our institution. Intravenous urography showed mild dilatation of the right pyelocaliceal system and large filling defect in the vesical lumen. Computed tomography revealed the right kidney to be smaller than the left, and with chronic pyelonephritis. The right ureter passed behind the inferior vena cava at the level of the pelvic-ureteral junction. The middle and lower ureter was dilated above a large ureterocele. Cystourethrography showed right vesicoureteral reflux. The patient underwent a resection of the ureterocele with reimplantation of the ureter. Follow-up at 3 months demonstrated resolution of the dilatation of the right ureter.

Endoscopic Management of Ureteral Fibroepithelial Polyps

Introduction: Although the ureteral fibroepithelial polyps are rather uncommon, an increase of their incidence was recorded during the recent period, probably because of better access to the investigative methods.1,2 The aim of this study was to determine the diagnosis and endoscopic treatment particularities in these patients. Materials and Methods: Our experience was based on eight patients evaluated during the last 10 years. The average patients' age was 32 years (between 26 and 49). Hematuria, suprapubic discomfort, flank pain, and urinary frequency were the main symptoms. Diagnosis was based on ultrasonography, intravenous pyelography (IVP), urethrocystoscopy, retrograde ureteropyelography, and ureteroscopy.3,4 Most of the authors report the last open surgical management of these polyps in the 90s.5 Although Ho:YAG laser's properties recommend it now as the ideal tool in ureteral fibroepithelial polyps treatment,4 this energy source is not available in every urological department. In the recent reported series the fibroepithelial polyps were treated using fulguration electrodes, cold biopsy forceps, baskets, lasers, etc.4–6 Results and Conclusions: In three patients were discovered smooth polypoid masses covered by apparently normal urothelium and protruding through the ureteral orifice. In four patients, the fibroepithelial polyps appeared as large ureteral filling defects in the lower ureter. In the last patient, a large, organized, blood clot protruding from the left orifice imposed ureteroscopy with the identification of a mid-ureteral polyp. Seven patients were treated by ureteroscopic Nd:YAG laser ablation. Transureteral resection was applied (the lasers being unavailable in our department at the time) in one patient. We used a Storz 12F ureteroresectoscope with cutting loop. This was the only patient treated by electroresection due to the concerns regarding the potential of the method to generate ureteral strictures. Nd:YAG laser, despite its deeper penetrability by comparison to Ho:YAG, proved to be safe and effective in excising the polyps, offering good control of the tumoral base and ureteral wall. No perforations were encountered in these patients. After complete excision of the polypoid base, a Double-J stent was indwelled for 4–6 weeks. Histology described the lesions as fibroepithelial polyps: hyperplastic urothelium overlying an intact basement membrane with extensive submucosal edema, dilated blood vessels, chronic inflammatory cells, and fibrous stroma. The follow-up protocol included ultrasonography, IVP, retrograde pyelography, and ureteroscopy. No recurrences and no ureteral strictures were found after a mean follow-up period of 48 months (range 3 to 72 months). Ureteral fibroepithelial polyps represent a rare pathology and ureteroscopy remains the gold-standard diagnostic method. The appearance and location of the lesions are pathognomonic, and complete excision may be performed by ureteroscopic approach. Recurrences seem to be rare in these tumors. No competing financial interests exist. Runtime of video: 7 min 1 sec

Stentless pediatric ureteroscopic holmium: YAG laser stone disintegration: is gravels retrieval an issue?

To evaluate the safety and efficacy of stentless pediatric ureteroscopic holmium laser stone disintegration without gravels retrieval. From Feb 2007 to Feb 2010, 21 children (12 boys and 9 girls) with unilateral single stone ureter, with an average age of 8.5 years (range 4-12 years), were treated with 6.9 Fr semirigid ureteroscope for a stone size ranged from 5 to 10 mm (mean 6.5 mm). All the stones were radioopaque, located in the upper ureter in 2 cases (9.5%), in the middle ureter in 5 cases (24%), and in the lower ureter in 14 cases (66.5%). Complete holmium laser stone disintegration was applied in all cases without gravels removal. No postoperative ureteral stent was inserted in any case. The stones were successfully approached and completely disintegrated in a single session in 20 cases (95.2%). All the procedures were done without ureteral orifice dilatation apart from 3 cases where another working guide wire was applied. No intraoperative complications were recorded in the form of mucosal injury, ureteral perforation, or urinary extravasation. There is no early postoperative complication in the form of urinary tract infection or colic apart from single case of hematuria which was successfully treated conservatively. Two weeks postoperatively, KUB (kidney, ureter, and bladder) films were completely free from any significant gravel (>3 mm) and US showed no hydronephrosis. Stentless ureteroscopic holmium laser disintegration without gravels removal is a safe and effective method for pediatric ureteral stone less than 10 mm in diameter.

1690 ROUTINE POSTOPERATIVE IMAGING IS IMPORTANT AFTER URETEROSCOPIC MANAGEMENT OF IMPACTED URETERAL STONES

INTRODUCTION AND OBJECTIVES: Improved endoscope and advanced intracorporeal lithotripsy devices have significantly decreased the incidence of complications during ureteroscopy (URS). Despite recent reports suggesting that routine postoperative imaging may not be necessary in all individuals after URS silent obstruction may develop in some, ultimately resulting in renal damage (Weizer AZ, et al. J Urol 168: 46–50, 2002.) We evaluated the incidence and factors associated with postoperative abnormal imaging and assessed the need for routine postoperative imaging after URS. METHODS: We retrospectively reviewed the records of 323 patients who underwent URS for impacted ureteral stones at our institution. Our URS procedure using a small-caliber ureteroscope and a holmium: YAG laser has been reported previously (J. Urol. 171: 89–91, 2004). All of the patients routinely underwent IVP in order to assess for obstruction or delayed excretion at 1 month after URS. Abnormal imaging was defined when postoperative imaging did not show improvement of hydronephrosis. RESULTS: Of the 323 patients 16 (5%) revealed abnormal postoperative imaging without symptoms. All 16 patients underwent secondary ureteroscopy in order to assess and alleviate obstruction. 16 patients with a mean age of 56 years were included. Mean diameter of the initial target stone was 15 mm (range 2–23) with stone location being 11 upper ureter and 5 lower ureter. Mean duration of impaction was 30 months (range 2–72). Second URS revealed obstruction due to ureteral stricture in 13, complete ureteral occlusion in 2 and ureteral tortuosity in 1. Second URS detected a severe ureteral stricture related to laser therapy distal to the successfully treated stone. The obstruction eventually resolved with endoscopic balloon dilation in 14 out of 16 patients. 2 patients ultimately received ureteroureterostomy and 2 were lost to follow-up. Among these 16 patients, initial URS revealed inflammatory ureteral polyps associated with the calculi in 8 and ureteral stricture in 4. Stone location, stone size, operative time, duration of impaction and stone composition were not associated with abnormal post-URS imaging. CONCLUSIONS: Our analysis suggests that silent obstruction remains a potentially significant complication after URS for long-term impacted ureteral stones which are frequently associated with ureteral polyps and strictures. Therefore, we recommend that routine postoperative imaging should be performed after URS to avoid the potential complications of unrecognized ureteral obstruction.

V863 SINGLE INCISION SURGERY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA (TCC): FEASIBILITY STUDY OF LAPAROENDOSCOPIC SINGLE SITE (LESS) RADICAL NEPHROURETERECTOMY COMBINED WITH RETROGRADE INTRAVESICAL RECONSTRUCTIVE SURGERY (RIVRS)

You have accessJournal of UrologyReconstruction, Transitional Cell Carcinoma & Adrenal1 Apr 2011V863 SINGLE INCISION SURGERY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA (TCC): FEASIBILITY STUDY OF LAPAROENDOSCOPIC SINGLE SITE (LESS) RADICAL NEPHROURETERECTOMY COMBINED WITH RETROGRADE INTRAVESICAL RECONSTRUCTIVE SURGERY (RIVRS) Rajan Sharma, Shashikant Mishra, Abraham Kurien, Arvind Ganpule, Veeramani Muthu, Ravindra Sabnis, and Mahesh Desai Rajan SharmaRajan Sharma Nadiad, India More articles by this author , Shashikant MishraShashikant Mishra Nadiad, India More articles by this author , Abraham KurienAbraham Kurien Nadiad, India More articles by this author , Arvind GanpuleArvind Ganpule Nadiad, India More articles by this author , Veeramani MuthuVeeramani Muthu Nadiad, India More articles by this author , Ravindra SabnisRavindra Sabnis Nadiad, India More articles by this author , and Mahesh DesaiMahesh Desai Nadiad, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.685AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Laparoendoscopic single site surgery (LESS) has been demonstrated to be feasible in various oncological ablative procedures. TCC upper tract traditionally required long and multiple incisions to manage the upper tract and the bladder cuff. With the introduction of laparoscopy, the upper tract incision could be avoided. We extended the LESS principal to radical nephroureterectomy and novel technique of transurethral retrograde intravesical reconstructive surgery (RIVRS) to complete a single incision procedure for TCC upper tract and assessed the feasibility of technique. METHODS 60 year old gentleman on evaluation of one episode of painless gross hematuria was detected to have a 2.9 cm right sided upper pole TCC. He was prepared for LESS radical nephroureterectomy with RIVRS. Patient was placed in lateral position for LESS Radical Nephroureterectomy which was performed using quadport variant of R-port TM (Advanced Surgical Concepts, Ireland) and Olympus endoeyeTM camera with coaxial light cable was used. Ureter was dissected till the bladder, then the patient was placed in supine oblique lithotomy position and bladder resection was done using a combination of hook cautery, and endoscissors. Bladder closure was done by endosutures (extracorporeal knotting) using 3-0 vicryl which were taken endoscopically using Sew right SR-5TM endosuturing instrument. The entire resection and suturing was also monitored laparoscopically through the R-port TM and the specimen was retrieved from the umbilical incision. RESULTS Procedure was completed successfully in a single umbilical incision of 5.5 cm length. The operative time was 210 minutes, estimated blood loss was 110 ml, and post operative hospital stay was 5 days with no complications. The urethral catheter was removed on 10th day after doing a cystogram which showed no leak. Post operative histopathology report revealed Stage T3a TCC (invading the renal parenchyma) and all margins were negative. CONCLUSIONS LESS radical nephroureterectomy combined with RIVRS is an efficient, feasible and minimally invasive technique for endoscopic management of upper and lower ureter in upper tract TCC and allows for primary endoscopic bladder closure and completion of entire surgery in a single umbilical incision preserving good oncological efficacy. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e346 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rajan Sharma Nadiad, India More articles by this author Shashikant Mishra Nadiad, India More articles by this author Abraham Kurien Nadiad, India More articles by this author Arvind Ganpule Nadiad, India More articles by this author Veeramani Muthu Nadiad, India More articles by this author Ravindra Sabnis Nadiad, India More articles by this author Mahesh Desai Nadiad, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V861 LAPAROSCOPIC TRANSVESICAL URETERIC RESECTION AND RE-IMPLANTION

You have accessJournal of UrologyReconstruction, Transitional Cell Carcinoma & Adrenal1 Apr 2011V861 LAPAROSCOPIC TRANSVESICAL URETERIC RESECTION AND RE-IMPLANTION Philippe Grange, Amrith Rao, Davinder Sharma, Christian Brown, and Angelika Zang Philippe GrangePhilippe Grange London, United Kingdom More articles by this author , Amrith RaoAmrith Rao London, United Kingdom More articles by this author , Davinder SharmaDavinder Sharma London, United Kingdom More articles by this author , Christian BrownChristian Brown London, United Kingdom More articles by this author , and Angelika ZangAngelika Zang London, United Kingdom More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.683AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Segmental excision and ureteric re-implantation is an accepted surgical option for benign stricture or localised transitional cell carcinoma (TCC) affecting the lower 1/3rd of the ureter. Most often, the operation is performed by an open approach, but increasingly laparoscopic approach is favoured because of the obvious advantages. One of the difficulties with the laparoscopic approach is dealing with the ureteric orifice & the intra-mural part of the ureter. Although we have performed this technique for benign ureteric strictures, this particular video is about a 62 year old lady with recurrent high-grade superficial TCC in the right lower ureter. With this high definition video, we demonstrate a transvesical laparoscopic lower ureteric excision and re-implantation. METHODS With the patient in lithotomy position, ureteroscopy is performed to look at the length that requires excision. Cystoscopic dismembering of the intramural ureter is carried out upto the perivesical fat using a Collin's knife. The bladder is then distended using the gas insufflation connected to the urethral catheter. A 10 mm VisiportTM along with the camera allows access to the bladder under direct vision. Further two 5 mm ports were inserted under the camera guidance. Bladder was also suspended using two percutaneous stitches, which allowed sufficient working space. Entire operation was performed with gas insufflation of the bladder. Ureter is mobilized further till the desired length of excision. A neo-orifice is created distally and the ureter is brought through this opening into the bladder. The site of the old ureteric orifice is then closed. The diseased distal segment is useful to manipulate the ureter and spatulation is carried out. The ureter is then anchored to the neo-orifice using interrupted sutures. The diseased segment is excised and retrieved urethrally. The guide-wire is passed via the urethra and directed into the ureter. JJ stent is subsequently inserted. RESULTS The total operative time was 180 minutes with blood loss < 50 mL. There were no intra- or post-operative complications. The in-hospital stay was 3 days. The patient was discharged home with a urethral catheter on free drainage, which was removed in 2 weeks after cystogram showing no evidence of leak. At the last follow-up ureteroscopy and multiple biospies, there was no evidence of stricture or disease recurrence. CONCLUSIONS We demonstrate in this video our technique of transvesical laparoscopic excision and ureteric re-implantation. We demonstrate that the short-term functional and oncological outcome is equivalent to the established open approach. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e345 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Philippe Grange London, United Kingdom More articles by this author Amrith Rao London, United Kingdom More articles by this author Davinder Sharma London, United Kingdom More articles by this author Christian Brown London, United Kingdom More articles by this author Angelika Zang London, United Kingdom More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Characterization of α 1-adrenoceptor Subtypes Mediating Contraction in Human Isolated Ureters

To characterize the contractile functions of the α(1)-adrenoceptor (AR) subtypes present in the human ureter. Specimens were taken from patients with renal cancer ("upper ureters;" n = 51) or bladder cancer ("lower ureters;" n = 23) who had not been treated by chemotherapy, radiation therapy, or immunotherapy before surgery. Patients systemically taking an α(1)-AR agonist or antagonist were excluded from this study. The effects of α(1)-AR antagonists against phenylephrine (α(1)-AR agonist)-induced contractions were evaluated in human isolated ureteral preparations. Pooled data from all ureters showed that phenylephrine (α(1)-AR agonist) induced a concentration-dependent tonic contraction (pD(2) value, 4.92 ± 011). The phenylephrine-induced maximum contraction was significantly greater in lower ureters than in upper ones. Prazosin (nonselective α(1)-AR antagonist), silodosin (selective α(1A)-AR antagonist), and BMY-7378 (selective α(1D)-AR antagonist) all shifted the concentration-contractile response curve for phenylephrine to the right, the rank order of potencies in all ureters (pK(B) values) being silodosin (9.72 ± 0.14) > prazosin (8.64 ± 0.08) > BMY-7378 (7.04 ± 0.14). The α(1A)-AR antagonist silodosin was thus much more potent than the other 2 antagonists. Our results suggest that among α(1)-ARs, the α(1A) subtype plays the major role in contraction in the human ureter.

Ureteroscopic lithotripsy using Swiss Lithoclast for the management of ureteral stones: our experience in 200 patients

Objective: To study the efficacy of ureteroscopic management of ureteric calculi using Swiss Lithoclast in a cohort of 200 patients. Materials and methods: The patients were diagnosed of ureteric stone on ultrasonography, radiography, intravenous urography or computed tomography. Ureteroscopic lithotripsy (URSL) was done using 8/9.8 F rigid Olympus ureteroscope and Swiss Lithoclast. Results: Patients aged between 15 to 70 years with 94 males and 106 females. Most common presenting complaint was the pain. Hydroureteronephrosis was seen in 57%. Most patients had stone on right side. Most of the stones were 5-10 mm in size. Majority of the stones treated were from the lower ureter (72.32%). Of the stones, 91.51% were successfully fragmented. D-J stent was used in 40% patients. Operation time was less than an hour in most of the cases. There were minimal severe or long-term effects (stricture, 0.5%). Mean hospital stay was 1.54 days. Only 2% patients had proximal stone/ fragment migration. Overall success rate of the treatment

Laparoscopic ureterolithotomy: minimally invasive second line treatment

To describe our experience of 33 laparoscopic ureterolithotomies for large ureteral stones. Since February 2004, in our department, 33 patients had undergone laparoscopic ureterolithotomy. Inclusion criteria were failure of SWL and\or ureteroscopic treatment. Stones were located in the lower ureter in 9 patients, in the mid ureter in 16 patients, and in the upper ureter in 8 patients. Mean age of the patients was 47 years (range 37-51). The mean stone size, at preoperative IVP, was 34 mm (range 18-55). All stones were impacted from 4 to 36 months before procedure. Successful rates were 100%. No conversion to open surgery occurred. No intraoperative and postoperative complications occurred. Mean operating time was 85 min (range 60-160). Mean intraoperative blood loss was 70 ml (range 30-120). Mean hospital stay was 3.4 days (range 2-7). Mean follow-up was 24 months (range 6-44). During follow-up, no major complications were observed in any patients. In our hand, first-line treatment after failure of SWL and\ or ureteroscopy is laparoscopic ureterolithotomy. Large stone size and previous open surgery did not affect the successful rates of laparoscopic ureterolithotomy.

Emergent Stenting After Uncomplicated Ureteroscopy: Evaluation of 23 Patients

To evaluate the causes of emergent stent placement during the postoperative early period after uncomplicated ureteroscopy in 23 patients. Of 276 uncomplicated ureteroscopy procedures performed for the management of ureteral calculi, double-J stent placement was necessary on an emergent basis in 23 patients because of intolerable colic pain and extreme patient discomfort. All stents were inserted within 24 hours after the procedure. Of the 23 patients requiring emergent stent placement, 14 were men and 9 were women. The stones had been located in the lower ureter in 11, mid-ureter in 6, and upper ureter in 6 patients. All patients had undergone an uncomplicated procedure with no complication evident either during or immediately after ureteroscopic stone management. The intraoperative findings for the 23 patients revealed extensive edema formation, unrecognized small stones embedded in the edematous ureteral wall, unpassed small fragments gathered at the orifice, obstructing blood clots, and kinking of the ureter. A retrospective evaluation of the operative CD recordings and radiographic findings clearly showed that a longer operative time, repeated access, management of a large stone, impacted calculi with ureteral wall edema, a mildly narrowed ureteral segment, ignored caliceal small calculi, and a recent history of urinary tract infection contributed to the need for postoperative intervention. Ureteral catheterization, at least in the form of overnight stent placement, might prevent the formation of transient ureteral obstruction, with resultant postoperative patient discomfort and colic pain evident in selected cases.

Delineation of upper urinary tract segments at MDCT urography in patients with extra-urinary mass lesions: retrospective comparison of standard and low-dose protocols for the excretory phase of imaging

Excretory-phase CT urography (CTU) may replace excretory urography in patients without urinary tumors. However, radiation exposure is a concern. We retrospectively compared upper urinary tract (UUT) delineation in low-dose and standard CTU. CTU (1-2 phases, 120 KV, 4 × 2.5 mm, pitch 0.875, i.v. non-ionic contrast media, iodine 36 g) was obtained with standard (14 patients, n = 27 UUTs, average 175.6 mAs/slice, average delay 16.8 min) or low-dose (26 patients, n = 86 UUTs, 29 mAs/slice, average delay 19.6 min) protocols. UUT was segmented into intrarenal collecting system (IRCS), upper, middle, and lower ureter (UU,MU,LU). Two independent readers (R1,R2) graded UUT segments as 1-not delineated, 2-partially delineated, 3-completely delineated (noisy margins), 4-completely delineated (clear margins). Chi-square statistics were calculated for partial versus complete delineation and complete delineation (clear margins), respectively. Complete delineation of UUT was similar in standard and low-dose CTU (R1, p > 0.15; R2, p > 0.2). IRCS, UU, and MU clearly delineated similarly often in standard and low-dose CTU (R1, p > 0.25; R2, p > 0.1). LU clearly delineated more often in standard protocols (R1, 18/6 standard, 38/31 low-dose, p > 0.1; R2 18/6 standard, 21/48 low-dose, p < 0.05). Low-dose CTU sufficiently delineated course of UUT and may locate obstruction/dilation, but appears unlikely to find intraluminal LU lesions.

Clinical diagnosis and treatment for urinary tract endometriosis

Objective To evaluate the diagnosis and treatment of urinary tract endometriosis.Methods Retrospective review of 10 female cases of urinary tract endometriosis was carried out. All cases age was from 28-49, and the average age was 39-year-old. The course of this disease was from 6 months to 3 years. Four of 10 cases were bladder endometriosis. The clinical presentations included the urgency, frequency, pain at micturition and lower abdomen pain during menstruation, gross hematuria coinciding with menstruation 1 case. B-ultrasound and CT showed the mass of bladder from 2. 0 -3.5 cm but were not specific. Four of 6 cases ureteral endometriosis were the left side and 2 cases were the right side. This clinical presentation included non-specific flank or abdomenal discomfort in 4 cases, intermittent gross hematuria in 1 case and 1 case renal hydronephrosis was found incidentally by B-ultrasound. B-ultrasound indicated unilateral upper urinary tract dilation and hydrops in all cases,with pyelic separation from 2.0-4.5 cm and ureteral separation from 1-2 cm. CT indicated stenosis of the lower ureter in 5 cases, ureter tumor in 1 case. Results All cases were treated surgically.Partial cystectomy were performed in 4 cases of bladder endometriosis, of which, 1 case bilateral oophorectomy and hysterectomy. Five cases were performed ureteral segmental resection, of which, 3 ureterocystostomy and 2 terminoterminal anastomosis. 1 case was performed radical nephrectomy and ureterectomy. Postoperative pathological findings confirmed the diagnosis of endometriosis. Postoperative oral hormone therapy was given to 9 cases for 6-12 months. All cases were followed for 12-60months. 2 cases ureteral endometriosis had recurrent hydronephrosis in 18-24 months. The 2 cases received ureteral stent and cured by oral hormone therapy or goserelin subcutaneous injection for 3 months. Conclusions Urinary tract endometriosis usually shows non-specific symptoms. The diagnosis can be missed on both clinical examination and preoperative work-up. Surgical treatment is effective and adjuvant hormone therapy is often recommended to prevent the recurrence. Key words: Urogenital system; Endometriosis; Surgical procedures, elective

Extracorporeal Shock Wave Lithotripsy for Ureteral Stones: Do Decompression Tubes Matter?

Extracorporeal shock-wave lithotripsy (SWL) offers an effective and minimally invasive method for treating ureteral stones. In the current study we investigated whether the presence of a double-J (JJ) stent or a percutaneous nephrostomy (PCN) has any impact on the SWL success rates for ureteral stones. All adult patients with ureteral stones treated with the second-generation Siemens Lithostar® Multiline (Siemens, Erlangen, Germany) lithotriptor between 2002 and 2007 were included. Exclusion criteria comprised radiolucent or nonsolitary stones, calculi >10 mm in diameter in the lower ureter, stones that were pushed back into the kidney during JJ stent insertion and patients who had undergone stent or nephrostomy tube insertion after initiation of SWL therapy, though having started treatment as "tubeless." In total, 342 individuals were divided into 3 groups: group I (n = 56) consisted of patients with a PCN; group II (n = 73) included patients with a JJ stent; and group III (n = 213) comprised individuals without any decompression tubes. All patients were reviewed in the outpatient clinic. The mean age for all patients was 50.1 years (range 16-90 years) and the mean ureteral stone size was 9.4 mm (SD = 3.6 mm). Successful stone clearance was achieved in 60.7%, 47.9%, and 59.2% of the 3 groups, respectively. There was no statistically significant difference in success rates between the aforementioned groups. The results of the current study suggest that the presence of either a PCN or a JJ uretral stent does not exert any influence on stone clearance after SWL treatment.

Ureteroscopic lithotripsy for treatment of ureteral calculi in children: efficacy and safety

Objective:To assess the efficacy and safety of the ureteroscopic lithotripsy in treatment of ureteral calculi in children.Methods: From March 2008 to May 2009,thirteen pediatric patients with ureteral stones were admitted to our department.There were six males and seven females,with an age range of 23 months to 11 years old.Six patients with stones located at the lower segments of the ureter,four at the middle segments,two at the upper segments,and one at pyelo-ureteral junction and lower ureter.The average diameter of the stones was(1.1±0.47) cm(range 0.6-2.0 cm).The patients were placed in a lithotomy position;under general or venous anesthesia,ureteroscopy was performed using a semirigid ureteroscope(WOLF Fr 7.5/6),and the ureteral orifice was dilated to 10-12 Fr.Then holmium laser(1.5 J,10 Hz) or pneumatic lithotripter was employed to fragment the stones(diameter of fragment less than 3 mm).Fr4.7 double-J stent was placed after operation and was removed 4 weeks later.Results: Eleven of the 13 patient underwent successful lithotripsy,with the first time successful rate being 84.6%.The mean lithotripsy time was 8 min and the mean operation time was 21 min.There was slight bleeding during operation,but with no noticeable perforation of ureter or post operation fever,etc.Post-operation B ultrasound examination and X ray image revealed no residual stones with diameter 3 mm in the 11 cases.Partial fragmentation was achieved in one patient with stone at upper ureter segment and one patient with stone at pyelo-ureteral junction and lower ureter,and the stones were excreted after extracorporreal shock wave lithotripy.Conclusion: Ureteroscopic lithotripsy is safe and effective in treatment of children with ureteral stones,which might become one of the first line treatment for children.

集学的治療が奏効し，長期間良好なＱＯＬを維持している尿管癌・肝／リンパ節転移の１例

A 56-year-old man presented with asymptomatic gross hematuria. Computed tomography (CT) scan revealed right hydronephrosis and a slightly enhanced invasive tumor in the right lower ureter, providing a diagnosis of ureteral cancer stage cT3NOM0. The patient underwent minimum incision endoscopic nephrouretectomy, and pathological examination of the resected specimen revealed urothelial carcinoma and squamous cell carcinoma with metastases to right obturator lymph nodes (pT3pN2). Ten months later, CT scan of the abdomen revealed two hepatic metastases. After three courses of combination chemotherapy consisting of gemcitabine and cisplatin (GC), one tumor completely disappeared and another achieved a partial response. The patient underwent radiofrequency ablation (RFA) for the residual followed by GC chemotherapy. However, eighteen months later, CT scan of the abdomen revealed two metastatic foci in other hepatic lesion. The patient underwent RFA again followed by GC chemotherapy and then all hepatic metastases have not revealed enlargement. More than three years after surgery, the patient has achieved a high quality of life.

Ureteral Endometriosis with Obstructive Uropathy

Endometriosis is a common disease, but ureteral involvement is rare. The symptoms and signs of ureteral endometriosis mimic those of ureteral malignancy. This case report describes a woman who presented with chronic back pain for 5 years. Imaging studies showed a right small contracted kidney with hydronephrosis and a bladder tumor. Endometriosis of the right lower ureter was ultimately diagnosed. The patient was healthy without recurrence during follow-up. It is difficult to differentiate between ureteral endometriosis and malignancy; in fact, renal loss may occur before diagnosis. Ureteral endometriosis should be considered for women with ureteral obstruction manifesting as chronic backache.

A Rare Case of Obstructive Uropathy in Renal Transplantation: Ipsilateral Indirect Inguinal Herniation of a Transplant Ureter

Urologic complications after renal transplantation occur in 10% of cases; (1–7) 50% cases are obstructive (8–13). Inguinal herniation of the transplanted ureter is an extremely rare event (14–17). We review the literature and report a case of obstructive uropathy in a renal transplant recipient caused by herniation of the transplant ureter into the inguinal canal. Case Presentation A 76-year-old man with end-stage renal disease secondary to membranous nephropathy had a successful renal transplant 20 years ago. He presented with vague abdominal pain and a right inguinal hernia. His baseline creatinine increased from 50 to 110 μmol/L. Abdominal ultrasound and CT scan demonstrated a moderate hydroureteronephrosis with right-sided inguinal hernia containing a loop of ureter (Fig. 1a). An urgent percutaneous nephrostomy tube confirmed the presence of stenosis (Fig. 1b). Subsequently, he had angiographic balloon dilatation followed by an antegrade ureteral stent placement; this reduced the ureter out of the hernia sac. The patient’s creatinine dropped to 65 μmol/L. Repair of the hernia was performed electively, and the stent was removed 2 months later with no impact on renal function with a 1 year follow-up.FIGURE 1.: (a) Computed-tomography of the abdomen shows moderate hydronephrosis of the transplant kidney with extension of the ureter into an inguinal hernia. (b) Percutaneous nephrostogram shows moderate hydronephrosis and distal stenosis of the ureter. (c) The ureter was catheterized with a 0.018 in. wire, angioplasty of the stenotic area with a 6 mm balloon was performed and a new nephrostogram shows the JJ catheter in good position.Significant morbidity can result from posttransplant urologic complications (2). Most cases of late ureteral obstruction posttransplantation result from obstruction in the lower ureter or ureterovesical junction (1, 4, 18, 19) and are secondary to technical factors or ischemia (9–13). Although native ureteral and bladder herniation in an inguinal hernia have been previously described (20, 21), only a few cases of transplant ureteral herniation are reported: one in the obturator canal occurring in a woman (22) and four inguinal (14–17). Of these four inguinal ureteral herniations, all occurred in men and three were older than 70 years of age, as in our case. This reflects the increased preponderance of inguinal hernias in men and the increased prevalence with age. In all cases, the diagnosis was made by imaging studies. In addition to the general risk factors for inguinal herniation, the following two factors may have contributed to this case: (i) stricture at the uretrovesical junction, which may have led to tortuosity and kinking of the ureter into the existing inguinal hernia, and (ii) the existence of a redundant long ureter. Other reported factors include placement of the donor ureter over the spermatic cord (15) or accidental ligation of the ureter at the time of an elective hernia repair (1). The definitive treatment is operative herniorrhaphy usually without the need for ureteral re-implantation (14–17, 22). In a report of inguinal herniation from a pediatric en bloc donor, transection and re-implantation of an extremely redundant ureter was necessary (15). However, similar to our case, the surgeons for the remaining reported cases did not manipulate the ureter owing to its tenuous vascularization and healing potential, as transection or re-anastomosis may predispose to ureteric strictures or leaks. Before elective repair, immediate attention to the herniated ureter is important. By the use of interventional radiology, we demonstrate the early reversal of obstructive uropathy until the patient underwent elective hernia repair. The stented ureter may also be protected from damage during the hernia repair. Raed Azhar Marylise Boutros Mazen Hassanain Gerry Polyhronopoulos Prosanto Chaudhury Jean Tchervenkov Department of Surgery, Hepatopancreatobiliary and Solid organ Transplantation McGill University Health Centre, Montreal QC, Canada Tatiana Cabrera Department of Radiology McGill University Health Centre, Montreal QC, Canada

Outcome of Retrograde Ureteroscopy URS for the Management of Ureteric Calculi: Four Years Experience

Objectives: To ascertain the efficacy of transurethral Ureteroscopy (URS) and Pneumatic Lithoclasty for the management of ureteral stones. Place and duration of study: This retrospective study was conducted from December 2005 to December 2009 at the Department of Urology and Renal Transplantation, Allied Hospital/Punjab Medical College, Faisalabad and Hospitals in Private sector. Methods: Patients with stones of different sizes and at different levels in the ureter were included in the study. Patients of less than 12 years of age and also patients with ureteric stones more than 3 cm were not included in the study.Such stones were managed by open Ureterolithotomy Results: A total number of 540 patients with ureteric calculi were included in the study. Cause of ureteric obstruction was stones in all cases. Among these 450 patients, 209 (38.6%) patients presented with lower ureteric stones, 266 (49.20%) patients presented with stones in the mid ureter, 65 (12.2%) patients presented with stones in the upper ureter. Bilateral ureteric calculi were present in 95 (17.5%) cases. Out of 540 cases 57 (10.62%) patients presented with anuria and they were initially treated by Percutaneous Nephrostomy PCN to relieve the obstruction followed by URS and Lithoclasty Overall, ureteric stones at different levels and of different sizes were treated successfully in 480 (89.0%) patients and in remaining 60 (11.0%) patients stones could not be broken. Stones were successfully fragmented and cleared in the 198 (94.73%) of 209 patients with stones in the lower ureter, in 253 (95.11%) of 266 patients with stones in the mid ureter and in 29 (44.61%) of 65 patients with stones in the upper part of ureter. Stones were successfully fragmented in 347 (98.21%) out of 354, 92 (85.18%) out of 108 and 41 (52.56%) out of 78 patients with stone sizes of <1 cm, 1-2 cm and 2-3 cm respectively. DJ stents were inserted in 426 (78.81%) cases. Procedure was not successful in 60 (11.0%) patients. Stones were migrated up in to renal pelvis in 31 (5.73%) patients, stone fragmentation failure was in 13 (2.40%) patients, failure of URS insertion up to stone was in 6 (1.10%) patients and ureteric avulsion was in 1 (0.18%). Conclusion: Transurethral rigid Ureteroscopy is still an acceptable procedure in the treatment of ureteric calculi of different sizes at different levels and it can be used safely with very good results in expert hands.