Nephrostomy Research Articles

When prolapse cannot be reduced: incarcerated procidentia due to pelvic mass

Our objective is to demonstrate a surgical approach to the treatment of incarcerated procidentia with obstructed ureters due to a pelvic mass. A 61-year-old woman presented with constipation, vaginal swelling, and difficulty voiding. On examination she had complete procidentia, which could not be reduced with gentle pressure. On imaging the prolapse appeared to contain a large pelvic mass measuring 11.5 cm in its greatest diameter, with features consistent with a mature teratoma. She was also noted to have bilateral ureteral obstruction and prominent hydronephrosis. After unsuccessful prolapse reduction under anesthesia, Bovie electrocautery was used to perform a posterior colpotomy. The obstructing mass was dissected away from the uterus and its connecting pedicle transected. The prolapse could then be reduced and a robotic hysterectomy performed. Pathology showed multiple pelvic masses including an 8-cm necrotic cystic nodule most consistent with uterine fibroids and a 4.5-cm mature cystic teratoma with associated seromucinous cystadenoma of the left ovary. Bilateral nephrostomy tubes were placed postoperatively. Incarcerated procidentia is an uncommon occurrence, which in rare cases may be due to a pelvic mass. Surgical management may be required with colpotomy for removal of the pelvic mass in order to reduce the prolapse and resolve the case.

Management of osteomyelitis of the pubic symphysis following urinary fistula in patients with radiation-induced urethral strictures after prostate cancer treatment.

Osteomyelitis of the pubic symphysis is a rare condition often occurring in patients with radiation therapy-related urethral strictures after prostate cancer treatment. We retrospectively reviewed patients who presented with osteomyelitis of the pubic symphysis from November 2016 to September 2021. We investigated the factors leading to urosymphyseal fistulas, clinical presentation, radiological assessment, treatments, and outcomes. A total 4 cases were collected. All patients underwent surgery and adjuvant or salvage radiotherapy for prostate cancer. Subsequently, they developed stricture of the vesicourethral anastomosis which was initially treated conservatively. Symptoms of pubic bone osteomyelitis included pain in the pubic area, fever, difficulty walking, and recurrent urinary tract infections. In all cases, computed tomography and magnetic resonance imaging showed a urinary fistula arising from the vesicourethral anastomosis with the involvement of the pubic bone, and severe osteomyelitis. Due to the failure of conservative treatment, debridement of the pubic bone with cystectomy and ileal conduit was performed in 3 patients. One patient refused surgery and bilateral percutaneous nephrostomies were placed. Patients regained their original performance status 1 to 6 months after surgery. General recommendations for the best diagnostic and therapeutic approach to osteomyelitis of the pubic symphysis due to urosymphyseal fistula still do not exist. Conservative treatment often fails and a surgical approach with definitive urinary diversion may be required.

V09-07 ROBOTIC INTRACORPOREAL SINGLE ILEAL INTERPOSITION FOR BILATERAL URETERAL STRICTURE

You have accessJournal of UrologyUpper Tract Reconstruction (V09)1 Sep 2021V09-07 ROBOTIC INTRACORPOREAL SINGLE ILEAL INTERPOSITION FOR BILATERAL URETERAL STRICTURE Sunchin Kim, and Matthew Gretzer Sunchin KimSunchin Kim More articles by this author , and Matthew GretzerMatthew Gretzer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002052.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bilateral ureteral obstruction is a common complication for patients who have undergone radiation treatment for cervical cancer. Given the effect of radiation to the bladder, the usual reconstructive options are limited and becomes a challenging problem for a urologist to manage. This video aims to offer a robotic, completely intracorporeal urinary diversion using a single ileal loop interposition for bilateral ureteral strictures. METHODS: A 29 year old female with cervical cancer underwent treatment with robotic radical hysterectomy, bilateral salpingectomy, para-aortic lymph node dissection, then radiation treatment. She developed a vesicovaginal fistula and underwent repair with a pudendal thigh flap, then developed bilateral obliterative ureteral strictures at the mid-distal junction managed with bilateral nephrostomy tubes. Discussion of other options included Boari flap, psoas hitch, buccal augment, appendiceal interposition, and autotransplant. Patient was placed in a steep Trendelenburg position with four 8-mm robotic trocars placed subcostally and one assistant 12 mm port. Bilateral ureters were dissected out and transected at the level of their obliteration. The left ureter was tunneled underneath the rectum and brought over to the right side for a spatulated Wallace anastomosis. The distance between the ureter and bladder was measured, and the ileal segment was harvested. RESULTS: The operative time was 5 hours and 30 minutes. Estimated blood loss was 30 ml. Length of stay was 8 days with no complications, had extended stay for pain control given significant prior narcotics use. Bowel function and flatus were present on postoperative day 3. Foley catheter was left in place for 10 days, and bilateral ureteral stents were left in for 6 weeks. Preoperative creatinine was 0.83. Post-stent removal creatinine was 0.55. A flexible cystoscopy after stent removal revealed widely patent vesico-ileal and ileo-ureteral anastomoses. CONCLUSIONS: Complete intracorporeal robotic ileal interposition for bilateral ureters is a safe and feasible option for bilateral ureteral strictures. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e689-e689 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sunchin Kim More articles by this author Matthew Gretzer More articles by this author Expand All Advertisement Loading ...

V01-11 ROBOT-ASSISTED SURGICAL REPAIR OF URETERO-ILEAL ANASTOMOTIC STRICTURE AFTER CYSTECTOMY AND ILEAL CONDUIT IN NEUROLOGICAL PATIENT

You have accessJournal of UrologyIncontinence & Female Pelvic Medicine/Reconstructive Surgery (V01)1 Sep 2021V01-11 ROBOT-ASSISTED SURGICAL REPAIR OF URETERO-ILEAL ANASTOMOTIC STRICTURE AFTER CYSTECTOMY AND ILEAL CONDUIT IN NEUROLOGICAL PATIENT Gilles Dosin, Juliette Hascoet, Clement Mazouin, Zine-Eddine Khene, Gregory Verhoest, Romain Mathieu, Karim Bensalah, Lucas Freton, Emmanuel Voiry, Claire Richard, Camille Haudebert, Etienne Courboin, Andrea Manunta, and Benoit Peyronnet Gilles DosinGilles Dosin More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Clement MazouinClement Mazouin More articles by this author , Zine-Eddine KheneZine-Eddine Khene More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Karim BensalahKarim Bensalah More articles by this author , Lucas FretonLucas Freton More articles by this author , Emmanuel VoiryEmmanuel Voiry More articles by this author , Claire RichardClaire Richard More articles by this author , Camille HaudebertCamille Haudebert More articles by this author , Etienne CourboinEtienne Courboin More articles by this author , Andrea ManuntaAndrea Manunta More articles by this author , and Benoit PeyronnetBenoit Peyronnet More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001970.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystectomy and ileal conduit (IC) are sometimes indicated for patient with a neurogenic bladder. However stricture of the uretero-enteric anastomosis are a common complication after this procedure. Robot-assisted uretero-enteric stricture repair may decrease the post operative morbidity and possibly increase the chance of success thanks to tools such as indocyanine green (ICG) and near infrared fluorescence (Firefly). The objective of this video is to assess the feasibility of this procedure. METHODS: We present the case of a 47 year-old patient with multiple sclerosis since 1987. She had a IC in 2018 with a Wallace 1 anastomosis for neurogenic detrusor overactivity refractory to conservative treatment with upper urinary tract deterioration and inability to self catheterize due to MS progression (cognitive dysfunction and upper limb impairment). She experienced multiple urosepsis with long hospital stays and eventually she needed bilateral nephrostomy tubes. Antegrade opacification revealed a stricture of the left uretero-enteric anastomosis. RESULTS: The patient is placed in 23° Trendelenburg position. Six ports are placed (4 robotic and 2 for the assistant) and the Da Vinci Xi robot is docked. We begin with adhesiolysis which allows to identify the ileal conduit. We carefully preserve the peri ureteral fat to ensure the best possible ureteral vascularization. We cut the ureters distally. The blood supply to the ureters end is checked using IV indocyanine green (ICG) injection and near infrared fluorescence (Firefly) and the ureters are cut as high as necessary and the ureter spatulation. A new uretero-enteric anastomosis is created according the Wallace 1 technique between the “ureteral plate” and the proximal stump of the ileal conduit. Two ureteral stents are placed for 10 days. CONCLUSIONS: Uretero-enteric anastomotic stricture in neurological patients can be treated using a robotic approach refection by robotic assisted procedure in a fully intracorporeal way is feasible. The magnified 3D vision, the precise dissection using the endowrist and the use of ICG may help preserve adequate blood supply to the ureter and minimize the risk of stricture recurrence The absence of large incision could also favored enhanced post operative recovery and minimize the risk of incisional hernias in this frail patient population. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e65-e65 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gilles Dosin More articles by this author Juliette Hascoet More articles by this author Clement Mazouin More articles by this author Zine-Eddine Khene More articles by this author Gregory Verhoest More articles by this author Romain Mathieu More articles by this author Karim Bensalah More articles by this author Lucas Freton More articles by this author Emmanuel Voiry More articles by this author Claire Richard More articles by this author Camille Haudebert More articles by this author Etienne Courboin More articles by this author Andrea Manunta More articles by this author Benoit Peyronnet More articles by this author Expand All Advertisement Loading ...

V05-04 STONE DISSOLUTION: CURRENT SAFE AND EFFECTIVE USE OF RENACIDIN

You have accessJournal of UrologyUrolithiasis & Endourology (V05)1 Sep 2021V05-04 STONE DISSOLUTION: CURRENT SAFE AND EFFECTIVE USE OF RENACIDIN Egor Parkhomenko, Vivian Williams, and Michael Kurtz Egor ParkhomenkoEgor Parkhomenko More articles by this author , Vivian WilliamsVivian Williams More articles by this author , and Michael KurtzMichael Kurtz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002012.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Struvite stones cause significant morbidity in urologic congenitalism. Though stone-free rates have improved with advanced endoscopic equipment, some anatomic circumstances make complete stone clearance impossible. Renacidin (Citric Acid, Glucono Delta-Lactone, and Magnesium Carbonate solution) to treat upper tract stones was popular in the 1960s, but after 6 deaths it was banned by the FDA and not re-approved until the 1990s. We wished to treat a patient in an extraordinary circumstance, which presented challenges as Renacidin therapy had not been used at our institution in 30 years. We present our experience and a step-by-step guide to infusion. METHODS: We conducted a literature review and collected national expert opinion. Key stakeholders from nursing, pharmacy, nephrology, infectious diseases, intensive care unit (ICU), and biomedical engineering developed a safe protocol for renacidin infusion. The patient was monitored on a 1:1 staff to patient ratio in the ICU initially. As the medication is in vials with non-sterile exteriors, pharmacy cleaned the vials and pooled it under a sterile hood. The biomedical engineering team recommended a gravity drip, elevated to 30 cm H2O above PCN tube entry site infused at 120 ml/hour (20 drips/minute) or 60 ml/hr (drop factor 10 drips/minute). A mock infusion was completed with a multidisciplinary team prior to the patient’s admission. A 27yF with severe scoliosis, reconstructed bladder, and tortuous ureter from prior ureterostomies leading to limited options for renal access had struvite stone recurrence after bilateral percutaneous nephrolithotomy. Bilateral nephrostomy tubes, an antegrade ureteral catheter, and a urethral catheter were placed. Daily electrolytes and urine cultures were drawn, and weekly CT scans performed to assess stone burden. Renacidin was infused unilaterally at full or half rate, depending on patient tolerance, during the day; nocturnal infusions were with normal saline. Continuous culture-directed IV antibiotics were administered throughout the infusion. RESULTS: Infusion was carried out for 60 days, initially on the left for 30 days (larger stone burden), and 30 days on the right. Total hospital stay was 71 days. The patient has been stone-free since end of Renacidin therapy for ∼150 days. There were no episodes of mucosal hemorrhage or sepsis. CONCLUSIONS: Renacidin infusion can be performed safely and effectively and may eliminate upper tract recurrent struvite stones in patients who have failed endoscopic therapy. An inpatient monitoring program and multidisciplinary collaboration is required for safe infusion. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e387-e387 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Egor Parkhomenko More articles by this author Vivian Williams More articles by this author Michael Kurtz More articles by this author Expand All Advertisement Loading ...

Concurrent bilateral emphysematous pyelonephritis and secondary iliopsoas abscess extending to thigh muscles with profuse rectal bleeding. A rare case scenario.

IntroductionBilateral emphysematous pyelonephritis is exceedingly rare.Case presentationA 56 year old diabetic male presented with high grade fever 40o c, chills, and bilateral loin pain since two weeks a picture of septic shock. CT showed bilateral emphysematous pyelonephritis, the left kidney was smaller in size, the right renal unit showed marked hydronephrosis, right iliopsoas abscess extending to the thigh. The patient was managed by bilateral nephrostomy tubes and two retroperitoneal drains. Initially, the patient recovered, but the general condition deteriorated and profuse rectal bleeding occurred. Colonoscopy showed bleeding colonic mucosa.ConclusionBilateral emphysematous pyelonephritis is devastating disease that should be managed promptly to avoid septic shock.

All in one, a rare case presentation of genitourinary tuberculosis

BackgroundThe kidneys are the most common site of urogenital tuberculosis. Tuberculosis of the urethra and bladder is caused by a descending infection through the urinary collecting system. Urogenital tuberculosis affects 2% to 10% of pulmonary tuberculosis cases in developed countries, but 15% to 20% in developing countries.Case presentationA 55-year-old male referred to us with bilateral percutaneous nephrostomy, which was done for obstructive uropathy with raised creatinine of 4.5 mg/dl. He was diagnosed with pulmonary tuberculosis two years back and took antitubercular therapy for one year. His routine blood parameters were within normal limits. On evaluation with bilateral nephrostograms, he was found to have right-sided pelvic ureteric junction stricture and left-sided vesicoureteric junction stricture. On retrograde urethrography, there was evidence of 4-cm stricture at proximal bulbar urethra. On contrast-enhanced CT whole abdomen, he was found to have small-sized right kidney and findings in par with nephrostogram with thickened, small capacity bladder (thimble bladder). Patient underwent urethroscopy and urethral dilatation followed by augmentation ileocystoplasty with left ureteric reimplantation and right nephrectomy done at 3 months of follow-up.ConclusionOnly 1.9 percent to 4.5 percent of all cases of urogenital tuberculosis are urethral tuberculosis, and it never happens alone. For urogenital tuberculosis diagnosis, imaging techniques are up to 91.4 percent sensitive, with intravenous urography and abdominal computerised tomography being the most widely used. Diagnosis relies on a range of signs such as “caliceal irregularities; infundibular stenosis; pseudotumor or renal scarring; nonfunctioning kidney; renal cavitation; urinary tract calcification (present in 7% to 19% of cases); collecting system thickening, stenosis, or dilatation; contracted bladder”.

Urological management and surgical procedures in migrants from Sub-Saharan Africa with urogenital schistosomiasis

Introduction and objectivesAn increasing number of urogenital schistosomiasis (UGS) is being diagnosed in Europe following the unprecedented migratory flux from Sub-Saharan Africa (SSA). This phenomenon represent a challenge for urologists working in a non-endemic area. The aim of this study is to describe the urological management and the surgical procedures of patients with UGS in a tertiary referral centre. PatientsAll subjects from SAA diagnosed with UGS from January 2011 to November 2018 were enrolled retrospectively. Detailed data of patients with UGS undergoing to urological procedures were collected and analysed. ResultsThirty patients were diagnosed with UGS, among them 12 (42.8%) were submitted to surgery. The most common surgical procedure was trans urethral resection of bladder (TURB) for suspected lesions persisted after praziquantel treatment performed in 7 cases (58%). Other surgical procedure were TURB and concomitant ureteroscopy with laser fragmentation for suspected bladder neoplasm with renal stone, endoscopic lithotripsy and percutaneous nephrolithotomy for bladder and renal stones, laparoscopic nephrectomy for end-stage kidney disease, placement of bilateral nephrostomy for hydroureteronephrosis, explorative testicular surgery for a suspected testicular torsion in one case each. Four patients (33%) were lost at the follow up. ConclusionAn increasing number of migrants from SSA diagnosed with UGS has been observed. Some patients required a surgical intervention for suspected neoplastic lesions or end-stage organ damage. It was particularly difficult to perform a regular follow-up in several patients. Further multicentric studies are needed to reach a proper standard in diagnosis, treatment and follow-up of subjects with UGS.

A case of giant hydronéphrosis on obstructive ureteral lithiasis

Adult giant hydronephrosis is a rare clinical entity. His clinical diagnosis is not obvious. We report a case of a 42-year-old man, who was admitted for a large intra-abdominal mass, painless, evolving for about 8 months. The clinical examination showed a very distended abdomen. The abdominal CT confirms the diagnosis of left giant hydronephrosis on ureteral lithiasis. Surgical treatment consisted of an emergency percutaneous nephrostomy followed by a secondary left nephrectomy. The evolution was favourable and the aftermath were simple.

A case report of bladder and intestinal endometriosis, and the relationship between sex hormone receptor expression and PIK3CA mutation analysis

BackgroundExtragonadal endometriosis is a rare condition, and its disease manifestation and long-term prognosis have not been elucidated. We report an extragonadal endometriosis case controlled by drug therapy for 14 years with analysis of the sex hormone receptor expression and PIK3CA mutation.Case presentationThe patient was diagnosed with bladder endometriosis at age of 30 years, and underwent bilateral nephrostomy and GnRHa therapy with add-back therapy. The patient was switched to dienogest therapy at age 35 and had hematuria and bloody stools at age 38. PET-CT revealed a 6-cm mass in the bladder with fluorodeoxyglucose accumulation and the diagnosis of endometriosis in the bladder, sigmoid colon, and cecum was confirmed after the biopsy result. The lesion’s tubular structures were positive for the estrogen receptor, but only 30% positive for the progesterone receptor, and the H1047R mutation in PIK3CA was found in tubular structures of the bladder lesion. GnRHa therapy caused the tumors to shrink.ConclusionDecreased progesterone receptor expression and oncogenic mutations may influence the course of less common and rare site endometriosis. Rare site endometriosis often requires long-term hormone therapy, and management should be tailored to the patient's life stage, keeping in mind complications, such as decreased bone density.

Manejo urológico y procedimientos quirúrgicos en migrantes del África Subsahariana con esquistosomiasis urogenital

Introduction and objectivesAn increasing number of urogenital schistosomiasis (UGS) is being diagnosed in Europe following the unprecedented migratory flux from Sub-Saharan Africa (SSA). This phenomenon represent a challenge for urologists working in a non-endemic area. The aim of this study is to describe the urological management and the surgical procedures of patients with UGS in a tertiary referral centre. PatientsAll subjects from SAA diagnosed with UGS from January 2011 to November 2018 were enrolled retrospectively. Detailed data of patients with UGS undergoing to urological procedures were collected and analysed. ResultsThirty patients were diagnosed with UGS, among them 12 (42.8%) were submitted to surgery. The most common surgical procedure was trans urethral resection of bladder (TURB) for suspected lesions persisted after praziquantel treatment performed in 7cases (58%). Other surgical procedure were TURB and concomitant ureteroscopy with laser fragmentation for suspected bladder neoplasm with renal stone, endoscopic lithotripsy and percutaneous nephrolithotomy for bladder and renal stones, laparoscopic nephrectomy for end-stage kidney disease, placement of bilateral nephrostomy for hydroureteronephrosis, explorative testicular surgery for a suspected testicular torsion in one case each. Four patients (33%) were lost at the follow up. ConclusionAn increasing number of migrants from SSA diagnosed with UGS has been observed. Some patients required a surgical intervention for suspected neoplastic lesions or end-stage organ damage. It was particularly difficult to perform a regular follow-up in several patients. Further multicentric studies are needed to reach a proper standard in diagnosis, treatment and follow-up of subjects with UGS.

URINARY BLADDER NECROSIS - AN EXTRAINTESTINAL MANIFESTATION OF INFLAMMATORY BOWEL DISEASE IN A PEDIATRIC PATIENT

Abstract Extraintestinal manifestations are common in inflammatory bowel disease (IBD), and genitourinary complications are known, including nephrolithiasis, fistulas, and ureteral obstruction. Bladder involvement is less common, and limited to cystitis including xanthogranulomatous cystitis. Bladder necrosis has not been previously described in association with IBD. Here, we describe an unusual case of IBD associated with total bladder necrosis at the time of initial diagnosis. An 8-year-old female with a history of chronic microcytic anemia presented with 1 week of hematochezia, hematuria, and fever with associated abdominal pain. Her exam was significant for mild lower quadrant abdominal tenderness including the suprapubic area, but was otherwise unremarkable. Blood work showed microcytic anemia and mild thrombocytopenia, elevated inflammatory markers, and hypoalbuminemia. Infectious workup was unremarkable. Upon admission, she developed oliguria and hypertension and rapidly progressed to renal failure requiring dialysis catheter placement and renal replacement therapy. A kidney biopsy revealed acute tubular injury but showed no glomerular involvement and had no evidence of hemolytic uremic syndrome or vasculitis. Imaging obtained including CT of her abdomen showed a thickened transverse colon and a thickened bladder wall with dilation of the renal collecting system, worse on the left. Bladder biopsy showed full-thickness necrosis of unclear etiology and had negative staining for microorganisms. She had bilateral nephrostomy tubes placed for drainage of her kidneys and her renal function subsequently returned to normal. MR imaging also revealed necrosis and confirmed complete bladder involvement. Her renal failure was presumed to be a secondary to ureterovesical junction obstruction from the bladder necrosis. She underwent esophagogastroduodenoscopy (EGD) and colonoscopy due to persistent hematochezia. The EGD was unremarkable. Her colonoscopy was grossly abnormal with evidence of colitis from the cecum to the rectum. Biopsies revealed both active and chronic inflammation with sparing of the terminal ileum, and immunohistochemical staining for infection was negative. Capsule endoscopy was largely unremarkable. She was diagnosed with ulcerative colitis and started on steroids and sulfasalazine. Her abdominal pain and stool consistency improved and her bloody stools resolved. Steroids were tapered and she continued sulfasalazine as maintenance therapy. This case presents a novel association of IBD and bladder necrosis. Vascular obstruction secondary to a hypercoagulable state might explain such an event, but this seems less likely given the diffuse nature of bladder involvement. A clinical index of suspicion for bladder involvement and/or necrosis is warranted in patients with IBD who present with obstructive urinary symptoms or hematuria.

Complications and survival after subcutaneous ureteral bypass device placement in 24 cats: a retrospective study (2016-2019).

The aim of this study was to document survival, complications and risk factors for the development of complications and mortality prior to discharge after placement of a subcutaneous ureteral bypass (SUB) device in cats. The medical records of cats with SUB placement between January 2016 and August 2019 were retrospectively analysed. The development of complications (overall, intraoperative, perioperative, short- and long-term complications) and risk factors for mortality prior to discharge were statistically assessed with univariate binary logistic regression. All variables with a P value ⩽0.10 in the univariate analysis were assessed in a multivariate model. Variables were significant if P <0.05. Twenty-four cats were included; 12 (50.0%) received a unilateral SUB, 11 (45.8%) a bilateral nephrostomy tube with single cystostomy catheter and the remaining cat (4.2%) two unilateral SUBs. Nearly 80% of the cats developed complications, ranging from mild to fatal, including (partial) SUB obstruction (33.3% of complications), lower urinary tract infection (20.8%), pyelonephritis (20.8%) and sterile cystitis (12.5%). Five cats (20.8%) died prior to discharge. Six cats (25.0%) underwent revision surgery. The overall median survival time (MST) was 274 days (range 1-311 days). Complications were most common in the long-term period (14/16 cats), followed by the short-term (9/18 cats), perioperative (10/23 cats) and intraoperative (4/24 cats) periods. Older cats had an increased risk for developing perioperative complications (P = 0.045) and were less likely to survive to discharge (P = 0.033). An increased haematocrit at presentation was a risk factor for the occurrence of short-term complications (P = 0.03). Although complications similar to those previously described were observed, the complication rate was higher and the MST shorter than previously reported in cats undergoing SUB placement. Despite good short-term survival, the development of complications may necessitate regular and intensive control visits. Owners that consider SUB placement should be informed that follow-up can be strenuous and expensive.

Purple bag syndrome: a visual clue for infection

A 35-year-old woman with recurrent, progressive stage IIIB squamous cell carcinoma of the cervix presented with a complicated urinary tract infection and was found to have bilateral purple bag syndrome....

BILATERAL CALCIFIED URETERAL STRICURE REQUIRING URINARY RECONSTRUCTION IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGITIS: A CASE REPORT

Calcified ureteral obstruction is a rare complication of vasculitis. Only a few cases of eosinophilic granulomatosis with polyangiitis (EGPA) have been published. We herein report a case of successful surgical repair of bilateral ureteral strictures in a patient with EGPA. A retrograde pyelogram revealed complete bilateral ureteral obstruction in the patient. Bilateral nephrostomies were placed because we were unable to introduce a double-J stent. The vasculitis and eosinophilia both responded to immunosuppressive therapy, but ureteral obstruction persisted. Surgical reconstruction was elected in order to eliminate the need for permanent external drainage. A combined nephrostogram/retrograde ureterogram revealed a 10 cm right ureteral gap and a 3 cm left ureteral gap. The left ureter was amenable to end-to- end anastomosis, pyeloureteroplasty, but repair of the right ureter required interposition of intestinal tissue. Right ureteral reconstruction was performed by combining the Yang-Monti ileal ureteral substitution and appendiceal interposition with a psoas hitch. The isolated appendix was interposed in an antiperistaltic fashion between the Yang-Monti tube and bladder. His kidney function has remained normal, and he is without vasculitic symptoms.

Clear Cell carcinoma of the urinary bladder, A case report: Surgical and oncological management

Bladder cancer is a condition characterized by a broad spectrum of histological variants and clinical courses. The morphological description of histological variants is becoming increasingly important. The 75% of cases of these cancers are classified as pure urothelial carcinoma, while the remaining 25% is represented by other histological variants. The clear cell carcinoma is part of urothelial group and is a very rare entity. Oncological outcomes of this variant are still uncertain, but seems to be worst than for patiens with pure urothelial carcinoma. Moreover it seems to metastasize more easily to the lymph nodes. We present a case of a Caucasian 73 year old woman who, after an episode of gross hematuria, underwent an ultrasound of the urinary system, a cystoscopy and a total body computed tomography (CT) which confirmed the presence of a bladder neoformation. A transurethral resection of the bladder (TURB) was performed: the result of the histological examination was "poorly differentiated clear cell carcinoma". Given the rarity of histological characterization, we required a PET CT scan for more accurate staging, at which a suspected right pelvic lymph node was detected. We proposed a radical cystectomy with hysteroannessiectomy and extended lymphadenectomy. During the pre-hospitalization process, the patient developed anuria, with acute renal failure and bilateral hydronephrosis, which required the placement of bilateral nephrostomies; we performed the planned surgical procedure and the histological exam confirmed: high grade urothelial carcinoma with a high percentage (more than 70%) of clear cell carcinoma, with a strong local aggression and lymphnode metastates. We referred the patient to the oncologist who suggested a treatment plan within an immunotherapy based clinical trial and cisplatin. The morphological description of histological variants in bladder cancer is gaining increasing importance, especially for infiltrating and aggressive forms. The clear cell carcinoma is a very rare entity part of the urothelial group; they would seem more aggressive forms with an early lymph node involvement. This evidence is confirmed by the clinical case described, in which we have seen a large local aggression with an involvement of the lymph nodes of the right side of the pelvis of the pre-sacral ones. In these cases, the multimodal approach is crucial.

Clear Cell carcinoma of the urinary bladder, A case report: Surgical and oncological management

Introduction: Bladder cancer is a condition characterized by a broad spectrum of histological variants and clinical courses. The morphological description of histological variants is becoming increasingly important. The 75% of cases of these cancers are classified as pure urothelial carcinoma, while the remaining 25% is represented by other histological variants. The clear cell carcinoma is part of urothelial group and is a very rare entity. Oncological outcomes of this variant are still uncertain, but seems to be worst than for patiens with pure urothelial carcinoma. Moreover it seems to metastasize more easily to the lymph nodes. Case report: We present a case of a Caucasian 73 year old woman who, after an episode of gross hematuria, underwent an ultrasound of the urinary system, a cystoscopy and a total body computed tomography (CT) which confirmed the presence of a bladder neoformation. A transurethral resection of the bladder (TURB) was performed: the result of the histological examination was "poorly differentiated clear cell carcinoma". Given the rarity of histological characterization, we required a PET CT scan for more accurate staging, at which a suspected right pelvic lymph node was detected. We proposed a radical cystectomy with hysteroannessiectomy and extended lymphadenectomy. During the pre-hospitalization process, the patient developed anuria, with acute renal failure and bilateral hydronephrosis, which required the placement of bilateral nephrostomies; we performed the planned surgical procedure and the histological exam confirmed: high grade urothelial carcinoma with a high percentage (more than 70%) of clear cell carcinoma, with a strong local aggression and lymphnode metastates. We referred the patient to the oncologist who suggested a treatment plan within an immunotherapy based clinical trial and cisplatin. Conclusions: The morphological description of histological variants in bladder cancer is gaining increasing importance, especially for infiltrating and aggressive forms. The clear cell carcinoma is a very rare entity part of the urothelial group; they would seem more aggressive forms with an early lymph node involvement. This evidence is confirmed by the clinical case described, in which we have seen a large local aggression with an involvement of the lymph nodes of the right side of the pelvis of the pre-sacral ones. In these cases, the multimodal approach is crucial.

Pleural Effusion Secondary to Obstructive Uropathy: A Case of Urinothorax.

Urinothorax is a rare type of pleural effusion and usually the result of genitourinary tract disease. An accurate and early diagnosis is crucial as resolution of the underlying pathology is the mainstay of treatment. We report the case of a 69-year-old man who was admitted to the Internal Medicine ward due to obstructive acute kidney injury of unknown origin. The patient was submitted to urinary catheterization and to right percutaneous nephrostomy. Two weeks after admission he developed a large left pleural effusion; a left urinoma was also visible on computed tomography. After thoracentesis, pleural fluid analysis demonstrated a paucicellular transudate with pH <7.40 and pleural fluid/serum creatinine ratio >1.0. The diagnosis of urinothorax was made and further study allowed the diagnosis of prostate cancer as the aetiology of the obstruction. When bilateral percutaneous nephrostomy was performed, resolution of the urinothorax and normalization of renal function occurred.LEARNING POINTSUrinothorax is a rare and possibly under-recognized cause of transudative pleural effusion; over the last five decades, fewer than 60 cases have been reported in the English literature worldwide.Diagnosis of urinothorax depends upon a high index of clinical suspicion and on pleural fluid analysis, but imaging can also support the diagnosis, for example by showing the presence of a urinoma.Clinicians should recognize urinothorax early in its clinical course as favourable outcomes are often achieved after correction of the underlying genitourinary tract pathology.

Advance in re-do pyeloplasty for the management of recurrent ureteropelvic junction obstruction after surgery

Ureteropelvic junction obstruction (UPJO) is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney. Open pyeloplasty had been regarded as the standard management of UPJO for a long time. Laparoscopic pyeloplasty reports high success rates, for both retroperitoneal and transperitoneal approaches, which are comparable to those of open pyeloplasty. However, open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%. The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation, ureteral ischemia, and inadequate hemostasis. In addition, failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO. In addition, poor preoperative split renal function, hydronephrosis, presence of renal stones, patient age, diabetes, prior endopyelotomy history, and retrograde pyelography history were considered as predictors of pyeloplasty failure. The failure is usually defined by persistent pain, persistent radiographic obstruction (infection or stones), continued decline in split renal function, or a combination of the above. And the failure of pye-loplasty often occurs in the first 2 years after the surgery. The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy, re-do pyeloplasty, stent implantation, percutaneous nephrostomy, ureterocalicostomy, and nephrectomy. Re-do pyeloplasty has such merits as high successful rates and rare complications, compared with endopyelotomy or ureterocalicostomy. And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible. Open pyeloplasty can enlarge the operating field, facilitate the exposure of the ureteropelvic junction, reduce the difficulty of operation, and thus reduce the occurrence of complications. There are no significant differences among the success rates of re-do pyeloplasty under open approach, traditional laparoscopy and robot-assisted laparoscopy, according to previous reports. However, traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology, small trauma, less postoperative pain, speedy recovery and shorter hospitalization, fewer complications and lower recurrent rates. If the primary pyeloplasty is an open operation in retroperitoneal approach, the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair. The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.

Unusual fetal ascites and spontaneous bladder rupture in a female fetus: a case report

BackgroundFetal bladder rupture causing urinary ascites is uncommon. It is generally related to invasive fetal medicine procedures or obstructive disorders such as in posterior urethral valves in male fetuses. An exceptional case of spontaneous bladder rupture in a female fetus occurred in a pregnant woman treated with high doses of opiates in an intensive care unit. This unusual obstetric situation leads to discussion of the possible causes of fetal bladder rupture, its management, and the pediatric prognosis.Case presentationWe report the case of a 30-year-old nulliparous black woman with a history of mesenteric cystic lymphangioma and multiple bowel resections leading to chronic malabsorption. During her pregnancy, our patient presented with an occlusive syndrome and major bilateral renal dilation. Urinary derivation resulted in iatrogenic bilateral ureteral perforation. Our patient thus presented with major uroperitoneum, bilateral pleural effusion and acute renal failure, treated by thoracic drainage and bilateral nephrostomy. Postoperative pain required treatment with level III analgesics. In this context, 5 days after morphine treatment introduction an enlarged fetal bladder was observed, followed 3 days later by voluminous fetal ascites. The diagnosis of spontaneous bladder rupture was suspected. After multidisciplinary discussion, expectant management was decided. At 31 weeks and 4 days gestation, our patient went into spontaneous labor with a subsequent vaginal delivery. The infant required resuscitation and paracentesis of ascites at birth. Her neonatal course was favorable with a simple urethral bladder drainage. Cystography at day 9 was normal. At 2 years of follow-up, the mother and the child have a normal course.ConclusionsAn iatrogenic origin of megacystis in a female fetus must be evoked in the event of maternal administration of high doses of opiates in the second part of her pregnancy. In our case, the megacystis was followed by spontaneous bladder rupture at 30 weeks of gestation, with a favorable maternal fetal issue.