Non-dilated Ureters Research Articles

Bilateraler Reflux – pro intravesikale Techniken

All surgical techniques in antireflux surgery are characterised by a high success rate of over 90 %. The common goal of all procedures is the formation of a submucosal tunnel which is four times longer than the diameter of the ureter. Successful treatment has been achieved worldwide with the extravesical antireflux technique according to Lich-Gregoir in non-dilated ureters and psoas hitch ureterocystoneostomy in dilated ureters. Intravesical surgical procedures include the Politano-Leadbetter technique and Cohen's cross-trigonal reimplantation. These open or laparoscopic/robotic standard procedures have higher rates of success than endoscopic subureteric injection.

MR urography (MRU) of non-dilated ureter with diuretic administration: Static fluid 2D FSE T2-weighted versus 3D gadolinium T1-weighted GE excretory MR

ObjectiveThe goal of this prospective study was to compare the efficiency of two types of MRU after diuretic administration to identify the non-dilated ureter. MethodsMR pelvic examinations were performed in 126 patients after receiving furosemide. Each patient underwent in addition to their protocol for context, two types of MRU: 2D T2-weighted FSE (T2w-MRU) and 3D Gd T1-weighted GE (CE-MRU). Four segments were checked for each ureter.For the first part of the analysis, readers evaluated the whole image quality using a four points subjective scale and for the second part, they were asked to score separately each ureteral segment as present or absent. Results1008 ureteral segments were checked. For the image quality, readers did not find any significant difference (3.8±0.5 vs 3.6±0.7, p value: 0.13) between MRU methods. The interobserver agreement was excellent with a κ correlation coefficient as high as 0.89 for T2w-MRU and 0.92 for CE-MRU, respectively.For the detection of the segments and considering the 9 rotations for the T2W MRU, there were no statistically significant differences between the two groups. ConclusionT2-weighted MRU with multiple orientations and diuretic is sufficient to identify the non-dilated ureter. It offers information on ureteral peristaltism. It can be suggested that this sequence is able to detect an initial obstruction before hydronephrosis occurs.

Écoulement urinaire chez la fille : quelle imagerie en 2012 ?

Continuous urinary leakage, despite normal deliberate voiding, must suggest the diagnosis of ectopic ureter, more specifically in girls. Ectopic ureter is usually associated with duplex kidney and complete ureteral duplication. The strategy of investigations has changed over the past few years, due to MRI development in the analysis of urinary tract malformations. We report the case of a 4-year-old girl who presented with these symptoms and had a suspicion of left duplex kidney on the prenatal ultrasonography (US). Two US examinations during the first months of life were compatible with a left duplex kidney without any complication. Another US at the age of 4 years was reported as normal. We completed the investigation with MR urography, which revealed a left duplex kidney with a poorly functioning dysplastic upper pole, and the orifice of the ureter of this upper pole inserting in the vagina. The surgical treatment, realized by celioscopy, was partial nephrectomy of the upper pole, removing most of the ectopic ureter. US is the first exam to investigate urinary tract malformations. However, duplex kidney with small dysplastic pole and ectopic insertion of a nondilated ureter may be difficult to see, and a normal US should never end the investigations. Intravenous urography and renal scintigraphy used to be the reference complementary exams, but are now replaced by MR urography. Without using ionizing radiation, MR urography can visualize duplex kidney and ectopic ureteral insertion with high resolution, and evaluates renal function of each kidney and each pole. These morphological and functional data are essential to determine the surgical treatment.

Uretero-Ileal Anastomosis in Orthotopic Neobladder: Antireflux versus Direct Techinique

We report on the long-term functional results of the orthotopic VIP neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. Between 1998 and 2009, 84 patients underwent cystoprostatectomy and orthotopic VIP neobladder for invasive bladder carcinoma. 96 renal units were reimplanted using the Enine-Ghoneim antirefluxing technique (group 1). The direct Nesbit end-to-side technique for ureteral reimplantation was applied in 72 renal units (group 2). The mean follow-up period was 54 months (range, 10-154 months). Of the 96 renal units who underwent the Enine-Ghoneim technique, 12 (12.5%) had uretero-ileal anastomotic stricture and 4 (4.1%) had reflux. Of the 72 renal units who underwent direct anastomosis, 11 (15.2%) patients had reflux, 2 (2.7%) had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Enine-Ghoneim technique is significantly higher than direct anastomosis. The incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than antireflux technique. The incidence of stone formation, renal scaring and pyelonephritis was comparable in both groups. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Enine-Ghoneim antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite the frequency of stricture formation.

Evaluation of direct versus non‐refluxing technique and functional results in orthotopic Y‐ileal neobladder after 12 years of follow up

We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.

Cyclooxygenase type 2 is increased in obstructed rat and human ureter and contributes to pelvic pressure increase after obstruction

Prostanoids exert physiological effects on ureteral contractility that may lead to pressure changes and pain during obstruction. In the present study, we examined whether (1) obstruction changes the expression of the two cyclooxygenase (COX) isoforms, COX-1 and COX-2 in human and rat ureters and (2) administration of a selective COX-2 inhibitor influences the pelvic pressure change after experimental ureteral obstruction. Rats were subjected to bilateral ureter obstruction. Ureters were removed and dissected into a proximal dilated and distal non-dilated segment. RNA and protein were extracted and analyzed for cyclooxygenase expression by quantitative polymerase chain reaction and Western blotting. Human ureter samples were obtained from patients undergoing radical nephrectomy. Rat and human ureteral samples were processed for immunohistochemistry. COX-1, but not COX-2 mRNA, was readily detected in the normal rat ureter. COX-2 mRNA and protein expression was increased in the proximal dilated ureter compared to distal non-dilated ureter. This increased COX-2 expression was associated with increased urinary prostaglandin E2 (PGE2) excretion after release of obstruction. Immunohistochemistry showed increased COX-2 labeling in surface epithelium and smooth muscle layers in both rat and human obstructed ureters compared to control ureters. Furthermore, contractile PGE2-EP1 and thromboxane TP receptors were expressed in ureteral smooth muscle. Systemic treatment with the COX-2 selective inhibitor parecoxib (5 mg/kg/day) attenuated the pelvic pressure increase during obstruction. In summary, COX-2 expression is significantly increased in the ureteral wall in response to obstruction in the rat and human ureter and COX-2 activity contributes to increased pelvic pressure after obstruction.

Ureteropelvic Junction Obstruction: Endourologic Relocation of Laterally Inserting Ureters

To describe a technique of endourologic management for ureteropelvic junction (UPJ) obstruction associated with lateral insertion of the ureter. Among 57 patients with primary UPJ obstruction selected to undergo retrograde endopyelotomy, 2 patients (3.5%) demonstrated a nondilated ureter inserting laterally along a hydronephrotic renal pelvis on retrograde pyelography. Using the hot-wire balloon catheter in one and a holmium laser inserted ureteroscopically in one, retrograde endopyelotomy was performed with the incision directed medially in order to marsupialize the ureter into the renal pelvis and to relocate the UPJ to the dependent portion of the medial aspect of the renal pelvis. The hospital stay for both patients was 1 night, and there were no complications. The stent was removed 4 or 6 weeks postoperatively. Intravenous urography 6 weeks thereafter demonstrated relocation of the UPJ to a medial and dependent position, associated with prompt drainage of contrast medium and decreased pelvocaliectasis compared with preoperative studies. Both patients are asymptomatic. In cases of primary UPJ obstruction associated with lateral insertion of the ureter, the UPJ can be relocated to the medial and dependent portion of the renal pelvis using minimally invasive endourologic techniques. The dictum of performing a endopyelotomy incision laterally does not hold true in all patients and may compromise functional outcomes in cases where the ureteral insertion is nondependent and laterally positioned.

Ureteropelvic Junction Obstruction: Endourologic Relocation of Laterally Inserting Ureters

Purpose: To describe a technique of endourologic management for ureteropelvic junction (UPJ) obstruction associated with lateral insertion of the ureter. Patients and Methods: Among 57 patients with primary UPJ obstruction selected to undergo retrograde endopyelotomy, 2 patients (3.5%) demonstrated a nondilated ureter inserting laterally along a hydronephrotic renal pelvis on retrograde pyelography. Using the hot-wire balloon catheter in one and a holmium laser inserted ureteroscopically in one, retrograde endopyelotomy was performed with the incision directed medially in order to marsupialize the ureter into the renal pelvis and to relocate the UPJ to the dependent portion of the medial aspect of the renal pelvis. Results: The hospital stay for both patients was 1 night, and there were no complications. The stent was removed 4 or 6 weeks postoperatively. Intravenous urography 6 weeks thereafter demonstrated relocation of the UPJ to a medial and dependent position, associated with prompt drainage of contrast medium and decreased pelvocaliectasis compared with preoperative studies. Both patients are asymptomatic. Conclusions: In cases of primary UPJ obstruction associated with lateral insertion of the ureter, the UPJ can be relocated to the medial and dependent portion of the renal pelvis using minimally invasive endourologic techniques. The dictum of performing a endopyelotomy incision laterally does not hold true in all patients and may compromise functional outcomes in cases where the ureteral insertion is nondependent and laterally positioned.

Vesicoureteral reflux grading in contrast-enhanced voiding urosonography

Introduction and objective: The sonographic diagnosis of vesicoureteral reflux (VUR) with contrast-enhanced voiding urosonography (VUS) is gradually increasing. With the introduction of VUS as part of the routine diagnostic imaging modalities for reflux significant reduction in the number of voiding cystourethrographies (VCUG) was possible. Like in VCUG grading of reflux in VUS is becoming more and more relevant. The aim of this study was to find out if there are any sonomorphologic and sonomorphometric parameters that would correlate with reflux grading in VCUG. Furthermore, a reflux grading system for VUS is proposed and the correlation of this grading system tested with the one of VCUG. Patients and methods: In one examination session a total of 186 children underwent both VUS and VCUG of whom 89 had VUR in at least one and the same kidney-ureter-unit (KUU) in both diagnostic imagings. The VUS was conducted with intravesical administration of ultrasound (US) contrast medium (Levovist®). Ureteral and pelvicalyceal dilatations before administration of US contrast medium and during reflux were documented. Renal pelvic diameter was measured. The density of microbubbles in the renal pelves was scored on a scale of 1–3 (low to high). A grading system for reflux in VUS was set up similar to the international reflux grading system for VCUG with the addition of one more differentiation parameter, namely whether the reflux was primarily in a dilated or non-dilated urinary tract. Reflux grades in VUS were compared with those in VCUG. Results: None of the sonomorphologic and sonomorphometric parameters demonstrated any clear cut finding that would simplify reflux grading in VUS. In 59/95 (62%) KUUs the reflux grades were the same in both examinations. In 10/95 (11%) and 26/95 (27%) KUUs, the reflux was graded lower or higher, respectively, in VUS than in VCUG. Fifty-seven percent were in a primarily dilated system and the remaining 43% in a non-dilated one. Seventy percent of KUUs diagnosed as having grade I reflux in VCUG, showed as grade 2 on VUS. Conclusions: A reflux grading system similar to the one used in VCUG can be applied in VUS. Adding the parameter reflux into a primarily dilated or non-dilated ureter and/or pelvicalyceal system may bring in a further dimension to the reflux grading in VUS. Most of the refluxes labelled as grade I in VCUG are actually grade II or higher.

Vesicoureteral Reflux

Vesicoureteral reflux describes a pathologic event in which urine progresses in a retrograde fashion from the bladder to the ureter and in many cases into the intrarenal collecting system. This pathologic event cannot be treated successfully in isolation. Appropriate care requires meticulous attention to the treatment and prevention of urinary tract infection; correction of any associated voiding dysfunction; and careful attention to such adjuvant care as perineal hygiene, hydration, and treatment of defecation disorders. Vesicoureteral reflux is classified according to the International grading system demonstrated in Figure 1. Grade I reflux represents retrograde flow into a nondilated ureter only. Grade II reflux refers to the filling of a nondilated ureter and a nondilated renal pelvis. With Grade III reflux, one begins to see a dilatation of the collecting system, but the fornices remain sharp. With Grade IV reflux, the fornices become blunted. Grade V reflux refers to associated massive dilatation and tortuosity of the collecting system. It is very important to classify ureteral reflux as primary or secondary in its etiology. Primary vesicoureteral reflux refers to a congenital deficiency of the ureteral insertion that results in an ineffective valve mechanism. Secondary vesicoureteral reflux refers to reflux that is caused by either bladder dysfunction or previous surgical intervention.

Vesicoureteral reflux.

Vesicoureteral reflux describes a pathologic event in which urine progresses in a retrograde fashion from the bladder to the ureter and in many cases into the intrarenal collecting system. This pathologic event cannot be treated successfully in isolation. Appropriate care requires meticulous attention to the treatment and prevention of urinary tract infection; correction of any associated voiding dysfunction; and careful attention to such adjuvant care as perineal hygiene, hydration, and treatment of defecation disorders.Vesicoureteral reflux is classified according to the International grading system demonstrated in Figure 1. Grade I reflux represents retrograde flow into a nondilated ureter only. Grade II reflux refers to the filling of a nondilated ureter and a nondilated renal pelvis. With Grade III reflux, one begins to see a dilatation of the collecting system, but the fornices remain sharp. With Grade IV reflux, the fornices become blunted. Grade V reflux refers to associated massive dilatation and tortuosity of the collecting system.It is very important to classify ureteral reflux as primary or secondary in its etiology. Primary vesicoureteral reflux refers to a congenital deficiency of the ureteral insertion that results in an ineffective valve mechanism. Secondary vesicoureteral reflux refers to reflux that is caused by either bladder dysfunction or previous surgical intervention.

Middle Ureteral Stones: Results of In Situ Extracorporeal Shock Wave Lithotripsy with EDAP LT-01 Lithotripters

It has been stated that because middle ureteral stones are difficult to detect ultrasonographically, they are not amenable to in situ treatment with EDAP LT-01 lithotripters. In our hands, 15 of 79 patients (mean age 45.1 years) with middle ureteral stones averaging 11.2 mm were successfully treated with an EDAP LT-01 lithotripter with the stones in situ. With an Aloka SSD-650 hand probe, the common iliac vessels were visualized; while the patient was kept prone and using the vessels as a landmark, these stones were detected along dilated ureters and focused on by machine's self-contained probe. In three patients, the stones were not relocated by the EDAP probe because of obesity or nondilated ureters. Of 16 patients whose stones could be focused on by the probe, 15 were treated successfully. Our method of using the common iliac vessels as a landmark for locating and focusing on middle ureteral stones allows us to expand the treatment possibilities of EDAP LT-01 lithotripters.

Ultrasonography compared with intravenous urography in the investigation of adults with haematuria.

To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. Radiology department of a teaching hospital. 155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. 81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.

Normal ureteral diameter in infancy and childhood.

Ureteral diameters were estimated on films from intravenous urography in 194 children (100 boys and 94 girls) aged 0-16 years. Children with signs of urinary tract infection, calculi, obstruction, duplication or malformation were excluded. Films obtained without abdominal compression were used for measurements, including only ureters visualized over 50 per cent of their lengths. A good correlation was demonstrated between ureteral diameter and age (r = 0.69) and between ureteral diameter and the length of a segment of the lumbar spine (r = 0.73). The widest part of the ureter was most often located just above the crossing of the iliac vessels. The right ureter was slightly wider than the left one. No difference between boys and girls was noted. The results are in good agreement with those of others obtained at autopsy. Bearing in mind the possible physiologic variations, it would seem that measuring the ureteral diameter can be of value for a more objective differentiation between dilated and non-dilated ureters.

Ultrasonic evaluation of simple and ectopic ureteroceles

Ureteroceles appear as transonic intravesical lesions on ultrasonic demonstration of the bladder, producing a 'cyst within a cyst' appearance. Four patients, three with simple ureteroceles and one with an ectopic ureterocele were investigated by intravenous urography (IVU), ultrasound (US) and cystoscopy. Two patients had bilateral simple ureteroceles with non-dilated ureters and two had unilateral ureteroceles, one simple, and one ectopic with a hydroureter. Previously ultrasonography of the fluid-filled bladder has demonstrated only large ureteroceles. The present study was successful in demonstrating both large and small ureteroceles.

Late results of ureteroureterostomy in puppies

Experimental resection of a segment of ureter in the puppy with end-to-end ureteroureterostomy led to severe anastomotic stricture, obstructive atrophy, and 100% ipsilateral renal loss at one year. This may have been the result of unrecognized anastomotic tension. Transureteroureterostomy was followed by normally functioning upper urinary tracts at the end of one year, without evidence of damage to the recipient ureter. These experimental findings in the growing animal suggest that transuretero-ureterostomy in the immature nondilated ureter is a safe and reliable procedure in the management of surgically acquired unilateral segmental ureteral defects.