Pelvis Ureter Research Articles

Surgical Enhancement with the Placement of Temporary Bilateral Ureteral Stents with Indocyanine Green Injection for all Stages of Endometriosis in vNOTES: Retrospective Cross-Sectional Study

Study ObjectiveTo demonstrate the time to place temporary bilateral stents with indocyanine green (ICG) injection, time to intra-operative identification of bilateral ureters - with and without the use of ICG, and number of times for ICG activation in endometriosis excision surgery. DesignRetrospective cross-sectional study. SettingSingle Tertiary Academic Hospital. PatientsFifty serial patients with functioning pelvic ureters, who underwent vaginal natural orifice transluminal endoscopic surgery (vNOTES) for all stages of endometriosis excision between September 2023 and May 2024. InterventionsPlacement of temporary bilateral ureteral stents with indocyanine green injection before the start of vNOTES, noting the time needed to identify intra-peritoneal ureters with and without ICG activation, and average number of times ICG was activated for endometriosis excision. Measurements and Main ResultsThe median time to place bilateral ureteral stents with ICG injection was 229 seconds. The median time for intra-operative ureteral identification with ICG was 1s (L) and 1s (R). The median time for intra-operative ureteral identification without ICG was 17s (L) and 17s (R). The median time ICG was activated for ureteral identification to perform endometriosis excision was 12 times (L), 11 times (R). From the observations previously described, we share the potential of improved efficiency and efficacy in using ICG in ureteral identification for endometriosis surgery. ConclusionPlacement of temporary bilateral ureteral stents with ICG has the potential for more efficient ureteral identification even after including time for ureteral stent placement and ICG injection. The upfront time needed to place stents may prove to lead to a safer, more efficient procedure.

Laparoscopic retrocaval ureteroplasty in a child with combined urodynamic disorders

Retrocaval location of the ureter in combination with aberrant renal vessels is a rare and complex urinary system malformation that requires careful verification. Currently, the most appropriate method for diagnosing retrocaval ureter is contrast-enhanced computed tomography. With the development of hydronephrosis or ureterohydronephrosis, the patient underwent laparoscopic ureteroplasty. Surgical treatment of retrocaval ureter involves resection of the altered ureter or pelvic–ureter segment with the formation of uretero-ureteral anastomosis or ureteropieloanastomosis anterior to the inferior vena cava. This article presents a successful laparoscopic ureteroplasty in a child with complex urodynamics of the urinary tract. Considering the presence of two levels of ureteral vascular crossing in the clinical example, pyelo-ureteral segment was performed to relocate the ureter in front of the inferior vena cava and aberrant inferior polar vessels. The patient was discharged in satisfactory condition to the outpatient stage of treatment, with subsequent hospitalization in the urological department. Retrocaval location of the ureter in combination with aberrant renal vessels is a rare congenital anomaly that requires prompt examination in a specialized clinic and an individual examination and treatment plan.

Upper Urinary Tract Urothelial Carcinomas: Benefits of Diagnostic Ureteroscopy and Results of Conservative Treatment

Upper urinary tract urothelial carcinomas (UTUC) are rare and predominantly male. They may be multifocal in around 30% of cases. They are of particular interest because of the difficulties involved in their diagnosis. We report a series of 08 patients collected in the urology department of the Hôpital Nord Franche-Comte (HNFC) in Trevenans between 01/2019 and 03/2022. There were 05 men (62.5%) and 03 women (37.5%) with an average age of 70.85 years. Clinical symptoms were dominated by low back pain in 04 patients (50%), haematuria in 2 patients (25%), and a combination of low back pain and haematuria in 1 patient (12.5%). The finding was fortuitous in 1 patient (12.5%). The uroscanner performed in all our Patients revealed ureteral lesions in 7 patients (87.5%), a combination of ureteral lesion and ureteropyelocalic dilatation (UPD) in 4 patients (50%) and a normal uroscanner in 1 patient (12.5%). Ultrasound was not performed in any of our patients. Cystoscopy revealed an infracentimetric polyp at the level of the bladder dome in 3 patients (37%), including 1 patient undergoing surveillance for UTUC and who had no history of bladder tumour; the other 2 were already being monitored for bladder tumour; a trigonal polyp measuring approximately 3cm in 1 patient (12.5%) who had a history of bladder tumour, an infracentimetric floor polyp in 1 patient (12.5%) who had no history of bladder tumour, and normal cystoscopy in the other 3 (37.5%). Ureteroscopy revealed a papillary lesion measuring approximately 1cm in the middle calyx of the right kidney in 1 patient (12.5%), a lesion of the pelvic ureter in 4 patients (50%) measuring approximately 1.5cm, 2cm, 3cm in the first 3 patients and a lesion occupying the entire pelvic ureter in the 4th patient; a lesion of the iliac ureter in 3 patients (37.5%) whose sizes are approximately 1cm, 2cm, and 4cm. Urine cytology showed a strong suspicion of a high-grade urothelial lesion in 2 patients (25%), an appearance of a low-grade ..

Recanalization of pelvic ureter in pelvic neoplastic obstruction: Technical approach

Introduction: Obstruction of the lower ureter by pelvic cancer requires palliative treatment. Percutaneous derivation is often performed in an emergency context. If the obstruction is limited to the perimeatic area; the percutaneous antegrade recanalization can be performed and may require a resection of the ureteral orifice. Objectives: We evaluate the results of percutaneous antegrade recanalization associated with possible bladder resection in the treatment of pelvic neoplastic ureteral stenosis. Materials and Methods: A retrospective, descriptive study from September 2016 to January 2021 included all patients with complicated pelvic tumor with ureteric hydronéphrosis. Under general anesthesia, in Valdivia modified position, a nitinol hydrophilic guidewire is passed through the nephrostomy and retrieved from the bladder to the urethral meatus, followed by a descent of ureteral catheter under X-ray control. We might need a resection over the presumed ureteric meatus as it will help open the lower extremity of the ureter, so it can be easily catheterized with a double J. When needed, the resection is performed in the modified Valdivia position, it requires significant vigilance and the resection is controlled by fluoroscopy by visualizing the proximity of the resector and the guidewire in the ureter. Results: In our study, 74 patients, including 29 men and 45 women, with an average age of 65 years (52–78 years). The Karnofsky index was ≥≥80% 80% in 92% and between 80% and 60% in 8% of patients. The average extent of ureteral stenosis was 2.25 cm (1–3.5 cm). The etiologies of obstruction were dominated by cervix cancer at 58.2%, followed by prostate cancer at 33.7% and bladder cancer at 8.1%. The recanalization is carried out in 40% on the left, 60% on the right, and bilaterality in 30% of the cases. In the event of bilateral obstruction, the repermeabilization was carried out in two deferred stages, one side at a time, the priority kidney being the one which seemed more functional with a good corticomedullary index. The improvement of renal function in 82%, however, 18% progressed to chronicity. The disappearance of the dilatation was present in 85%, whereas 15% of the cases presented a residual dilation without alteration of the renal function. The resection of the ureteral meatus was performed in 75% of the cases. We had only one recanalization failure in our series because the stenosis was extensive, due to the intrinsic invasion of the ureter by the tumor. A few complications were noted: pyelonephritis (7%), isolated flank pain (10%), and bladder irritative syndrome (13%). The average survival of these patients depended essentially on pelvic cancer responsible for the obstruction, ranging from 11 months to 45 months. Conclusion: Percutaneous recanalization associated with bladder resection is an attractive, reproducible, and well-tolerated technique. Very few complications are reported. It provides a good quality of life to patients.

Oncological Outcomes of Distal Ureterectomy for High-Risk Urothelial Carcinoma: A Multicenter Study by The French Bladder Cancer Committee.

Upper urinary tract urothelial carcinoma (UTUC) is an uncommon disease and its gold-standard treatment is radical nephroureterectomy (RNU). Distal ureterectomy (DU) might be an alternative for tumors of the distal ureter but its indications remain unclear. Here, we aimed to evaluate the oncological outcomes of DU for UTUC of the pelvic ureter. We performed a multicenter retrospective analysis of patients with UTUC who underwent DU. The primary endpoint was 5-year cancer-specific survival (CSS), followed by overall survival (OS), intravesical recurrence-free (IVR) and homolateral urinary tract recurrence-free (HUR) survivals as secondary endpoints. Univariate and multivariate Cox regressions were performed to assess factors associated with outcomes. 155 patients were included, 91% of which were high-risk. 5-year CSS was 84.4%, OS was 71.9%, IVR-free survival was 43.6% and HUR-free survival was 74.4%. Multifocality, high grade and tumor size were the most significant predictors of survival endpoints. Of note, neither hydronephrosis nor pre-operative diagnostic ureteroscopy/JJ stent were associated with any of the endpoints. Perioperative morbidity was minimal. In conclusion, DU stands as a possible alternative to RNU for UTUC of the pelvic ureter. Close monitoring is mandatory due to the high risk of recurrence in the remaining urinary tract.

Fluoroscopy-guided trans-urethral exchange of double-J ureteral stents

BackgroundFor patients with malignant ureteral obstruction or stricture who require long-term internal drainage, plastic double-J stents (DJ stents) represent the mainstay of therapeutic strategies. DJ stents should be replaced at least once every 6 months to avoid infection or obstruction. Although DJ stents are generally replaced under cystoscopy, successful fluoroscopy-guided retrograde replacement of DJ stents in the interventional suite has been described in the literature.MethodsBetween April 2004 and May 2020, we exchanged 143 DJ stents in 19 male and 22 female patients under fluoroscopic guidance using Nelaton catheters, snare catheters, and 8F DJ stents. All procedures were performed with patients under sedation and local anesthesia. There were 39 patients with malignant ureteral obstruction and two patients with benign ureteral strictures. This study was approved by the Institutional Review Board. Technical success, clinical success, complications, procedure time, and mean interval between two procedures were retrospectively reviewed, and the factors affecting the success rate of the procedure were analyzed.ResultsObstruction was detected at the abdominal ureter in 4 patients, pelvic ureter in 29 patients, and intravesical ureter in 8 patients. Twenty-six patients underwent two or more sessions of the procedures, whereas 15 patients underwent single-session procedures. Total 34 outpatient-based procedures and 109 inpatient-based procedures were performed. Technical success and clinical success were achieved in 94.4% (135/143) and 93.3% (126/135) procedures, respectively. Mean procedure time was 21.5 min (range 9–192 min). Mean procedure interval was 101.8 days (range 5–306 days). Technical success was negatively affected by male sex and obstruction at the pelvic ureter and was positively affected by previous successful exchange. Left-sided ureteral stent placement and old age negatively influenced clinical success. Septic shock occurred in one patient and was treated with antibiotics.ConclusionFluoroscopy-guided trans-urethral exchange of DJ stents is an effective and less painful procedure.

Sliding ureteral inguinal hernia: An uncommon embryological trick. Case report and literature review.

IntroductionInguinoscrotal herniation of the bladder is a rare clinical entity, with a frequency between 0.5% and 4% of all inguinal hernias. When the whole bladder and ureters migrate into the scrotum, it may cause urinary disorders as hydronephrosis.Case reportA 77-year-old male patient suffering from hypertrophic obstructive cardiomyopathy, obesity and diabetic disease presented with urinary disorders and left-sided inguinoscrotal hernia. Under clinical suspicion of sigmoid colon involvement in the inguinal canal, abdominal and pelvic computed tomography (CT scan) with endovenous contrast was performed, revealing a left inguinoscrotal hernia, containing the sigmoid colon and the left pelvic ureter causing left hydronephrosis.DiscussionWithout create urinary bladder wall leakage, the content of the hernial sac was reduced into the abdominal cavity. Previous subarachnoid anesthesia a left hernioplasty was performed by means of Lichtenstein's method with self-fixating mesh (Bard Adhesix) and subsequent complete resolution of the hydronephrosis.ConclusionUreter involvement should be suspected when a clinical inguinal hernia is diagnosed concurrently with unexplained hydronephrosis, renal failure, or urinary tract infection, as in the case described. When suspected, the preoperative diagnosis, particularly with CT scan, is essential to avoid complications and to reduce risk of bladder and ureter injuries during hernia repair.

Bladder Macrolithiasis Complicating Vesical Neck Stenosis, A Rare Cause of Renal Failure: A Case Report

Bladder lithiasis refers to the disease associated with the formation of stones in the bladder. These stones, which can reach several centimetres in size, are formed from aggregates of various mineral and organic substances. Most often these stones are formed as a result of poor bladder evacuation. We report a case of bladder macrolithiasis associated with two stones: right ureteral and renal on bladder neck stenosis revealed by hypogastric pain and signs of lower urinary tract and complicated by renal failure in a 42 year old patient. The physical examination revealed bilateral lumbar tenderness and a hard hypogastric palpable mass. Imaging revealed the presence of a bladder macrolithiasis occluding almost the entire bladder associated with a pelvic ureter stone and a right renal corraliform stone. The treatment consisted of a suprapubic cystotomy with extraction of the macro bladder stone and the ureteral stone delivered through the meatus by ureterolithotomy with cervical incision of the bladder neck. The postoperative course was simple. The evolution was marked by the normalization of the renal function. The patient underwent a lumbotomy for his right kidney stone 2 months later.

Формирование пиелоэнтероуретероанастамоза у ребенка с рецидивом гидронефроза, обусловленным протяженным стенозом мочеточника

Hydronephrosis is a disease characterized by expansion of the renal pelvis and calyces resulted from improper urine outflow in the pelvic ureter that causes damage to the kidney parenchyma and a progressive decrease in its function. Anderson–Hynes pyeloplasty is a highly effective surgical method for this disease. The recurrence rate after this procedure does not exceed 3–5%. One of the possible causes of relapse is long-term ureteral stenosis, which requires a repeated reconstructive surgery. We report a case of recurrent hydronephrosis associated with long-term ureteral stenosis. The patient has undergone laparoscopic surgery with the formation of pyeloenteroureteroanastamosis. Key words: hydronephrosis, relapse, laparoscopy, pyeloenteroureteroanastamosis, pyeloplasty

Primary squamous cell carcinoma of renal pelvis and kidney- Sole diagnosis by histopathology

Primary Squamous cell carcinoma of the renal pelvis is rare and accounts to only 0.5- 0.8 % of malignant renal tumours having poor prognosis. Chronic irritation, inflammation and infection induce the pathogenesis of this malignancy. A 53 year old male patient, presented with left flank pain since one month. On radiological investigation, his CT revealed atrophic shrunken left kidney measuring 7.9x5.2cms showing significant parenchymal thinning and complete loss of corticomedullary differentiation. A left upper ureteric calculus is seen measuring 7.5 mm with significant left renal hydronephrosis.Clinically, it was diagnosed as Xanthogranulomatous Pyelonephritis. Grossly the radical nephrectomy specimen measures 10.5x5.5x3.5cm. External surface is irregular & bosselated. On Cut surface renal architecture is effaced by necrotic mass measuring 9.5x5.0x3.0 cm involving pelvic ureter and most of renal parenchyma.Hematoxylin and eosin stained tissue revealed characteristic feature such as keratin pearls and intracellular bridges seen, rendering the diagnosis of well-differentiated keratinising squmaous cell carcinoma seen with 40% tumour necrosis associated with Keratinizing Squamous Dysplasia. In the present case, obstructive uropathy has triggered the event of malignancy. The radiologic differential diagnosis includes primary and secondary renal neoplasms and xanthogranulomatous pyelonephritis associated with renal calculi. XGP is commonly associated with lithiasis however, rarely causes keratinizing squamous metaplasia and its manifestations closely mimic renal neoplasm, leading to misdiagnosis of malignancy.The prognosis is dismal with a 5-year survival rate of <10%. CT and MRI play a crucial role in diagnosis and staging of these tumors, though histology always remains confirmatory and diagnostic.

INFILTRATING UROTHELIAL CARCINOMA ALONG THE URINARY TRACT OF A YOUNG ADULT

Objective: To present a rare case of infiltrating urothelial carcinoma along the urinary tract on a young adult. Case(s) Presentation: A 39 year old Asian male patient with > 20 pack-year smoking history, came to the hospital with a chief complaint of hematuria and flank pain since two weeks ago. Physical examination revealed Eastern Cooperative Oncology Group (ECOG) Performance Status 1, the right kidney was palpated, no tenderness on fist percussion. Abdominal ultrasound (USG) revealed 1.5 cm and 0.5 cm masses located in the urinary bladder. The CT scan show mass in the bladder was exophytic, > 3 cm in size, and occupying lesion was located on the right posteroinferior and left lateral bladder wall accompanied with dilatation of pelvic calyces and right ureter. Histopathology of the specimen revealed low-grade infiltrating urothelial carcinoma of bladder and right ureter. The pathological stage was pT2NxMx, The patient refused neoadjuvant chemotherapy and surgery. Four months after TURBT, he came with weakness and right flank pain. The patient consent to surgery and underwent the right nephroureterectomy. Histopathology of the specimen showed infiltrating urothelial carcinoma of right kidney, ureter, Gerota fascia with lymphovascular invasion (pT3NxMx). Discussion: Urothelial carcinoma (UC) is commonly arising in the urinary bladder, but it can develop along the urinary tract. Cigarette smoke contains a lot of carcinogenic agents and stimulates DNA damage. Conclusion: Upper tract urothelial carcinoma (UTUCs) is subset of UC with a poor prognosis. Cigarette smoking is the main risk factor that induces DNA damage. 

Уродинамика нижних мочевыводящих путей при реконструкции тазовых отделов мочеточников

The problem of impaired urodynamics of the lower urinary tract after reconstructive surgery of the pelvic ureter remains almost unexplored in modern literature. There are only a few publications about the effect of operations in the area of the ureterovesical segment on bladder function. To study the function of bladder after replacing the pelvic ureter with bladder flap, small intestine or appendix. We performed a retrospective analysis of reconstructive operations of the distal ureter, which were performed in 273 patients. Boari flap or its modifications were used in 142 (52%) cases; ureteroappendicocystanastomosis - 23 (8.4%) patients, and replacement of the pelvic ureter with small intestine in 105 (38.5%) cases. A follow-up urodynamics was carried out on the 10-14th day of the postoperative period, after 3 months, then after 6 and 12 months. We evaluated: uroflowmetry, cystometry, and pressureflow study. In 75 (53%) of 142 patients who underwent Boari flap or its modifications, varying degrees of disturbance of bladder urodynamics were observed. After isoperistaltic intestinal ureteroplasty in 2 (2.5%) of 79 patients, detrusor hyperactivity was observed, which was regressed following conservative therapy. Urodynamics of bladder did not suffer after appendicoplasty. Deformation, denervation and devascularization of detrusor are the main causes of bladder dysfunction after flap operations. Ileal ureter substitution with isoperistaltic position of the graft provides physiological passage urine from the kidney to the bladder, following good bladder function. The inclusion of antiperistaltic ileal loop in the urinary tract negatively affects the urodynamics.

Fluorescence Imaging of the Ureter in Minimally Invasive Pelvic Surgery

Determine near-optimal dose, safety, and efficacy of nerindocianine in pelvic ureter detection with near-infrared fluorescence imaging in women undergoing minimally invasive pelvic surgery with 3 Food and Drug Administration-cleared imaging systems. Open label, phase 1/2a study. University of Alabama at Birmingham. Forty-one female subjects undergoing minimally invasive gynecologic surgery. Subjects received a single dose of nerindocianine sodium, starting at 0.06-mg/kg body weight and increased/decreased until the near-optimal dose was determined (part A). Examine the degree of concordance between endoscopic and robotic devices (part B). In part A, composite scores were collected every 10 minutes for 30 minutes and then every 15 minutes through 90 minutes using a scale measuring the anatomy/laterality of ureter visualization. In part B (paired imaging system efficacy), 2 cohorts of 8 subjects each received the near-optimal dose. Composite scores for visualization of the ureter were collected at 10 and 30 minutes postinfusion with the Firefly Imaging System and either the PINPOINT or 1588 AIM endoscope. Composite scores were compared to examine the degree of concordance between devices. Part A comprised 25 total subjects enrolled in dosing groups 1, 2, and 3 (0.06-, 0.12-, and 0.045-mg/kg, respectively). Median time to first ureter visualization was 10 minutes (all groups). The nerindocianine 0.06-mg/kg and 0.12-mg/kg groups had longer length of time of visualization than the 0.045-mg/kg group, resulting in the selection of 0.06 mg/kg as the near-optimal dose. Part B enrolled 16 total subjects in 2 groups dosed at 0.06 mg/kg. Efficacy analysis showed no statistically significant difference in composite scores with Firefly versus PINPOINT or 1588 AIM. Nerindocianine was well tolerated with visualization of the ureter demonstrated in 88.9% of the subjects through 90 minutes postdosing. No meaningful visualization differences were observed among the Food and Drug Administration-cleared surgical imaging systems used.

Use of a shaving technique for surgical management of partial ureteral obstruction due to endometriosis

To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. Tertiary referral center. A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Experience of treating patients with urolithiasis in the urological clinic of the Aleksandrovskaya hospital

The article presents the experience of treating patients with urolithiasis in the urological clinic of the Aleksandrovskaya hospital. Due to the improvement of technologies, the number of minimally invasive surgeries such as contact ureterolithotripsy, percutaneous nephrolithotripsy and percutaneous nephrolitholapaxy has increased significantly. Performing open surgical interventions is indicated only in complicated cases such as the presence of purulent calculous pyelonephritis. The indication for contact ureterolithotripsy is the localization of concretions in the pelvic ureter, as well as long-term (more than 4 weeks) presence of concretions in any part of the ureter. Percutaneous nephrolitolapaxy is the method of choice in the treatment of urolithiasis in case of uninfected kidney stones smaller and larger than 20 mm in diameter, especially in elderly patients. Emergency contact lithotripsy is indicated for treatment of acute serous obstructive pyelonephritis caused by concretion of any localization. When stones locate in lower calices of kidney effective method is percutaneous nephrolitholapaxy.

2 Methods for Identification and Preservation of Hypogastric Nerve During Laparoscopic Die (Deep Infiltrating Endometriosis) Surgery

Video Objective In this video, we are going to introduce two methods for proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery. Setting Single institute, single surgical team's experience. Interventions USL is the mostly frequently involved area of pelvic endometriosis. Hypogastric nerves just lie between USL and pelvic ureter, locate in the Okabayashi pararectal space. They are frequently involved (either direct infiltration, or just encasement by surrounding tissue fibrosis) by the DIE lesions. En-bloc excision of USL DIE lesions frequently result in inadvertent hypogastric nerve injury, or even pelvic plexus injury. Proper identification and preservation of the hypogastric nerves is mandatory during nerve-sparing DIE surgery. We develop two methods to identify the hypogastric nerve within the USL DIE complex. (1) “Contralateral nerve traction test”: If we can clearly identify and isolate the hypogastric nerve on the more healthy side, by gentle pulling on this side hypogastric nerve, we can see the contralateral hypogastric nerve move on the other side. Thus we can have a good mapping of the course of hypogastric nerve within the DIE complex. (2) “Antegrade tracing from pre-sacral region”: If we move upward to the pre-sacral region, starting dissection from the virgin site, proximal part of hypogastric nerve can be easily identified. Antegrade tracing along the hypogastric nerve, un-roofing and bi-half the overlying DIE USL tissue, the whole course of hypogastric nerve can be safely traced and the nerve can be well-preserved. Conclusion Proper identification and preservation of the hypogastric nerves within the USL (uterosacral ligament) DIE (deep infiltrating endometriosis) complex during laparoscopic nerve-sparing DIE surgery is important. By this two simple methods and concepts (“contralateral nerve tract test” and “antegrade tracing”), we can minimize the risk of inadvertent nerve injury.

Multisystemic Imaging Findings in Chinese Patients With Erdheim-Chester Disease.

OBJECTIVE. Radiology is essential for diagnosing and managing Erdheim-Chester disease (ECD), a rare multisystemic non-Langerhans cell histiocytic neoplasm. This study aimed to systemically investigate imaging characteristics of patients with ECD. MATERIALS AND METHODS. Radiographic, CT, and MR images of 28 Chinese patients (14 male, 14 female; 5-65 years old) diagnosed with ECD on histopathology at our medical center between January 2014 and January 2019 were retrospectively analyzed. Two radiologists analyzed the images in consensus and recorded the imaging manifestations qualitatively. RESULTS. Seventeen of the 23 patients (73.9%) who underwent CNS evaluation had findings positive for ECD including supratentorial and infratentorial regions; infiltration of the corpus callosum, choroid plexus, pineal body, and walls of cerebral arteries; and brain nodules mimicking metastases. In the facial and orbital regions, postorbital masses (34.8%) and masses in the nasal sinuses and mastoid processes were noted. Moreover, bone involvement was found in 27 (96.4%) patients, with lower extremities most commonly affected (85.7%); pathologic fracture caused by bone involvement was also observed. On chest CT, pulmonary parenchyma, mesenchyme, pleura, and mediastinum were seen to be infiltrated by ECD (57.1%). Half (50.0%) of the 28 patients had cardiovascular involvement with infiltration of the aorta and its branches, coronary arteries, or branches of the superior mesenteric artery resulting in stenosis and ischemic symptoms. In addition to retroperitoneal involvement in 13 (46.4%) patients, a presacral mass wrapping bilateral pelvic ureters and thickening of the mesentery, peritoneum, and omentum were also detected. CONCLUSION. Patients with ECD should be evaluated systemically, because involvement of vital organs could be lethal.

How to assess the ureters during pelvic ultrasound.

BACKGROUND: Endometriosis, fibroids and gynecological malignancy can all impact the pelvic ureters. Ureteric involvement is likely to be an important factor in determining the extent and timing of surgery in women with these conditions and assessment of the pelvic ureters is now a recommended component of the imaging work-up for women with endometriosis. The aim of this paper is to provide a step-by-step guide for the identification and assessment of the distal ureters during pelvic ultrasound. We hope that this detailed explanation of the examination technique will help ultrasound examiners to develop this skill and enable them to integrate assessment of the pelvic urinary tract into their routine ultrasound examination. CONTENT: In this paper, we describe a '6 step' detailed approach to ultrasound assessment of the ureters during pelvic ultrasound examination. We discuss tips and common examination findings. CONCLUSION: The pelvic segments of normal ureters can be identified in almost all women on transvaginal ultrasound examination and the method described is useful in detecting urinary tract abnormalities.

Gross and Histologic Anatomy of the Pelvic Ureter: Clinical Applications to Pelvic Surgery.

To further evaluate relationships of the pelvic ureter to clinically relevant structures and to characterize the anatomy, histology, and nerve density of the distal ureter. In this observational cadaveric study, 35 female cadavers were examined, 30 by gross dissections and five microscopically. Ureter length and segments of pelvic ureter were measured. Closest distances between the ureter and clinically relevant points were recorded. The distal pelvic ureter and surrounding parametrium were evaluated microscopically. Nerve density was analyzed using automated quantification of peripheral nerve immunostaining. Average measurements of nerve density in the anterior and posterior quadrants surrounding the ureter were statistically compared using a two-tailed t test. Descriptive statistics were used for analyses with distances reported as mean±SD (range). Gross dissections revealed ureter length of 26.3±1.4 (range 24-29) cm (right), 27.6±1.6 (25-30.5) cm (left). Lengths of ureter from pelvic brim to uterine artery crossover were 8.2±1.9 (4.4-11.5) cm (right), 8.5±1.5 (4.5-11.5) cm (left) and from crossover to bladder wall 3.3±0.7 (2.4-5.8) cm (right), 3.2±0.4 (2.6-4.1) cm (left). Intramural ureter length was 1.5±0.3 (1-2.2) cm (right) and 1.7±1.2 (0.8-2.5) cm (left). Distances from the ureter to uterine isthmus: median 1.7 (range 1-3.0) cm (right) and 1.7 (1.0-2.9) cm (left); lateral anterior vaginal fornix 1.5 (1.0-3.1) cm (right) and 1.7 (0.8-3.2) cm (left); lateral vaginal apex 1.3 (1.0-2.6) cm (right) and 1.2 (1.1-2.2) cm (left) were recorded. Microscopy demonstrated denser fibrovascularity posteromedial to the ureter. Peripheral nerve immunostaining revealed greater nerve density posterior to the distal ureter. Proximity of the ureter to the uterine isthmus and lateral anterior vagina mandates careful surgical technique and identification. The intricacy of tissue surrounding the distal ureter within the parametrium and the increased nerve density along the posterior distal ureter emphasizes the importance of avoiding extensive ureterolysis in this region.

Clinical and Pathological Aspects of the Sequelae of Urogenital Schistosomiasis: Findings Regarding 43 Cases

Purpose: To describe the clinical-pathological profile of sequelae of urogenital schistosomiasis. Patients and methods: We performed a retrospective study of the sequelae for cases of urogenital schistosomiasis treated between January 2011 and December 2016. These cases were from Senegal and neighboring countries. Results: We included 43 cases. The mean age of the patients was 43.2 ± 16.6 years (14 - 75 years). The sex ratio was 3.3. The sites of the sequelae lesions were the bladder and pelvic ureters in 83.7%, the bladder only in 13.9%, and the ureters only in 2.3% of the patients. Bladder wall calcification was the most common lesion (74.4%), followed by bladder masses (48.8%). Stenosis of the orifice was the most common ureteral lesion (30.2%). The bladder masses were a squamous cell carcinoma in ten cases, a urothelial carcinoma in one case, and a schistosomiasis granuloma in five cases. In one patient, the histological type was not specified. Of the ten cases of squamous cell carcinoma, eight had died of cancer. Of the twelve cases of ureteral orifice stenosis treated by ureterocystoneostomy, the outcome was good in nine cases and poor in three patients. Conclusion: In this study, sequelae of urogenital schistosomiasis were most often observed in young adult males. The most common sequelae were vesical and ureteral calcifications, bladder cancers, and pelvic ureter strictures.