Pelvicaliceal System Research Articles

Résultats fonctionnels à court terme de la cystectomie avec dérivation urinaire non continente par laparoscopie robot assistée dans le cadre de troubles du bas appareil urinaire : une étude rétrospective monocentrique

ObjectiveTo assess the short-term functional outcomes and morbidity of robotic-assisted cystectomy (RAC) and intracorporeal urinary diversion (ICUD) in patients with lower urinary tract dysfunction (LUTD). MethodsAll consecutive patients who underwent RAC+ICUD for LUTD in a tertiary hospital center, between July 2018 and May 2021 were retrospectively included. Medical records were systematically reviewed and patient, perioperative and postoperative data were collected. A good short-term functional outcome was defined by the combination of a satisfying urostomy equipment (absence of urine leakage and easy appliance of the urostomy bag), the absence of pelvicaliceal system dilatation on sonography, and the absence of renal function decrease at the 2months post-operative consultation. Intraoperative parameters and post-operative complications were collected to assess morbidity. ResultsThirty-five patients were included. Eight (22.8%) patients needed intraoperative conversion to laparotomy. Twenty-five patients (92,5%) met criteria for a good functional outcome 2months post-operatively. The median operative time was 346min (86.5–407.5). The median blood loss was 100mL (100–290) and 5 patients (18.5%) required blood transfusion. The median times to return of bowel function was 3 days (2–4) and the median length of hospital stay was 10 days (10–18). Peri-operative complications were reported in 16 patients (59.2%): 6 (22.2%) minor complications Clavien ≤ II and 10 (37%) major complications Clavien ≥ III. There was no significative decrease of the renal function (mean preoperative creatininemia of 61.2μmol/L (50.5–74.5) vs 64.5μmol/L (47–85.25) postoperatively) ConclusionRAC+ICUD in LUTD can provide good short-term functional outcomes while limiting blood transfusion, time to return of bowel function and the length of hospital stay. These results should be confirmed by larger prospective study. Level of evidence4

Renal Mass with Renal Stones: A Challenging Scenario Managed with Robotic Assistance

Introduction: A renal mass with a concurrent stone is a complex challenge. The challenge is to tackle both pathologies using a single anesthetic without compromising the oncologic or renal functional outcomes. This video demonstrates two cases using robot-assisted nephron-sparing surgery (RA-NSS) and provides tips for effective management to maintain the oncologic and functional safety. Methods: Simultaneous RA-NSS with stone retrieval was performed with DaVinci SiHD system using three robotic arms in two cases after obtaining due consent as per our previously described technique.1 Case 1 was a 66-year-old man, whereas the second case was a 56-year-old woman. In Case 1, during resection of the tumor the renal stone was identified through the opening in the pelvicaliceal system (PCS), which was further extended and three stones were retrieved intact. For Case 2, after dissecting the hilum, the renal pelvic dissection was performed followed by a pyelotomy to retrieve the stones. This mimics a previous published technique by Garisto et al.2 The PCS was closed with 3-0 polygalactin sutures over a Double-J stent (DJS), in both cases. Results: The warm ischemia time (WIT) was 27 minutes in Case 1 and the renal hilum was not clamped in Case 2. The estimated blood loss was 800 and 200 mL and the length of hospital stay was 7 and 5 days for Cases 1 and 2, respectively. The histopathology report in both the cases was clear cell with negative margins. The DJS were removed at 4 weeks. No adjuvant treatment was offered in both the cases. Both the patients were recurrence free with normal renal function at a follow-up of >5 years. Conclusions: During RA-NSS the focus is to limit WIT and maintain the oncologic margins. In a situation where a renal stone is large and the tumor is close to PCS (index Case 1), the NSS is performed initially followed by an incision further into pelvis for stone extraction. However, when the stone is in the pelvis and the tumor is in the periphery (index Case 2), pyelolithotomy should be performed first followed by NSS to decrease or avert the WIT. Patient consent statement: Both the patients of this video submission gave full consent for recording the surgical procedure and its use for publication. The authors have received and archived patient consent for video recording/publication None of the authors have any competing financial interests. Runtime of video: 8 mins 10 secs

Percutaneous Nephrolithotomy Removal of Eroded Hem-o-lok Clip Post-Partial Nephrectomy

Clinical History: This video is a demonstration of the removal of an eroded Hem-o-lok clip post-partial nephrectomy through percutaneous nephrolithotomy (PCNL). The index patient is a 69-year-old gentleman, who received robotic partial nephrectomy 10 years ago for a right kidney lower pole renal cell carcinoma. Later he was presented with hematuria. Physical Examination: Physical examination was unremarkable. Diagnosis: A computer tomography scan discovered an eroded Hem-o-lok clip into the system at lower pole of the right kidney. There were associated stones. Otherwise, there was no other lesion in the urinary system explaining his symptoms. Intervention: Retrograde intrarenal surgery (RIRS) was performed but failed to access the lower pole Hem-o-lok and the associated stones. PCNL was attempted with modified prone position. Antegrade access with ultrasound-guided upper pole puncture was performed. Upper pole was punctured as it allows access to all calixes, including the lower pole, and also because of the distorted anatomy after partial nephrectomy observed in fluoroscopy in the previous RIRS. Holmium laser was employed for disengagement of the clip from surrounding mucosa. Stones were fragmented with Lithoclast lithotripter. Clip and the related stones were removed with forceps. Follow-Up/Outcomes: Patient was discharged one day postoperation and the pelvicaliceal system was clear of stones on a later computed tomography scan. Removal of eroded surgical clips endourologically with PCNL is a safe and possible method. No competing financial interests exist. Runtime of video: 4 mins 34 secs Patient Consent Statement: The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Clearance of Metal Particles After Percutaneous Nephrolithotomy with Trilogy Lithotripter.

Purpose: To evaluate the clearance of metal particles produced and released in the pelvicaliceal system (PCS) during percutaneous nephrolithotomy (PCNL) with the use of the Swiss Lithoclast® Trilogy dual-energy (EMS Urology, Nyon, Switzerland) lithotripter. Methods: An experimental in vivo study and a clinical investigation of case series were conducted. An in vivo porcine model with two pigs for lithotripsy (after inserting artificial stones into the collecting system) and two pigs for submucosal injection of metal particles (provided by the manufacturer of Trilogy) was conducted. Porcine kidney histology analysis for metal leftovers was conducted immediately or 2 weeks after the surgery. A prospective observational study design included 10 consecutive patients treated with conventional 30F PCNL or with 22F mini-PCNL technique. Only the patients with the confirmed metal particles in the PCS during the initial PCNL and the need for additional retrograde intrarenal surgery over a period of 2-4 weeks were selected. The presence of metal particles was evaluated during the second endoscopic surgery. Results: The generated metal particles during PCNL and the submucosally injected particles were not found macroscopically 2 weeks postoperatively in porcine models. No pathologic changes such as foreign body granuloma or inflammation were found. Similarly, no metal particles were observed during the second look endoscopy (n = 10). Conclusion: Metal particles observed endoscopically using the Trilogy lithotripter are cleared with no pathologic evidence of tissue damage from the metal particles 2 weeks after the procedure. Thus, the intraoperative release of any particle by the Trilogy lithotripter should not raise any safety concerns.

Role of Retrograde Intrarenal Surgery in the Management of Diabetic Renal Papillary Necrosis.

Introduction: It is challenging to diagnose diabetic renal papillary necrosis (RPN) radiologically due to the limitation in performing a contrast study in patients with compromised renal function. Endoscopic management by Double 'J' (DJ) stenting or percutaneous nephrostomy is the preferred treatment. The aim of our study was to analyze the role of retrograde intrarenal surgery (RIRS) in the management of RPN by retrieving necrosed papillae. Methods: This retrospective study included diabetic patients who presented with acute pyelonephritis or urosepsis at our institute. After evaluating with appropriate laboratory and radiological investigations, retrograde pyelography (RGP) and DJ stenting were performed in those who did not respond to intravenous antibiotic therapy. The RIRS was performed in patients who had filling defects in the pelvicaliceal system (PCS) on RGP after 3 weeks at the time of DJ stent removal. Patients with a minimum follow-up period of 6 months were included. Results: A total of 187 patients (81 female, 106 male) with diabetes with a mean age of 58.3 years were enrolled in this study. The mean serum creatinine was 2.7 mg/dL and mean estimated glomerular filtration rate was 32.8 mL/min/1.73 m2. One hundred twenty-six patients (67.3%) had hydroureteronephrosis (HUN), out of whom 74 (58.7%) had necrosed papillae in the PCS. In 61 (32.6%) patients, there was no HUN; however, 25 (41%) of these patients had necrosed papillae in PCS. Necrosed renal papillae were retrieved in 83 patients (46.1%) by RIRS. All the patients were followed up for a minimum period of 6 months; seven patients (3.8%) had recurrent pyelonephritis. Conclusions: The RIRS plays a significant role in the management of diabetic RPN. Retrieving necrosed papillae from the PCS after confirming their presence by RGP prevents ureteric obstruction, which leads to urosepsis, and presumptively prevents or delays future episodes of pyelonephritis.

Robot-Assisted Radical Nephroureterectomy.

First proposed by Kimball and Ferris in 1933 for the treatment of papillary tumors in the upper urinary tract, radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard for management of high-risk upper tract urothelial carcinoma involving the proximal ureter and/or pelvicaliceal system. Over three decades since the first description of laparoscopic RNU, minimally invasive approaches to RNU have continued to evolve and become increasingly utilized. More recently, robot-assisted RNU (RARNU) has increasingly become a viable approach. Specifically, RARNU affords a reduction in perioperative morbidity and improved convalescence as a minimally invasive approach, all while adhering to traditional open surgical principles and providing surgeons with improved technical ergonomics and streamlined operating room logistics, particularly with the advent of the da Vinci Xi platform. In this study, we describe our approach to transperitoneal RARNU, including indications, operating room setup, step-by-step surgical technique, and perioperative care.

V04-04 CLINICAL APPLICATION OF 3D ANATOMICAL MODELING SOFTWARE (IRIS TM ) DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN) FOR COMPLEX RENAL MASSES

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-04 CLINICAL APPLICATION OF 3D ANATOMICAL MODELING SOFTWARE (IRISTM) DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN) FOR COMPLEX RENAL MASSES Ahmed Ghazi, Tyler Holler, Thomas Frye, William Tabayoyong, Jonathan Bloom, Hani Rashid, and Jean Joseph Ahmed GhaziAhmed Ghazi More articles by this author , Tyler HollerTyler Holler More articles by this author , Thomas FryeThomas Frye More articles by this author , William TabayoyongWilliam Tabayoyong More articles by this author , Jonathan BloomJonathan Bloom More articles by this author , Hani RashidHani Rashid More articles by this author , and Jean JosephJean Joseph More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: IRISTM is an interactive three dimensional (3D) anatomic modeling software allowing functional manipulation of anatomical models for the surgical planning of renal masses. The software represents converted DICOM files of CT images to 3D virtual anatomical models, viewed on an iOS device during preoperative surgical planning and the da Vinci surgical system TilePro input for intraoperative navigation. The objective of this video is to demonstrate the clinical utility and application of IRISTM as a preoperative planning and intraoperative navigation tool during RAPN in two patients with highly complex renal masses. METHODS: The first case is a 73 year old male patient with a 2.7 cm right, completely endophytic hilar renal mass. Nephrometry score was 10h. The second case was a 45 years old male presenting with a 7.8 by 7.6 cm, exophytic, left hilar posterior renal mass with a nephrometry score of 11p. Preoperative planning was completed utilizing axial imaging and IRIS on an iOS device and a surgical plan put forth. Intraoperative navigation was via the da Vinci surgical system TilePro input. Perioperative and intraoperative patient data was collected. RESULTS: In the first case, IRIS helped visualize the resection cavity exposing the surrounding vascular branches that could be injured during tumor resection, identifying the feeding vessels perfusing the tumor and predicting structures encountered during suturing at the base of the resection bed during renoprraphy. Estimated Blood loss (EBL) was 100cc, Warm ischemia time (WIT) 17 minutes, with minimal change in postoperative renal function. Final pathology was positive for an Oncocytoma with negative margins. In the second case with an exophytic tumor, the transparency function allowed for identification of vital structures that would be encountered at the resection base. In this case a large portion of the pelvicaliceal system (PCS) abutting the tumor base and a feeding branch to the tumor from the renal artery were accurately localized by altering parenchyma and tumor transparency in the IRIS model. EBL was 60cc, WIT 28 minutes and renal function was maintained postoperatively. Pathology was positive for clear cell carcinoma with negative margins. CONCLUSIONS: IRISTM technology with its interactive features, offered valuable preoperative and intraoperative information not attainable by standard axial imaging in the robotic approach for surgical management of complex renal masses. Source of Funding: Inuititive Inc. Clinical trial © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e292-e292 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Tyler Holler More articles by this author Thomas Frye More articles by this author William Tabayoyong More articles by this author Jonathan Bloom More articles by this author Hani Rashid More articles by this author Jean Joseph More articles by this author Expand All Advertisement Loading ...

Renal Cortex, Medulla and Pelvicaliceal System Segmentation on Arterial Phase CT Images with Random Patch-based Networks.

Renal segmentation on contrast-enhanced computed tomography (CT) provides distinct spatial context and morphology. Current studies for renal segmentations are highly dependent on manual efforts, which are time-consuming and tedious. Hence, developing an automatic framework for the segmentation of renal cortex, medulla and pelvicalyceal system is an important quantitative assessment of renal morphometry. Recent innovations in deep methods have driven performance toward levels for which clinical translation is appealing. However, the segmentation of renal structures can be challenging due to the limited field-of-view (FOV) and variability among patients. In this paper, we propose a method to automatically label the renal cortex, the medulla and pelvicalyceal system. First, we retrieved 45 clinically-acquired deidentified arterial phase CT scans (45 patients, 90 kidneys) without diagnosis codes (ICD-9) involving kidney abnormalities. Second, an interpreter performed manual segmentation to pelvis, medulla and cortex slice-by-slice on all retrieved subjects under expert supervision. Finally, we proposed a patch-based deep neural networks to automatically segment renal structures. Compared to the automatic baseline algorithm (3D U-Net) and conventional hierarchical method (3D U-Net Hierarchy), our proposed method achieves improvement of 0.7968 to 0.6749 (3D U-Net), 0.7482 (3D U-Net Hierarchy) in terms of mean Dice scores across three classes (p-value < 0.001, paired t-tests between our method and 3D U-Net Hierarchy). In summary, the proposed algorithm provides a precise and efficient method for labeling renal structures.

A Single-Center Prospective Comparative Study of Two Single-Use Flexible Ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China).

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to compare in vivo performance and surgical outcomes with two single-use ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China) with secondary objective being to compare in vivo vision by independent endourologist blinded to ureteroscope manufacturer. Materials and Methods: Fifty patients undergoing retrograde intrarenal surgery with <2 cm renal stones were prospectively allocated: Group 1 (25 patients) for LithoVue and group 2 (25 patients) for Uscope. Pre-, intra-, and postoperative parameters were evaluated. Vision of both ureteroscopes with and without accessory was evaluated by an independent endourologist, blinded to the make of the ureteroscope. Stone clearance was assessed with kidney, ureter, and bladder radiograph (KUB) and ultrasonography KUB at 1 month. Student's t-test for quantitative and chi-square for categorical data was used. Results: Pre- and intraoperative parameters such as need for ureteral dilatation (p > 0.05), ureteral access-sheath size (p = 0.78), accessibility to pelvicaliceal system (p > 0.05), and maneuverability (p > 0.05) were comparable in both groups. Lower-pole access was possible in all cases of LithoVue and slightly difficult in three cases of Uscope (p > 0.5). Intraoperative vision was hazy in four cases of LithoVue and eight cases of Uscope (p = 0.32) during lasing along with three cases of Uscope with accessory (p = 0.24). Blinded endourologist reported more cases of hazy vision with or without accessory or lasing in Uscope arm (p > 0.05). One device had malfunction in LithoVue arm. Complete stone clearance was achieved in all cases at 1 month. Conclusions: We conclude that performance of these two single-use ureteroscopes, LithoVue and Uscope, is comparable in clinical settings with similar clinical outcomes and complications.

Chronic Unilateral Hematuria: Compound Papillae Are Likely to Bleed.

Objectives: The present study investigated the recent outcomes of chronic unilateral hematuria (CUH), focusing on the detailed distribution of bleeding points based on the anatomical classification of the pelvicaliceal system. Materials and Methods: We evaluated 75 CUH patients treated in the past decade. Bleeding points were recorded separately as five levels of minor calices (Top, Upper, Middle, Lower, and Bottom). Bleeding point detection, immediate success, and recurrence-free rates were assessed. Results: The median age was 47 (range: 13-81) years. Bleeding points were detected in 62 patients (83%), including at the Top calix in 24 patients (32%), the mid-calices (Upper, Middle, and Lower) in 20 patients (27%), and the Bottom calix in 18 patients (24%). As there are typically six total calices in the mid calices, the probability of bleeding per renal papilla was higher in the compound papillae at the Top and Bottom calices than in the simple papilla at the mid calices. The bleeding point detection rate was significantly higher in the 65 patients with confirmed unilateral gross hematuria than in the 10 patients without confirmation (88% vs 50%, p < 0.01). The immediate success rate was 97% (73/75), and only two patients (3%) needed a second ureteroscopy. Ultimately, all patients achieved the disappearance of gross hematuria, including 13 patients (17%) whose bleeding points were not identified by ureteroscopy. The recurrence-free rate was 100% at a median follow-up of 42 (3-139) months. Conclusions: Compound papillae are more likely to bleed than simple papillae. Therefore, we recommend evaluating the Top and Bottom calices carefully during the initial ureteroscopic observations. Since the patients with confirmed gross hematuria from the unilateral orifice had a higher rate of bleeding point detection than those without confirmation, it is important to perform cystoscopy while the bleeding is persistent.

Injury to Biliary Tract During Percutaneous Nephrolithotomy: Minimally Invasive Management of a Dreadful Complication

Background: Percutaneous nephrolithotomy (PCNL) is an effective minimally invasive surgical modality for the management of renal calculi. It is generally considered safe with commonly encountered complications being urinary extravasation, fever, and bleeding. Injury to the biliary tract or puncture of the gallbladder is an extremely rare but a grave complication of PCNL. Case Presentation: We present a case of a 70-year-old man who underwent PCNL for an obstructing right renal pelvic calculus. Upon middle caliceal puncture to access the pelvicaliceal system, an unexpected green aspirate suggestive of bile was noted egressing through the puncture needle when stiletto was detached. The needle was swiftly withdrawn and percutaneous renal access was effective on the second puncture to complete the procedure. In the postoperative period, biliary ascites was confirmed on imaging, which was managed in a minimally invasive manner with an ultrasonography-guided abdominal drain insertion. The patient recovered well and was discharged home. Conclusion: Biliary ascites with or without peritonitis is a rare but potentially fatal consequence of biliary tract injury that can occur during PCNL. If there is recognition of biliary aspirate during a percutaneous renal procedure, aggressive management, including diverting the biliary fluid in appropriately selected cases, can obviate the need for emergent open or laparoscopic surgical intervention as highlighted in our case.

Double J stent migration in the contralateral ureter during robotassisted pyeloplasty: an unique complication

The placement of double-J (DJ) stent in the urinary tract is a part of urologic practice for many indications. However, this may cause many complications ranging from stent-related irritative lower urinary tract symptoms (LUTS) to advanced renal failure. Although complications such as encrustations, proximal, and distal migrations within the pelvicaliceal system (PCS) are reported frequently in the literature, stent displacement into the contralateral ureter is rare and not previously described at our knowledge. Keywords: Double J stent dislocation; robotic pyeloplasty; hydronephrosis

Mucinous Cystadenoma Arising From Renal Pelvis

Primary mucinous cystic tumors occurring in the renal pelvis or the entire pelvicaliceal system are uncommon. Most are mucinous cystadenoma and less frequently mucinous cystadenocarcinomas. In fact, the publications on these neoplasms are limited to a few cases. Because mucinous cystadenomas of kidney are exceedingly rare, little is known about their natural history, pathogenesis and clinicopathologic features. Herein, we describe a case of mucinous cystadenoma arising from the renal pelvis, which resembled hydronephrosis. The patient presented with a history of intermittent dull pain on the left loin for 6 months. He had no history of removing urinary calculus or long- standing chronic infection in urinary system. The histopathology was unique since the inner surface of the cyst was covered by a mucinous epithelium connected to a urothelium, a transition from non- neoplastic urothelium to mucinous epithelium. This suggests that mucinous cystadenoma of renal pelvis, like its malignant counterpart, may arise in foci of metaplastic mucinous areas. Faridpur Med. Coll. J. Jul 2019;14(2): 104-106

Endourologic Treatment in Two Cases of Ureteral Valves.

Introduction: Congenital ureteral valves are a rare cause of ureteral obstruction that may lead to renal function deterioration. We present two clinical cases treated endoscopically by monopolar electrocautery and laser fiber ablation. Presentation of Case: The first case is a 13-year-old male with several episodes of abdominal pain and was found to have severe left hydronephrosis. Ultrasonography showed a dilated ureter and pelvicaliceal system with an obstructive renogram curve. We performed a retrograde pyelogram, finding a dilated ureter 5 cm up from the vesicoureteral junction with ureteral valves in that place. Ablation of the valves was conducted using monopolar electrocautery. The second case is a 2-year-old male with left ureterohydronephrosis shown in abdominal ultrasonography. In the radiologic findings, a high-risk pyelocaliceal dilatation with renal parenchyma thinning and a diameter of 3.3 cm for the left ureter is described, with an obstructive renogram. We performed a cystoscopy, observing the presence of valves in the ureter at 3 cm that conditioned an obstruction. The complete section of the valves was performed through a 270μm holmium laser fiber. Our patients made an uneventful postoperative recovery and continue to remain completely asymptomatic. A significant decrease in renal dilation was observed and renal function recovered in both cases. Conclusion: Ureteral valves are an uncommon cause of ureteral obstruction. Advances in endourologic techniques allow us to give a minimally invasive approach to these diseases, obtaining good long-term results in our small series of patients.

MP22-07 THE IMPORTANCE OF HANDS-ON TRAINING FOR FLEXIBLE URETEROSCOPE (FURS)

INTRODUCTION AND OBJECTIVE: In recent years, advancement in endoscopic technology has led to the increase in the number of retrograde intrarenal surgery using a flexible ureteroscope (fURS). The treatment performance of fURS are affected by the technique of the surgeon. However, educating non-experts therefore serves as an important challenge. For this reason, since 2015, we have been hosting fURS hands-on seminars using the actual device. In this study, we reviewed the questionnaires issued to the seminar students to evaluate the usefulness of the training. METHODS: Of the 82 seminar students who have attended the seminars since 2015, we evaluated 22 individuals (5 experts and 17 non-experts), using the questionnaires completed prior to training, and 3 months post-training. After attending the lecture concerning URS, to function as hands-on training, the students practiced the fURS skills using the scope trainer (Figure 1a). Hands-on training included four processes (1: Device-setting and observation from ureter to the renal pelvis, 2: Observation from renal pelvis to each renal calix, 3: Practice of manipulating basket forceps in the renal pelvis, and 4: Catch and release of stones in the pelvicaliceal system). In principle, the training was involved holding the endoscope in the left hand and extracting stones with the right hand (one-person stone extraction; Figure 1b). RESULTS: All urologists indicated that the hands-on training was more useful than the lecture. Among the four processes, the most common positive feedbacks showed that 60% of non-experts found “Observation from renal pelvis to each renal calix” being effective, while 37% of experts found “Device-setting and observation from ureter to the renal pelvis” being effective. After training, 7 students (50%) switched to the approach of performing endoscopic manipulations using the left hand; only 3 students (21%) switched to the one-person stone extraction approach. The most common change after the seminar was the change in the method of guiding one’s juniors (7 people: 50%), followed by less damages to the ureteroscope (6 people: 44%). CONCLUSIONS: The fURS hands-on seminar was demonstrated to not only help to familiarize students with the basic manipulation of the ureteroscope, but was also useful in establishing a method in guiding juniors.Source of Funding: no

A Case of Type 1 Papillary Renal Cell Cancer with Pelvic Tumor Thrombus Masquerading as Urothelial Cancer with Review of Literature

Background: Adult renal tumors vary from renal cell carcinoma (RCC) to upper tract urothelial cancer (UTUC). Tumor characteristics such as renal vein and inferior vena cava tumor thrombus are usually seen with RCC, but tumor thrombus into pelvicaliceal system (PCS) is a rare entity in RCC. At present only 11 cases have been reported in the literature. Case Presentation: We report an unusual case of papillary type 1 RCC in a young Muslim man mimicking as UTUC radiologically and found to have free tumor thrombus in PCS. At follow-up of 6 months after right nephroureterectomy with bladder cuff excision, he is doing well clinically and radiologically without any recurrence. Conclusion: RCC with tumor thrombus into PCS is an uncommon entity. It can give similar appearance as an urothelial cancer of the pelvis on radiologic imaging. Pelvic tumor thrombus is now considered as a factor of poor prognostic importance and rarely encountered with pure papillary type of RCC.

Percutaneous Nephrolithotomy in an Elderly Female with Severe Kyphoscoliosis: Modified Prone Position

Percutaneous nephrolithotomy (PCNL) is one of the important options in the management of large (>2 cms) and complex renal calculi. Traditionally the prone position has been used to access the pelvicaliceal system as well as to remove renal calculi. Several modifications to this position have been suggested and reported by several urologists. We performed PCNL in an elderly female with a severe kyphoscoliosis by modifying the classical prone position.

Evaluation of individual and cumulative sites of extrarenal tumor invasion in pT3a clear cell renal cell carcinoma

IntroductionThe Tumor-Node-Metastasis classification of renal cell carcinoma (RCC) for pT3a tumors includes sinus fat invasion (SFI), perinephric fat invasion (PFI), renal vein invasion (RVI), and/or pelvicaliceal system invasion (PSI). The purpose of this study was to determine the association between these patterns of invasion (assessed individually and cumulatively) with the development of metastases and cancer-specific mortality (CSM). Materials and methodsWe identified 160 patients who underwent radical nephrectomy for pT3a clear cell RCC between 2011 and 2017. The association between individual patterns of invasion and metastases and cancer-specific survival were evaluated with multivariate logistic regression. Cox Hazard proportion ratios and Kaplan-Meier survival curves were generated for patterns of invasion (assessed individually and cumulatively). ResultsThe number of individual invasive patterns was as follows: 97/160 (61%) presented with RVI, 91/160 with SFI (57%), 62/160 with PFI (39%), and 24/160 (15%) with PSI. At multivariate analysis, both PFI and RVI were associated with metastases (P < 0.001 and 0.028, respectively). PFI (hazard ratio [HR] 4.12, 95% confidence interval [CI] 2.14–7.92; P < 0.001), RVI (HR 2.44, 95% CI 1.18–5.01; P = 0.015), SFI (HR 2.13, 95% CI 1.05–4.34; P = 0.036) had higher CSM, while PSI (HR 1.43, 95% CI 0.65-3.16; p = 0.38) did not show increased CSM. Furthermore, cumulative analysis showed that multiple invasive patterns resulted in worse CSM (p < 0.001). ConclusionsIn our study, PFI was associated with the most aggressive behavior while PSI was the most indolent. Furthermore, the presence of more than one pattern of invasion was associated with worse CSM. These results indicate that reporting of the individual location and cumulative amount of pT3a patterns of invasion in clear cell RCC is clinically relevant.

Proposal for a Simple Anatomical Classification of the Pelvicaliceal System for Endoscopic Surgery.

We herein propose a nomenclature for renal calices and anatomical classification of the renal pelvis for endoscopic surgery. We prospectively collected data on a total of 270 patients (540 kidneys) who underwent CT-urography. We then constructed three-dimensional images of the renal pelvis and examined their morphologic classification. Forty-eight kidneys were excluded from this study because of severe hydronephrosis or large renal cysts. The remaining 492 kidneys were included. We systematically categorized each minor calix into five levels: top, upper, middle, lower, and bottom. The upper, middle, and lower calices were typically found in pairs: anterior and posterior. The most common total number of minor calices was eight (51%), followed by seven (30%). We also classified the form of the pelvis into type I: single pelvis (58%) and type II: divided pelvis (42%), according to the branch patterns of the renal pelvis. In type II, the renal pelvis is always bifurcated into the upper branch (top and upper) and lower branch (middle, lower, and bottom). Type I was subclassified into three types: type Ia (43%), the standard type; type Ib (4%), with a wide pelvis; and type Ic (11%), with a narrow pelvis. This anatomical classification can divide the renal pelvis into two major types (subdivided into four types) and name each minor calix. This simple classification enables to share common intrarenal information, thus leading to the development of concrete treatment strategies.

A Challenging Case of Poorly Differentiated Transitional Cell Carcinoma of the Kidney

When describing carcinomas, poorly differentiated defines how little the tumor tissue resembles the normal tissue it came from. The origin of these types of tumors cannot be determined by histological findings alone. Imaging findings and patient history play a strong role in determining the source of the patient’s cancer. Imaging features of urothelial cancer of the renal pelvicaliceal system can be challenging for any sonographer or radiologist. When tumors are hyperechoic relative to nearby renal parenchyma, they may be obscured by the surrounding hyperechoic renal sinus fat, causing these carcinomas to be difficult to detect regardless of whether they are well defined or poorly differentiated. This case study delves into the difficulty in sonographically imaging a poorly differentiated transitional cell carcinoma without sonographic evidence of a primary circumscribed mass.