Proximal Ureter Research Articles

Clinical utility of urinary comprehensive genomic profiling in diagnosing metachronous upper tract urothelial carcinoma: a case report

Introduction and aim of studyMetachronous upper tract urothelial carcinoma (UTUC) is a rare yet aggressive malignancy that is often multifocal and invasive at the time of diagnosis. Unfortunately, the rarity of metachronous UTUC results in a paucity of targeted data, as current literature and clinical management of this tumor is largely extrapolated from that of bladder cancer. Urinary comprehensive genomic profiling with the UroAmp assay identifies six general classes of tumor-mutations present in the urine and thus, may aid in detecting UTUC when the limitations of current tools impede definitive diagnosis. We describe the utility of urinary comprehensive genomic profiling in confirming the provider’s suspicion for metachronous UTUC and recommending radical nephroureterectomy.Patient caseA 68-year-old male with a history of recurrent carcinoma in situ (CIS) of the bladder presented to the urology clinic in 2022 for continued surveillance. Abnormal soft tissue thickening surrounding the proximal right ureter, revealed on computerized tomography urography, prompted further evaluation. Selective right upper tract cytology was indeterminate, and urinary comprehensive genomic profiling was ordered to adjudicate. No tumor was visualized on ureteroscopy however the cytologic brush biopsy of the renal pelvis and proximal ureter were positive for urothelial carcinoma (UC) and/or CIS. UroAmp testing identified genomic features associated with high-grade UC, risk of invasion, and a high genomic disease burden.ResultsThe patient underwent a right kidney and ureter nephroureterectomy in September 2022. Surgical pathology confirmed non-invasive multifocal urothelial CIS. A postoperative urinary comprehensive genomic profiling in February and May of 2023 detected no evidence of residual disease, consistent with complete resection of the tumor. The provider will continue intensive urinary comprehensive genomic profile monitoring coupled with conventional surveillance.ConclusionUrinary measurement of mutated UC genes correlate with disease burden, pathologic grade, and invasion risk and provide clinical utility when reliance on visual confirmation and cytology were not definitive or feasible.

Comparing the efficacy of extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy in the treatment of proximal ureteral stones in children: A retrospective study.

Ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy methods are commonly used in the treatment of proximal ureteral stones. There are no adequate studies showing which method is more effective in children. In our study, we aimed to evaluate and compare the efficacy of two treatment methods, commonly used for proximal ureteral stones in children. A total of 78 patients who underwent ureteroscopic lithotripsy (n = 38) and extracorporeal shock wave lithotripsy (n = 40) due to stones located in the proximal ureter between 2010 and 2021 were included in the study. Demographic data, clinical characteristics, and treatment outcomes were retrospectively analyzed. Kolmogorov-Smirnov, Chi-square, and Mann-Whitney U tests were used for statistical analysis. There was no statistical difference between the demographic characteristics of the groups, except for the mean age values (p = 0.008). A statistically significant difference was found in favor of the extracorporeal shock wave lithotripsy group in terms of stone-free rates after the first intervention, complication rates requiring intervention, re-intervention rates, and the average number of anesthesia sessions per patient until stone-free status (p = 0.043, p = 0.009, p = 0.017, and p < 0.001, respectively). The results of this retrospective study suggest that extracorporeal shock wave lithotripsy is the primary treatment option for single, non-complicated proximal ureteral stones.

Robotic-assisted double lingual mucosal graft ureteroplasty for multifocal ureteral strictures: Case report and technical description.

Ureteroplasty with a single onlay graft for proximal ureter stricture has been widely used in the clinic. However, robotic ureteroplasty with a double lingual mucosal graft (RU-DLMG) has not been reported. The intraoperative measured ureteral stricture lengths of patient 1 were 1.8, 2.5, and 4.6cm, and those of patient 2 were 2.5 and 3.5cm. We performed a RU-DLMG in which the diseased ureter was incised longitudinally from the ventral side and repaired with a double lingual mucosal graft to widen the ureteral lumen. Because of the presence of a distal ureter stricture, RU-DLMG combined with ureteral reimplantation was performed in patient 1. Antegrade urography showed no obstruction of the reconstructed ureteral segment after removing the ureteral stent. The patients had no complaints about the donor site and flank pain during the 12-month follow-up. RU-DLMG appears to be a suitable option for multifocal ureteral strictures.

Effect of ureteral stent length and implantation position on migration after implantation.

Ureteral obstruction is a urinary system disease that causes urinary retention, renal injury, renal colic, and infection. Ureteral stents are often used for conservative treatment in clinics, and their migration usually results in ureteral stent failure. The migrations include proximal migration to the kidney side and distal migration to the bladder side, but the biomechanism of stent migration is still unknown. Finite element models of stents with lengths from 6-30cm were developed. The stents were implanted into the middle of the ureter to analyze the effect of stent length on its migration, and the effect of stent implantation position on 6-cm-long stent migration was also observed. The stents' maximum axial displacement was used to assess the ease of stent migration. A time-varying pressure was applied to the ureter outer wall to simulate peristalsis. The stent and ureter adopted friction contact conditions. The two ends of the ureter were fixed. The radial displacement of the ureter was used to evaluate the effect of the stent on peristalsis. The maximum migration occurs in the positive direction for a 6-cm-long stent implanted at the proximal ureter (CD and DE), but in the negative direction at the distal ureter (FG and GH). The 6-cm-long stent demonstrated almost no effect on ureteral peristalsis. The 12-cm-long stent diminished the radial displacement of the ureter from 3-5s. The 18-cm stent diminished the radial displacement of the ureter from 0-8s, and the radial displacement within 2-6s was weaker than other time. The 24-cm stent diminished the radial displacement of the ureter from 0-8s, and the radial displacement within 1-7s was weaker than other time. The biomechanism of stent migration and ureteral peristalsis weakening after stent implantation was explored. Shorter stents were more likely to migrate. The implantation position had less influence on ureteral peristalsis compared with the stent length, which provided a reference for stent design aimed at reducing stent migration. Stent length was the main factor affecting ureteral peristalsis. This study provides a reference for the study of ureteral peristalsis.

Evaluation of risk factors, treatment options, and prognostic-related factors in patients with benign ureteral strictures: An 8-year single-center experience.

To investigate the etiology, therapeutic effect, and prognosis-related factors of benign ureteral strictures. We analyzed the date of 142 patients with benign ureteral strictures from 2013 to 2021. Ninety-five patients received endourological treatment and 47 patients underwent reconstruction. Preoperative, intraoperative, and postoperative information were compared and analyzed. Symptomatic improvement and radiographic blockage alleviation defined therapeutic success. Stone-related factors caused 85.2% of cases. The overall success rate of endourological treatment was 51.6% versus 95.7% of reconstruction (p < 0.01). However, endourological treatment was better in terms of postoperative hospital stay time, operation time, and intraoperative blood loss (p < 0.001). In endourological group, patients with stricture length ≤2 cm, mild-to-moderate hydronephrosis, proximal or distal stricture had a higher success rate. Multivariate regression analysis showed that the surgical method was the only independent risk factor affecting success and recurrence. Reconstruction success rate was higher than endourological treatment (p = 0.001, OR 0.057, 95% CI (0.011-0.291)), and recurrence rate was also lower (p = 0.001, HR 0.074, 95% CI (0.016-0.338)). No obvious recurrence was seen in reconstruction, and the median recurrence time in endourological treatment was 51 months. Stone-related factors are an important cause of benign ureteral strictures. Reconstruction is the gold standard treatment due to its high success rate and low recurrence rate. Endourological therapy is also preferred as the initial treatment in proximal or distal ureter with length ≤2 cm and mild-to-moderate hydronephrosis. Further close follow-up is required after treatment.

Role of Ureteroscopy (URS) and Stone Treatment in Patients with Recurrent UTIs: Outcomes over a 10-Year Period.

Background. The study aimed to assess whether the eradication of kidney stones might result in a substantial reduction in the onset of recurrent UTIs. Methods. We selected all the patients who underwent ureteroscopy (URS) for stone disease between 2012 and 2021, with either a history of recurrent UTIs (rUTIs), urosepsis or pre-operative positive urine culture (UC). Data included patient demographics, microbiological data, stone parameters, stone-free and infection-free rates (SFR and IFR, respectively) at follow-up, defined as fragments <2 mm at imaging and the absence of symptoms and urine-culture-proven UTI. Results. Overall, 178 patients were selected. The median age was 62 years. The median cumulative stone size was 10 mm (7-17.25), and the commonest locations were the lower pole (18.9%) and proximal ureter (14.9%). The overall stone-free rate at follow-up was 89.3%. The IFR at 3 months was 88.3%. As follow-up duration increased, the IFR reduced to 85.4%, 74.2%, 68% and 65% at 6, 12, 18 and 24 months, respectively. Patients who had infection recurrence were more likely to present stone persistence or recurrence compared to those who were infection-free at follow-up (20% vs. 4.4%, p = 0.005). Conclusions. SFR after URS is a significant predicting variable for the likelihood of infection-free status at follow-up in patients with an rUTI or positive UC at the time of URS.

Laparoscopic buccal plasty of the pyeloureteral segment and proximal ureter

BACKGROUND: With recurrent extended strictures of the pyeloureteral segment and the proximal ureter, when standard operations are ineffective or technically impossible, the narrowed area can be replaced with a flap from the cheek mucosa.&#x0D; AIM: The aim of the study is the results of laparoscopic plastic surgery of the pyeloureteral segment and proximal ureter with buccal graft.&#x0D; MATERIALS AND METHODS: Minimally invasive plastic surgery of the extended stricture of the pyeloureteral segment, upper and middle third of the ureter with a flap from the cheek mucosa was performed in 27 patients. There were 16 men, 11 women, and the average age was 51 years. The cause of narrowing in 16 patients was previously performed pyeloplasty, in 10 contact ureterolithotripsy in the proximal ureter, in 1 his injury during laparoscopic excision of a parapelvical kidney cyst. Laparoscopic access was used in 24 patients, and robot-assisted access was used in 3 patients. In 17 of them, the narrowed area was replaced by the onlay technique, in 10 patients, anastomosis augmentation was performed with a buccal graft.&#x0D; RESULTS: There were no intraoperative complications. The duration of operations ranged from 115 to 340 minutes. There were no cases of urine leaking through the drainage. Fever up to 38.0 C was observed in 5 (18.5%) patients, 3 (11.1%) of them underwent antibacterial therapy (grade II according to Clavien), and 2 (7.4%) without nephrostomy drainage, puncture nephrostomy (grade IIIa according to Clavien) was performed. There were no complications according to Clavien IIIb degree. On excretory urograms and computed tomography, the area of the ureter replaced by a buccal flap is wide and well passable. In patients with pyeloureteral segment strictures, a decrease in the size of expanded cups and pelvis was observed in dynamics. Clinically, all operations were successful, as it was possible to relieve patients from nephrostomy drainage and symptoms of upper urinary tract obstruction.&#x0D; CONCLUSIONS: Buccal ureteroplasty may be the method of choice in patients with extensive narrowing of the pyeloureteral segment and proximal ureter. It is a relatively simple operation and does not require extensive mobilization of the ureter and provides good functional results.

The First Robotic Day Care Procedure in the Management of Testicular Vein Syndrome: A Rare Cause of Hydroureteronephrosis

Clinical History: A 46-year-old gentleman with no comorbidities presented with dull aching pain in the left loin for 6 months. Physical Examination: Examination was unremarkable. Diagnosis: He was evaluated with contrast-enhanced CT scan of the urinary tract that revealed left gross hydroureteronephrosis secondary to midureteral stricture caused by compression of the left testicular vein. Renogram (diethylenetriamine pentaacetate scan) was performed that showed 44% split renal function of the left kidney with a glomerular filtration rate of 86 mL/min. Intervention: He underwent a day-case robotic ureteroureterostomy and intraoperatively the upper ureter was dilated with testicular vein transposing above the midureter that had a stricture, causing dilatation of proximal ureter with hydronephrosis. Upper ureter was transected above the stricture and brought anterior to the testicular vein and the constricted segment was excised. Ureteroureterostomy was performed over 5F/26 cm Double-J stenting using 2-0 Stratafix suture. Outcomes: Follow-up included stent removal at 6 weeks and serial creatinine thereafter has been normal. Follow-up imaging was done in the form of ultrasonography that showed resolution of hydronephrosis at 3 months and 6 months. Patient Consent Statement: Written informed consent was obtained from the patient to publish this research. No competing financial interests exist.This research received no specific grant from any funding agency, commercial or nonprofit sectors. All authors confirm that they have been involved in the conception and design of the study, drafting of the study for intellectual content, and are accountable to the accuracy of all aspects of the content.Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure Runtime of video: 4 mins 17 secs

Finding the optimal candidate for shock wave lithotripsy: external validation and comparison of five prediction models

We aimed to externally validate five previously published predictive models (Ng score, Triple D score, S3HoCKwave score, Kim nomogram, Niwa nomogram) for shock wave lithotripsy (SWL) single-session outcomes in patients with a solitary stone in the upper ureter. The validation cohort included patients treated with SWL from September 2011 to December 2019 at our institution. Patient-related variables were retrospectively collected from the hospital records. Stone-related data including all measurements were retrieved from computed tomography prior to SWL. We estimated discrimination using area under the curve (AUC), calibration, and clinical net benefit based on decision curve analysis (DCA). A total of 384 patients with proximal ureter stones treated with SWL were included in the analysis. Median age was 55.5 years, and 282 (73%) of the sample were men. Median stone length was 8.0 mm. All models significantly predicted the SWL outcomes after one session. S3HoCKwave score, Niwa, and Kim nomograms had the highest accuracy in predicting outcomes, with AUC 0.716, 0.714 and 0.701, respectively. These three models outperformed both the Ng (AUC: 0.670) and Triple D (AUC: 0.667) scoring systems, approaching statistical significance (P = 0.05). Of all the models, the Niwa nomogram showed the strongest calibration and highest net benefit in DCA. To conclude, the models showed small differences in predictive power. The Niwa nomogram, however, demonstrated acceptable discrimination, the most accurate calibration, and the highest net benefit whilst having relatively simple design. Therefore, it could be useful for counselling patients with a solitary stone in the upper ureter.

V01-01 UTILITY OF 3-D MODELING IN COMPLEX UPPER TRACT RECONSTRUCTION: ROBOTIC-ASSISTED URETEROPELVICOSTOMY OF NATIVE URETER TO TRANSPLANT RENAL PELVIS

You have accessJournal of UrologyCME1 Apr 2023V01-01 UTILITY OF 3-D MODELING IN COMPLEX UPPER TRACT RECONSTRUCTION: ROBOTIC-ASSISTED URETEROPELVICOSTOMY OF NATIVE URETER TO TRANSPLANT RENAL PELVIS Bridget L. Findlay, Jayson P. Kemble, Elizabeth N. Bearrick, Katherine T. Anderson, and Boyd R. Viers Bridget L. FindlayBridget L. Findlay More articles by this author , Jayson P. KembleJayson P. Kemble More articles by this author , Elizabeth N. BearrickElizabeth N. Bearrick More articles by this author , Katherine T. AndersonKatherine T. Anderson More articles by this author , and Boyd R. ViersBoyd R. Viers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: 3-D models have been used successfully in oncologic planning, however there are limited data supporting their use and efficacy in complex genitourinary reconstructive cases. Due to complex and variable regional anatomy with transplant vasculature and collecting system, surgical planning requires an individualized approach based on anatomic relationships. Herein, we aim to illustrate the novel utility of 3-D modeling in surgical planning for complex upper tract reconstruction, and to describe an alternative approach to transplant proximal ureteral stricture reconstruction. METHODS: The index patient is a 17-year-old male with a history of bilateral grade 4 vesicoureteral reflux (VUR) who developed end stage renal disease despite ureteroneocystostomies in childhood. He underwent a living-unrelated donor renal transplantation in November 2021, complicated by a focal proximal ureteral stricture. His anatomy was further complicated due to prior ligation of his native distal right ureter and intraperitoneal location of his transplant kidney. Therefore, a 3-D printed anatomical model was created to aid in surgical planning. RESULTS: The 3-D model highlighted a complex trajectory of the proximal transplant ureter and area of stricture directly posterior to the renal hilar vessels. Additionally, the native right ureter ligation was noted distal to the transplant renal pelvis and was not amenable for use in reconstruction. Given these anatomic considerations, the patient underwent an uncomplicated robotic-assisted ureteropelvicostomy between his native left proximal ureter and transplant renal pelvis. Total robotic operative time was 2 hours 17 minutes. He was dismissed on postoperative day (POD) 1 with a creatinine nadir near his post-transplant baseline level at 10-week follow-up. CONCLUSIONS: 3-D printed models have utility in select cases with complex anatomy. These models facilitate accurate regional and spatial anatomy of critical structures to enable effective operative planning. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e79 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bridget L. Findlay More articles by this author Jayson P. Kemble More articles by this author Elizabeth N. Bearrick More articles by this author Katherine T. Anderson More articles by this author Boyd R. Viers More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-12 TISSUE AND PHARMACOKINETIC RESPONSE TO TREATMENT WITH A DRUG-COATED BALLOON IN A PORCINE URETER MODEL

You have accessJournal of UrologyCME1 Apr 2023MP42-12 TISSUE AND PHARMACOKINETIC RESPONSE TO TREATMENT WITH A DRUG-COATED BALLOON IN A PORCINE URETER MODEL Michael Borofsky, Casey Dauw, and Sean Elliott Michael BorofskyMichael Borofsky More articles by this author , Casey DauwCasey Dauw More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Paclitaxel Drug Coated Balloons (PDCBs) have proven efficacious in the treatment of urethral stricture disease. Application of PDCBs for ureteral strictures holds promise but safety and efficacy of their use have yet to be evaluated. This study was designed to gather data concerning; pharmacokinetics, histology, safety and healing potential for the ureter after ureteral dilation with a PDCB in a porcine model. METHODS: Ureteral dilation with PDCBs was performed on three anesthetized female pigs. In all cases one ureter was treated with PDCB dilation alone while the contralateral ureter was treated first with holmium laser endoureterotomy followed by PDCB dilation. Treatments were delivered in the proximal and distal ureter on each side using either an 8mm x 50 mm or 10 mm x 50 mm PDCB. Retrograde pyelograms (RPG) were performed to assess for extravasation after dilation. Ureteral stents were placed. Animals were terminated at 10, 28 and 45 days and gross necropsy was performed. Ureteroscopy with RPGs were also performed during the 28 & 45 day termination procedure. Paclitaxel concentration was quantified from plasma, urine, and tissues. Histology was also performed on treatment site and adjacent tissue. RESULTS: PDCB dilation according to study protocol was successful in each case. Contrast extravasation was seen at each laser endoureterotomy/PDCB sites and none of the PDCB alone sites. All three animals survived to their scheduled termination date. RPG performed at 28 & 45 days showed complete resolution of extravasation though panureteral dilatation was seen in each case presumably related to stenting. Ureteroscopic and gross necropsy confirmed complete healing of treatment sites. Histology at 28 & 45 days showed only minimal inflammation of the PDCB alone treatment sites and complete healing of the endoureterotomy sites with otherwise minimal inflammatory response (Figure 1). Paclitaxel remained detecA in urine and target tissue for up to 45 days with plasma levels being below level of quantification. CONCLUSIONS: PDCBs are capable of delivering paclitaxel to the upper urinary tract and do not appear to inhibit potential for healing despite significant ureteral injury among healthy female pigs. Further data is necessary prior to applying this technique to strictured ureters in human subject. Source of Funding: Urotronic © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e571 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Borofsky More articles by this author Casey Dauw More articles by this author Sean Elliott More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER

You have accessJournal of UrologyCME1 Apr 2023V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER Rainjade Chung, Justin Lee, George W Moran, Miyad Movassaghi, Belinda Li, and Christina P. Carpenter Rainjade ChungRainjade Chung More articles by this author , Justin LeeJustin Lee More articles by this author , George W MoranGeorge W Moran More articles by this author , Miyad MovassaghiMiyad Movassaghi More articles by this author , Belinda LiBelinda Li More articles by this author , and Christina P. CarpenterChristina P. Carpenter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrocaval ureter, also known as “circumcaval ureter” or “preureteral vena cava,” is a relatively rare anatomical variant with an incidence of 0.13% that occurs when the right ureter courses posterior to the vena cava rather than anterior. More commonly seen in males, the etiology is a developmental abnormality of the vena cava, not the ureter. Many cases are clinically silent, but surgical reconstruction is indicated if the patient has severe hydronephrosis, significant functional obstruction, or pain. This patient presented with right flank pain, severe hydronephrosis, and a characteristic "S sign" on retrograde pyelogram (Figure 1). Our objective was to describe our approach to an uncommon case, robotic ureteroureterostomy of a retrocaval ureter. METHODS: The patient was placed in the left lateral decubitus position. The Da Vinci Xi system was utilized and 4 ports were placed in a linear fashion at the lateral border of the rectus 6 cm apart. A 5 mm AirSeal was placed between the 2nd and 3rd arm. ProGrasp Forceps are used in the 1st arm, Maryland bipolar forceps are used in the 2nd arm, and a monopolar curved scissor is used in the 4th arm. Vessel loops were placed on the proximal and distal ureter on either side of the vena cava and were pulled back and forth to allow for visualization and dissection (Figure 2). RESULTS: Successful robotic ureteroureterostomy of a retrocaval ureter. CONCLUSIONS: Robotic ureteroureterostomy is a minimally invasive procedure to manage ureteropelvic junction obstruction caused by a retrocaval ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e82 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rainjade Chung More articles by this author Justin Lee More articles by this author George W Moran More articles by this author Miyad Movassaghi More articles by this author Belinda Li More articles by this author Christina P. Carpenter More articles by this author Expand All Advertisement PDF downloadLoading ...

MP69-14 THE IMPLEMENTATION OF SYSTEMATIC BIOPSIES IN THE ENDOSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CANCER

You have accessJournal of UrologyCME1 Apr 2023MP69-14 THE IMPLEMENTATION OF SYSTEMATIC BIOPSIES IN THE ENDOSCOPIC MANAGEMENT OF UPPER TRACT UROTHELIAL CANCER Andrea Gallioli, Angelo Territo, Basile Giuseppe, Pietro Diana, Paolo Verri, Francesco Sanguedolce, Josep Maria Gaya, Pavel Gavrilov, Alessandro Uleri, Sofia Fontanet, Paula Izquierdo, Jordi Huguet, Ferran Algaba, Joan Palou, and Alberto Breda Andrea GallioliAndrea Gallioli More articles by this author , Angelo TerritoAngelo Territo More articles by this author , Basile GiuseppeBasile Giuseppe More articles by this author , Pietro DianaPietro Diana More articles by this author , Paolo VerriPaolo Verri More articles by this author , Francesco SanguedolceFrancesco Sanguedolce More articles by this author , Josep Maria GayaJosep Maria Gaya More articles by this author , Pavel GavrilovPavel Gavrilov More articles by this author , Alessandro UleriAlessandro Uleri More articles by this author , Sofia FontanetSofia Fontanet More articles by this author , Paula IzquierdoPaula Izquierdo More articles by this author , Jordi HuguetJordi Huguet More articles by this author , Ferran AlgabaFerran Algaba More articles by this author , Joan PalouJoan Palou More articles by this author , and Alberto BredaAlberto Breda More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003332.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Diagnosis of upper tract urothelial cancer (UTUC) is crucial. In this regard, uretheral systematic biopsies (USB) have never been considered. We aim to investigate the safety and usefulness of USB in the diagnosis of UTUC and its impact on disease management. METHODS: We relied on a prospectively maintained database of patients who underwent diagnostic ureteroscopy (URS) for UTUC between 2015-21. USB included at least 2 biopsies in each UT portion: pelvis, proximal, medium, and distal ureter. Perioperative complications were graded using the Clavien-Dindo (CD) classification. We assessed the surgical safety and diagnostic impact of USB and estimated the 2-yr nephroureterectomy free-survival (NFU-FS) according to USB results. Then, we investigated the added value of USB over high-risk tumor variables according to EAU prognostic model. Finally, uni and multivariable logistic regression (MLR) analyses investigated preoperative predictors of positive USB. RESULTS: Overall, 91/360 (25.3%) patients underwent USB. Compared to patients who did not undergo USB, USB did not increase the risk of perioperative and major (CD >3a) complications, nor the risk of readmission (all p>0.05). USB was positive in 43 (47.25%) cases, negative in 30 (33%) patients. 58/300 (19.3%) biopsies were not diagnostic. In 36 (39.5%) patients both USB and biopsy of a suspicious lesion were performed. In 7 (19.4%) cases, USB outperformed the biopsy of the lesion in detecting UTUC. 11 (12%) patients were diagnosed with a distal ureter tumor. In 5 (45.4%) cases USB detected UTUC in other upper tract portions. The 2-yr NFU-FS rates were 87.7% (95CI%: 78.1-98.5) vs 53% (95%CI: 39.4-71.2) (p=0.001) for negative vs positive USB patients. At Cox-regression model accounting for predefined variables, patients with positive USB (vs. negative) had a higher risk of being treated with NFU [Hazard ratio: 3.38, 95%CI: 1.46-7.80, p=0.004)]. At MLR analysis, after adjusting for age, pre-operative positive cytology, smoking status, previous bladder cancer and previous UTUC, patients with negative pre-operative CT scan had a higher probability of having a positive USB (Odds ratio: 8.36, 95%CI: 1.57-71.18, p=0.02). CONCLUSIONS: USB is a safe procedure and detected a non-visible tumor at URS in one over five patients. Positive USB increases the risk of radical treatment and possibly changes the treatment algorithm in almost 50% of the patients with distal ureteral tumor candidates to conservative management. When UTUC is suspected, patients with preoperative negative CT scan may benefit the most from USB. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e969 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea Gallioli More articles by this author Angelo Territo More articles by this author Basile Giuseppe More articles by this author Pietro Diana More articles by this author Paolo Verri More articles by this author Francesco Sanguedolce More articles by this author Josep Maria Gaya More articles by this author Pavel Gavrilov More articles by this author Alessandro Uleri More articles by this author Sofia Fontanet More articles by this author Paula Izquierdo More articles by this author Jordi Huguet More articles by this author Ferran Algaba More articles by this author Joan Palou More articles by this author Alberto Breda More articles by this author Expand All Advertisement PDF downloadLoading ...

Metanephric adenoma in a young female: a rare case report from Nepal

Introduction: Metanephric adenomas (MAs) of the kidney are rare benign epithelial lesions in the kidney that have been described in the literature, mainly through case reports, representing ~0.2% of renal masses. No prior case reports have been published from Nepal. We report one such case with MA presented to our center. Case presentation: A 25-year-old lady presented with complaints of recurrent hematuria for the past 6 months. Ultrasound of the abdomen revealed left gross hydronephrosis and reduced left renal parenchyma. A contrast-enhanced computerized scan of the abdomen and pelvis showed a heterogeneously enhancing soft tissue density lesion 65 mm×57 mm at the left renal pelvis extending into mid calyx and distally to proximal ureter, ~34 mm distal to pelviureteric junction causing moderate hydronephrosis, likely urothelial cell carcinoma. Urine cytology was negative for malignancy. Laparoscopic left nephroureterectomy with bladder cuff excision lymphadenectomy was done. The histopathology report came out to be consistent with MA and the lymph nodes were negative for malignancy. Immunohistochemistry study showed that the cells were positive for PAX8. During follow-up, she did not have hematuria and her postoperative period was uneventful. Discussion: From this report, we want to highlight the need to consider MA as a differential diagnosis of renal mass and differentiate MA from upper tract urothelial carcinoma, renal cell carcinoma, Wilms tumor, and papillary adenomas. Conclusion: MA is a rare renal lesion that may present as upper tract urothelial carcinoma. MA should be evaluated through histology and immunohistochemistry studies.

Evaluation of ureteral injuries caused by ureteral access sheath insertion during ureteroscopic lithotripsy.

To evaluate ureteral injuries caused by insertion of a 13-Fr ureteral access sheath and identify factors (other than pre-stenting) that are predictive of ureteral injury. We enrolled 201 patients who underwent ureteroscopic lithotripsy (URSL). We excluded 80 patients who underwent ureteral stent insertion before URSL, 10 patients who did not use a ureteral access sheath, and 2 patients in whom a ureteral access sheath could not be inserted. In total, 109 patients were analyzed; all underwent insertion of a 13-Fr ureteral access sheath. We investigated ureteral injuries using the Traxer ureteral injury scale. There were 21 (19.3%) cases of ureteral access sheath-related ureteral injury, including 11 (10.1%) grade 2 cases and 10 (9.2%) grade 3 cases. The ureteral injury location was the proximal ureter in 20 cases (18.3%), middle ureter in one case (0.9%), and distal ureter in zero cases. Multiple logistic regression analysis showed that male sex and smaller stone diameter were significant predictive factors for ureteral injury (p=0.037, odds ratio [OR]: 5.19, 95% confidence interval [CI]: 1.11-24.3 and p=0.02, OR: 0.83, 95% CI: 0.71-0.97, respectively). Postoperative ureteral stricture did not occur in any cases. The rate of ureteral injury caused by a 13-Fr ureteral access sheath was considerable, and most ureteral injuries occurred in the proximal ureter. Male sex and smaller stone diameter were significant predictive factors for ureteral injury. The proximal ureter should be confirmed when using a 13-Fr ureteral access sheath, particularly in male patients and patients with small stones.

Multivisceral resection for primary pancreatic signet ring cell carcinoma.

Primary pancreatic signet ring cell carcinoma (PPSRCC) is a rare and aggressive tumor with poor prognosis. Here, we report a case of PPSRCC treated with curative surgery. A 49-year-old man presented with right mid-abdominal pain. Imaging tests showed a 3.6cm tumor extending around the head of the pancreas, the second portion of the duodenum, and the retroperitoneum. Involvement of the right proximal ureter resulted in moderate right hydronephrosis. A subsequent tumor biopsy revealed suspected pancreatic adenocarcinoma. No apparent lymph node or remote metastases were observed. The tumor was considered resectable, and radical pancreaticoduodenectomy was planned. Pancreaticoduodenectomy, right nephroureterectomy, and right hemicolectomy were conducted to resect the tumor en bloc. Final pathology revealed a poorly differentiated ductal adenocarcinoma of the pancreas with signet ring cells infiltrating the right ureter and transverse mesocolon (pT3N0M0, stage IIA, according to UICC for International Cancer Control TNM classification). The postoperative course was uneventful, and oral fluoropyrimidine (S-1) was administered as adjuvant chemotherapy for 1year. At the 16-month follow-up, the patient was alive without any evidence of recurrence. Pancreaticoduodenectomy with right hemicolectomy and right nephroureterectomy was performed for curative resection of PPSRCC infiltrating the transverse mesocolon and right ureter.

Robot-Assisted Laparoscopic Ureteroureterostomy of an Obstructive Retrocaval Ureter

Clinical History: A 32-year-old woman without significant medical history presented with incidentally found right severe hydronephrosis from a computed tomography scan after car accident. Her symptoms include only intermittent right flank pain. She has no dysuria or hematuria. Physical Examination: Examination was notable for right-sided costovertebral angle tenderness. Diagnosis: A computed tomography urogram scan was performed, which revealed severe right hydronephrosis with abrupt transition point at proximal ureter. The transition point was located posterior to the inferior vena cava, consistent with retrocaval ureter anatomy. Renal nucleotide scan showed 40% right kidney split function as well as a t1/2 of 35 minutes in right kidney, suggesting obstruction. Intervention: Given symptomatic pain, radiologic evidence of ureteral obstruction, good residual right renal function, and performance status, decision was made to perform a right robot-assisted laparoscopic ureteroureterostomy. Follow-up/Outcomes: Patient tolerated the procedure well and was discharged home the morning after surgery with drain removed. She had prompt return of daily activities and complete resolution of flank pain. Her ureteral stent was removed in clinic 6 weeks after the surgery. Repeat renal nucleotide scan 3 months after the surgery demonstrated resolution of obstruction with new t1/2 of 8.7 minutes. Patient Consent Statement: The author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors have no conflicts of interest that may alter the results of this study. Runtime of video: 4 mins 28 secs

Utility of 3D Modeling in Complex Upper Tract Reconstruction: Robot-Assisted Ureteropelvicostomy of Native Ureter to Transplant Renal Pelvis

Clinical History: The case is a 17-year-old boy with a history of bilateral grade 4 vesicoureteral reflux and end-stage renal disease who underwent a living-unrelated donor renal transplantation in November 2021. He presented in June 2022 with vague abdominal pain and creatinine 4.3 mg/dL. Physical Examination: Transplant biopsy showed no evidence of acute rejection. Antegrade nephrostogram at the time of nephrostomy tube placement demonstrated hydronephrosis and a focal stricture of the proximal transplant ureter. His anatomy was further complicated because of prior ligation of his native distal right ureter at the time of transplant and intraperitoneal location of his transplant kidney through a peritoneal window. Diagnosis: Focal proximal stricture of transplant ureter. Intervention: Given the complex anatomy, a 3D-printed anatomical model was created to facilitate surgical planning. The 3D model highlighted a complex trajectory of the proximal ureter and strictured segment directly posterior to the transplant hilar vessels. In addition, the transplant kidney was directly overlying the dome of the bladder because of its intraperitoneal location. Given these anatomic considerations, the patient underwent an uncomplicated robot-assisted ureteropelvicostomy between his native left ureter and transplant renal pelvis. Follow-Up/Outcomes: Total robotic operative time was 2 hours 17 minutes. He was dismissed on postoperative day 1 with a creatinine nadir equivalent to his post-transplant baseline at 10-week follow-up. 3D-printed models have utility in select cases with complex anatomy. These models facilitate accurate regional and spatial anatomy of critical structures to enable effective operative planning. No competing financial interests exist. Patient consent statement: Patient consented to the use of nonidentifiable intraoperative photography and video recording for the purpose of medical education and publication in professional journals. Source of 3D model: Mayo clinic 3D Anatomic Modeling Laboratory. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. Music: All music was from Pixabay.com, royalty free. Runtime of video: 04 mins 58 secs

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

An experimental study of magnetic compression technique for ureterovesical anastomosis in rabbits

This study aimed to explore the feasibility of the magnetic compression technique (MCT) for ureterovesical anastomosis in a rabbit model with ureteral obstruction. The distal ureteral obstruction model using female New Zealand rabbits was induced by ligating the distal end of the right ureter with silk thread for four weeks. A pair of cylindrical NdFeB magnets (daughter magnet and parent magnet) with a hole in the center was used for the ureterovesical anastomosis. The daughter magnet and the parent magnet were respectively placed close to the obstruction site through the dilated proximal ureter and urethra, and then the daughter-parent magnets pair was attracted together automatically. Postoperative X-rays were taken to confirm the position of the magnets. The anastomotic stoma specimens were obtained two weeks postoperatively, and the anastomotic stoma formation was observed by the naked eye and histological staining. The operation time and the anastomotic burst pressure were measured. The ureter was significantly dilated in the fourth week after ligation, which satisfied the placement of the daughter magnet. The ureterovesical magnet placements were successfully performed in ten experimental rabbits, with an operation time of 36.5 ± 6.09 min. The parent and daughter magnets attracted each other well and were subsequently removed through the urethra two weeks postoperatively, resulting in the establishment of ureterovesical anastomosis. The anastomotic burst pressure was 147.5 ± 14.59 mmHg. Gross specimens and histological examination of the anastomotic stoma showed that the anastomotic stoma healed well. MCT is feasible and simple for ureterovesical anastomosis.