Proximal Ureteral Strictures Research Articles

2150 Successful Endoscopic Closure of a Pyeloduodenal Fistula Using the Over-the-Scope Clip System

INTRODUCTION: Approximately 100 cases of pyeloduodenal fistula (PDF) have been reported in the literature. PDF most often results from pyelonephritis due to nephrolithiasis, when inflammation extends to the duodenum given its relative immobility and lack of posterior peritoneal covering. Diagnosis of a PDF is usually made with computed tomography (CT) of the abdomen with contrast. The mainstay of therapy for PDF is nephrectomy and primary closure of the duodenum. We are presenting the second documented case of endoscopic closure of a PDF using the over-the-scope clip (OTSC) system and the third case of endoscopically treated PDF. This method provides an alternative to open surgery. CASE DESCRIPTION/METHODS: A 62 year old female presented with sharp, severe abdominal pain. She denied back pain, hematuria, fever, and dysuria. She had no significant past medical history and did not take any medications. CT abdomen and pelvis demonstrated a large right-sided staghorn calculus extending into the renal pelvis. The patient underwent percutaneous nephrolithotomy, which was complicated by perforation of the renal pelvis and abdominal compartment syndrome. Subsequently, a proximal ureteral stricture was refractory to stenting and balloon dilation. CT urography demonstrated a PDF (Image 1). After placement of a metallic ureteral stent and nephrostomy tube, a nephrostogram was negative for extravasation, so the patient underwent EGD to evaluate for the resolution of the PDF. During the procedure, iohexol contrast and methylene blue were inserted via nephrostomy tube, and fluoroscopic imaging showed contrast in the right kidney and bladder without extravasation. However, on endoscopy, methylene blue extravasation led to identification of two mucosal defects in the anterior duodenal sweep (Image 2). The larger defect was closed using the helix tissue retractor and OTSC system (12/6 t-type) (Image 3). The smaller defect was closed with 2 hemostasis clips. Follow-up renal scan and CT imaging showed no evidence of contrast extravasation. DISCUSSION: The OTSC is an innovative endoscopic technique most often used for hemostasis and for treatment of endoscopic or surgical complications (e.g., fistula, leakage, or perforation). Most reports document successful OTSC use for fistula closure including gastrocutaneous and esophageal fistulas. Our case is, to our knowledge, the second ever documented PDF closure using the OTSC system.

V03-12 ROBOTIC DISTAL URETEROURETEROSTOMY FOR FOCAL DISTAL URETERAL STRICTURES

INTRODUCTION AND OBJECTIVES:Primary excision of a ureteral stricture followed by ureteroureterostomy (U-U) has been well reported for focal mid- and proximal ureteral strictures. For a distal urete...

Ileocalicostomy Ureteral Substitution for Complex Ureteropelvic Junction Stricture: Technique and Initial Experience

ObjectiveTo present our novel surgical technique, ileocalicostomy ureteral substitution, for the management of long upper ureteral strictures in patients without a dilated extra-renal pelvis. Materials and MethodsTwo patients were identified with long, complex proximal ureteral strictures who were treated with our novel surgical technique by a single surgeon at a single institution. Perioperative data for these two patients are presented along with a detailed description of the surgical technique. ResultsIleocalicostomy ureteral substitution was successfully performed in two cases. The total operative time for these cases was 436 minutes and 246 minutes, with estimated blood loss of 300 mL and 200 mL. Length of stay for the two patients was 8 days and 6 days, respectively. There were no major (Clavien-Dindo Classification ≥ grade 3) complications. Both patients are entirely free of urinary tubes with unobstructed kidneys since reconstruction. ConclusionIleocalicostomy ureteral substitution is a feasible reconstructive option for select patients. To our knowledge this report is the initial experience in the literature presented.

IJU this issue

Treatment of advanced renal cell carcinoma has progressed significantly in the past decade. Pal et al. (Duarte, CA, USA) reported a large retrospective review of advanced renal cell carcinoma in the USA. They reviewed the medical charts of 1173 patients from 318 physicians, and indicated that sunitinib and everolimus remain the most commonly used first and second targeted therapies, respectively. This article shed light on real-world practice in the USA. Cancer-related death is rare for men with biopsy-confirmed prostate cancer and a Gleason score of ≤6. This seems to be partly explained by undergrading of biopsies. Alberts et al. (Rotterdam, the Netherlands) retrospectively reviewed the biopsy specimens of 98 men with a Gleason score of ≤6 or 3 + 4 = 7. This review included 15 men who died, and had a clinical T 1/2 Gleason score of ≤6 at prevalence screening in the European Randomized study of Screening for Prostate Cancer Rotterdam cohort. They also confirmed that the International Society of Urological Pathology 2014 grading system was more accurate for prognostic assessment than the classic Gleason score. This issue includes two interesting Original Articles focusing on prostate biopsy. Shoji et al. (Tokyo, Japan) reported the accuracy of a new technique, real-time magnetic resonance imaging-transrectal ultrasound fusion transperineal target biopsy for biopsy-naïve men. They concluded that targeted biopsy is superior to conventional systemic biopsy. However, a systemic biopsy is still important, because although targeted biopsy alone diagnosed 79% of significant cancers, combined targeted + systematic biopsies diagnosed 95% of significant cancers. Kamei et al. (Tokyo, Japan) reported the prevalence and characteristics of fecal antimicrobial-resistant Escherichia coli in Japanese men undergoing transrectal prostate biopsy. Transrectal biopsy is a common procedure for the diagnosis of prostate cancer, but it has a risk of life-threatening infectious complications. Current guidelines recommend prophylactic use of fluoroquinolone. However, the results of the study revealed fecal carriage rates of fluoroquinolone-resistant E. coli and extended-spectrum b-lactamase-producing E. coli at 9.8% and 5.9%, respectively. An important article in functional urology, Ferreira et al. (Le Mans, France) reported the midterm outcomes of laparoscopic implantation of artificial urinary sphincters in women with intrinsic sphincter deficiency. They reported that 76% of patients experienced resolution, and 16% reported improvement of incontinence. The report was one of the largest series with the longest follow up for this patient population. This issue included two interesting Case Reports. The first report by Fahmy et al. (Selangor, Malaysia) described a unique ureteral substitution technique using buccal mucosa for a 64-year-old woman with a long proximal ureteral stricture after multiple bowel surgeries. Postoperative renal function was improved. The second report by Sugino et al. (Nagoya, Japan) presented a case of the successful treatment of an impacted ureteral stone in a 2-year-old girl with a single session of combined percutaneous nephrostomy and ureteroscopy using a holmium laser.

Robotic Buccal Mucosa Graft Ureteroplasty

Introduction: Morbidity associated with traditional reconstruction of complex ureteral strictures has led to interest in applying the success of buccal graft urethroplasty to the ureter. Case reports suggest that this is a feasible technique, but it has never been reported in a minimally invasive repair.1 Materials and Methods: We performed robotic buccal mucosa graft ureteroplasty in a 24-year-old female presenting with a 6 cm left proximal ureteral stricture, which occurred after traumatic ureteroscopy.2 Oral and abdominal procedures were performed synchronously. Positioning was a modified right lateral decubitus lithotomy with port placement similar to robotic pyeloplasty. The endotracheal tube was secured to the right side and the buccal graft taken from the left. The graft was sutured as a dorsal onlay and secured to an omental flap wrapped around the anastomosis. The flexible ureteroscope easily traversed the anastomosis. A Double-J stent, periureteral drain, and Foley were placed. Results: The operative time was 298 minutes, and the blood loss 75 mL. The patient had an uncomplicated recovery and was discharged on postoperative day 3. After 2 months, ultrasound showed mild pelviectasis and 3-month diuretic renal scan revealed prompt drainage. The patient was without pain or infection 8 months post-procedure. Conclusions: Buccal mucosa graft ureteroplasty is a promising option for complex proximal ureteral strictures. This technique is easily applied in minimally invasive surgery. Further study is needed to evaluate efficacy and morbidity compared to traditional techniques. No competing financial interests exist. Running time: 5 mins 59 secs

Robotic Ileal Ureter: A Completely Intracorporeal Technique

The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure. A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2). Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

NYU Technique for Robot-Assisted Boari Flap

Introduction and Objective: Robot-assisted laparoscopic techniques are being adopted by urologists for reconstruction of the upper urinary tract. Specifically, this technique is being increasingly used to manage complex ureteral strictures. In this video, we demonstrate the use of robotic technology to repair a proximal ureteral stricture utilizing a boari flap. Methods: Utilizing all of the principles of open surgery, we created a minimally invasive technique to perform a robot-assisted boari flap. Using a high-definition recording system and iMovie software with narrative and annotative editing, we created a video outlining the pertinent steps of this procedure. We review and present our data from a retrospectively collected cohort of patients undergoing robot-assisted ureteral reimplant. Results: Between 2005 and 2012, we performed a total of 23 robot-assisted ureteral reimplants of which 13% were boari flaps. Average age was 65. There were 11 females and 12 males. Average body mass index (BMI) was 27.4. Of the 23, 11 were right reimplants, 12 were left-sided, none were bilateral and 10 had previous repairs. Average operative time was 271.4 minutes. Average length of stay (LOS) was 2.3 days. There were 3 complications—a lower extremity neuropathy secondary to positioning, a stent migration, and an inadvertent enteromy. Average follow-up was 6.4 months. Symptom resolution as assessed by radiology was 94.7% and clinical symptom resolution at most recent follow up was 100%. Conclusion: The use of robot-assisted surgery provides a safe, reproducible, and durable technique to manage even the most complex upper urinary reconstructive procedures. This video illustrates many of the advantages provided by the use of robotics and how the open surgical technique can be reproduced in a minimally invasive environment. No competing financial interests exist. Runtime of video: 7 mins 31 secs

Robotic Management of Benign Mid and Distal Ureteral Strictures and Comparison With Laparoscopic Approaches at a Single Institution

To present our experience and outcomes with robotic mid and distal ureteral reconstruction and to compare these results with our previous laparoscopic series. In an institutional review board-approved retrospective study, 16 patients underwent robotic mid and distal ureteral repair (13 ureteral reimplantations and 3 ureteroureterostomies) at our institution from August 2008 to September 2011. Proximal ureteral stricture, extrinsic obstruction, and ureteropelvic junction obstruction cases were excluded. The demographic, perioperative, and postoperative data were reviewed in the reimplantation and ureteroureterostomy robotic groups. These data were compared with the outcomes from our previously published series on laparoscopic ureteral reimplantation. The data from 16 robotic procedures were included in the present study, including 2 open conversions because of excessive scar tissue. A symptomatic bowel injury (Clavien grade IIIb) occurred in 1 case. In our previous series, 5 of the 6 laparoscopic procedures were performed completely laparoscopically with 1 open conversion for anastomosis completion. No major complications occurred. The mean robotic surgery time was 258.6 minutes (range 146-450) compared with 276.5 minutes (range 180-360) for the laparoscopic group. The mean robotic hospital stay was 2.5 days (range 1-8) compared with 2.7 days (range 2-5) for the laparoscopic group. The mean robotic estimated blood loss was 171 mL (range 30-500) compared with 150 mL (range 50-250) for the laparoscopic group. All cases were clinically and radiographically successful at the last follow-up examination. Although early in our experience, the robotic repair of mid and distal ureteral strictures appears to be an efficacious approach comparable to laparoscopy for such conditions.

10 ROBOTIC MANAGEMENT OF BENIGN MID AND DISTAL URETERAL STRICTURE DISEASE: RETROSPECTIVE COMPARISON TO LAPAROSCOPIC APPROACHES AT A SINGLE INSTITUTION

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery I1 Apr 201210 ROBOTIC MANAGEMENT OF BENIGN MID AND DISTAL URETERAL STRICTURE DISEASE: RETROSPECTIVE COMPARISON TO LAPAROSCOPIC APPROACHES AT A SINGLE INSTITUTION Kevin Baldie, Jordan Angell, Kenneth Ogan, Nedra Hood, and John Pattaras Kevin BaldieKevin Baldie Atlanta, GA More articles by this author , Jordan AngellJordan Angell Atlanta, GA More articles by this author , Kenneth OganKenneth Ogan Atlanta, GA More articles by this author , Nedra HoodNedra Hood Atlanta, GA More articles by this author , and John PattarasJohn Pattaras Atlanta, GA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.052AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteral stricture disease has been treated via various surgical approaches. Open repair has traditionally been the gold standard for strictures refractory to endourologic methods. Recent work has shown the efficacy of laparoscopic techniques. We hypothesize that robotic ureteral stricture reconstruction is as effective as laparoscopy. METHODS In an IRB approved retrospective study, 16 patients underwent robotic mid and distal ureteral reconstruction (13 ureteral reimplantations, 3 ureteroureterostomies) at our institution from August 2008 to September 2011. Proximal ureteral stricture, extrinsic obstruction and ureteropelvic junction (UPJ) obstruction cases were excluded. Demographics, perioperative and postoperative data were reviewed and compared to laparoscopic outcomes from our previously published laparoscopic series at the same institution. RESULTS Fourteen of 16 procedures were performed completely robotically in the robotic group. There were two open conversions for Boari flap reconstruction and reimplantation with psoas hitch, respectively. A grade IIIb Clavien complication occurred involving an intraoperative bowel injury requiring additional surgery. By comparison, 5 of 6 procedures in the laparoscopic group were performed completely laparoscopically, with one patient undergoing an elective open conversion to complete the reimplantation. A grade II Clavien complication involving postoperative fevers occurred and was treated via oral antibiotics. Table 1 illustrates outcomes for total robotic, robotic reimplantation (RI), robotic ureteroureterostomy (UU), and laparoscopic reimplantation (RI) groups. All cases were clinically and radiographically successful to date. Data± Total Robotic Robotic RI Robotic UU Laparoscopic RI Demographic n = 16 n = 13 n = 3 n = 6 Age (years) 44(40;23-77) 42(39;23-77) 53(51;51-57) 56(53;35-79) BMI (kg/m2) 28.5(28.1;17.8-42.3) 28.4(27.8;17.8-42.3) 28.8(28.4;20.4-37.7) 27.2(27.1;21.6-32.9) Perioperative Operative Time (minutes) 258.6(252.0;146-450) 266.7(275.0;146-450) 223.0(207.0;168-294) 276.5(277.5;180-360) EBL (mL) 171(100;30-500) 187(100;30-500) 100(100;50-150) 150(175;50-250) LOS (days) 2.5(2;1-8) 2.8(2;1-8) 1.3(1;1-2) 2.7(2;2-5) Complications⁎ IIIb (1) IIIb (1) None II (1) Conversions 2 2 0 1 Postoperative F/U Time (months) 5.4(3.9;1-14) 3.9(2.5;1-12) 11.8(12.3;10-14) 13.2(9.5;2-33) Success C, R: 100 C, R: 100 C, R: 100 C,R: 100 ± Presented as mean (median; range); BMI = body mass index; EBL = estimated blood loss; LOS = length of stay; F/U = follow-up; C = Clinical Success; R = Radiographic Success ⁎ Clavien Classification Grade (events). CONCLUSIONS Though early in our experience, robotic repair of mid and distal ureteral strictures appears to be an efficacious approach for ureteral obstruction. The robotic method may offer additional benefits including improved visualization and technical capacity. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e4 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Baldie Atlanta, GA More articles by this author Jordan Angell Atlanta, GA More articles by this author Kenneth Ogan Atlanta, GA More articles by this author Nedra Hood Atlanta, GA More articles by this author John Pattaras Atlanta, GA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

New Combined Approach in Metallic Ureteral Stenting to Avoid Urothelial Hyperplasia: Study in Swine Model

We assessed the therapeutic value of a new treatment option for ureteral strictures that may avoid urothelial hyperplasia, which is the main cause of metallic stent failure. We used 24 pigs in this study. An experimental model of ureteral stricture was induced in all animals. Obstruction was confirmed by ultrasound and retrograde ureteropyelogram 6 weeks after model creation. The pigs were then randomly allocated to 2 experimental groups. Therapy involved placement of a 6 × 30 mm metallic ureteral covered stent in the ureteral stricture in group 1 and subsequent endoureterotomy at the ureteral segments adjacent to the 2 ends of the stent in group 2. A double pigtail stent was then deployed for 3 weeks. Completion studies 6 months after therapy included retrograde ureteropyelogram, endoluminal ultrasound and ureteroscopy to assess urothelial hyperplasia formation. At the end of the study evidence of urothelial hyperplasia was seen in 50% of the pigs in group 1 and in 29% in group 2. Four and 2 cases of cranial stent migration in groups 1 and 2, respectively, were seen at 6 months. Hyperplasia and renal involvement were statistically significantly different between the groups with more damage in group 1 than in group 2. Hyperplasia was markedly reduced when ureteral peristalsis was inhibited by endoureterotomy at the area of interaction between the stent and the ureter.

A New World Revealed: Early Experience With Digital Ureteroscopy

The latest digital ureteroscope, the DUR-D (Gyrus ACMI Inc., Southborough, Massachusetts) offers image quality that greatly exceeds current analog image capabilities. The purpose of this report was to document the applicability of this device in studying the earliest stages of stone formation. Symptomatic patients with nephrolithiasis (less than 1 cm in diameter) were prospectively enrolled and their renal papilla digitally mapped prior to stone removal. Recovered stones were photographed and analyzed using micro-computerized tomography. If the procedure could not be completed with the DUR-D, a conventional ureteroscope was used. Minors, pregnant patients and those with systemic disorders were excluded. Eight patients (10 renal units), 2 cystine and 6 calcium oxalate stone formers, were studied with a mean age of 50.1 years. Excellent images were collected for all papilla except in 2 cases; a proximal ureteral stricture and acute angulation of the lower pole collecting system, respectively. There were no mechanical device failures. Of the 10 renal units 7 had stents postoperatively and there were no patient complications. The ease of use and high quality images of digital ureterorenoscopy will allow the documentation of the earliest stages of calcium oxalate stone formation and, thereby, advance our understanding of the pathogenesis of calcium oxalate stone formation.

Robotic-Assisted Laparoscopic Ureterocalicostomy

Ureterocalicostomy is a well-established treatment option for patients with recurrent ureteropelvic junction obstruction or proximal ureteral stricture refractory to endoscopic management in the setting of diminutive or intrarenal pelvis or significant peripelvic fibrosis. We report a case of robotic-assisted laparoscopic ureterocalicostomy using the da Vinci robotic system in a patient with proximal ureteral stricture refractory to endoscopic management. All techniques described to date for ureterocalicostomy have been either open or purely laparoscopic. We report a case of robotic-assisted laparoscopic ureterocalicostomy in a patient with refractory proximal ureteral stricture secondary to multiple interventions for stones. We used laparoscopy for the initial dissection and exposure and robotic techniques for lower pole amputation and ureterocaliceal anastomosis. Intraoperative nephroscopy was also performed through the lower pole calix. The patient had resolution of the obstruction at 10 weeks postoperatively with the stent out and radiographic confirmation of excretion and drainage. Robotic-assisted laparoscopic ureterocalicostomy is a feasible alternative to open or laparoscopic techniques for treating refractory proximal ureteral stricture or ureteropelvic junction obstruction. To our knowledge, this is the first described case of robotic-assisted laparoscopic ureterocalicostomy with intraoperative nephroscopy.

Complications after percutaneous radiofrequency ablation of renal tumors

ObjectivesTo evaluate our experience with percutaneous radiofrequency ablation (pRFA) to determine common characteristics of patients with complications, to elucidate possible relative contraindications to therapy. MethodsMedical records of all patients undergoing pRFA were reviewed for demographic data, medical and surgical history, indication, tumor characteristics, and treatment information (complications and management). The group of patients with complications was analyzed for common characteristics. ResultsFrom January 2000 to September 2003, 24 patients (mean age 61 years, 5:1 male/female) with 32 renal tumors were treated with pRFA. Indications for pRFA included prior renal surgery and/or chronic renal insufficiency, significant medical disease, patient choice, von Hippel-Lindau disease, and treatment of a metastasis. Average pretreatment tumor size was 2.4 cm (range 0.5–8.6 cm). Of the 5 patients experiencing complications from pRFA treatment, 2 developed perinephric hematomas, 1 had a persistent urinoma and proximal ureteral stricture, and 2 had colonic injuries. Among patients with complications, 3 of 5 had undergone prior partial nephrectomy on the pRFA-treated kidney. Two of four patients treated for multiple tumors and 57% of patients (4 of 7) with anteriorly located tumors experienced complications. ConclusionsEarly experience with pRFA for renal tumor seems promising, but patient selection criteria are evolving. On the basis of our limited experience, we recommend caution when using renal pRFA in patients with prior partial nephrectomy, multiple tumors treated in the same setting, and tumors located anteriorly or centrally. Further clinical experience will help establish guidelines for the use of this powerful technology in the management of renal tumors.

Ureterocalicostomy: A contemporary experience

To report our contemporary experience with ureterocalicostomy to determine whether the indications or results have changed in modern practice. Ureterocalicostomy is a well-established treatment for patients with complicated ureteropelvic junction (UPJ) obstruction and other forms of proximal ureteral obstruction. Although both retrograde and antegrade endourologic interventions have become accepted forms of management, the success rates do not approach those of open or even laparoscopic interventions, potentially leading to a greater number of patients with treatment failure and the need for more complicated reconstruction. Between July 1991 and February 2004, 11 patients (4 women and 7 men), aged 19 to 68 years (mean 38), underwent open surgical ureterocalicostomy. The indications for surgery were primary UPJ obstruction in 4, failed cutting balloon incision for UPJ obstruction in 3, proximal ureteral stricture after ureteroscopic stone removal in 2, and obliterated UPJ after percutaneous nephrolithotomy and failed antegrade endopyelotomy in 1 patient each. Hospitalization ranged from 4 to 7 days (mean 5.1). No patient experienced a significant perioperative complication. With follow-up ranging from 5 to 32 months (mean 10.1), relief of obstruction was evident in all patients as documented by intravenous urography or nuclear renography. Furthermore, differential function on the involved side improved from a mean of 54.6% preoperatively to 60.1% postoperatively (P <0.05). The spectrum of indications for ureterocalicostomy has changed, although excellent results can still be achieved. Although laparoscopic approaches are currently being evaluated, most patients currently undergoing this reconstructive procedure still require open operative intervention.

Pyeloureterostomy with Interposition of the Appendix

We describe the successful repair of a 6 cm. ureteral stricture involving the right ureteropelvic junction and proximal ureter using appendix as a ureteral substitute. A 37-year-old man involved in a motorcycle accident presented with a retroperitoneal urinoma and a 6 cm. proximal ureteral stricture. At flank exploration we were unable to perform successfully primary pyeloureterostomy through renal descensus with ureteral mobilization. The appendix was selected to bridge the ureteral defect. The right colon and cecum were mobilized to the area of the diseased ureter and the appendix was transected across the base of the cecum. Ureteral scar tissue was resected and the appendix was interposed in an isoperistaltic orientation from renal pelvis to proximal ureter. Convalescence was unremarkable. Retrograde pyelography and flexible ureteroscopy 2 months postoperatively demonstrated a patent anastomosis and viable appendix. The ureteral stent was removed at that time. Excretory urography 3 months postoperatively revealed prompt enhancement of the 2 kidneys and visualization of the 2 ureters. Mercaptoacetyltriglycine-3 renal scan 5 months postoperatively confirmed no scintigraphic evidence of obstruction. The patient was asymptomatic 6 months postoperatively and renal function tests were normal. The appendix can be considered for proximal ureteral defects extending to the right renal pelvis.