Recurrent Pyelonephritis Research Articles

Modified Psoas Hitch with Lich-Gregoir Onlay Technique for the Reconstruction of Lower Ureter during Gynecologic or Obstetric Operations

Aims: We retrospectively review patients who underwent ureteral implantation with a psoas hitch during obstetric or gynecologic operations and describe a new modification. Methods: Between December 1997 and May 2005, 20 patients between 26 and 56 years underwent ureteral reimplantation by using the nonrefluxing, extravesical Lich-Gregoir onlay technique with psoas hitch at our institution by the same reconstructive surgery team. Additionally, we used a urethral catheter balloon as a landmark for the bladder mucosa and fixed the bladder to the psoas tendon by using the balloon. We performed 14 ureteral reimplantations during the surgery as intraoperative reconstruction. In 6 patients, delayed reconstruction of the ureter was performed a few days following the previous operation. Results: For intraoperative and delayed reconstructions, the mean operation time for ureteral reimplantation was 24 and 75 min. We took out the urethral catheter on the second operative day and the anastomotic drain on the third. The average hospital stay was 5.7 days. No cases of chronic flank pain, recurrent pyelonephritis, persistent severe hydronephrosis or compromised renal function occurred. No patient required reoperation. Conclusions: Modified psoas hitch ureteral reimplantation is an effective and safe way of reconstruction for treating defects in ureteral length.

Family History and Risk of Recurrent Cystitis and Pyelonephritis in Women

Recurrent urinary tract infections and pyelonephritis have risk factors suggesting genetic sources. Family history variables indicative of genetic risk merit further investigation. We evaluated the risk of recurrent cystitis and pyelonephritis in women with and those without a family history of urinary tract infection. We conducted a population based case-control study of 1,261 women 18 to 49 years old enrolled in a Northwest health plan. Participants were cases identified from plan databases with documented recurrent cystitis (431) or pyelonephritis (400). Shared controls (430) were similar age women with no urinary tract infection history. We evaluated the history of urinary tract infection and pyelonephritis in first-degree female relatives (mother, sister[s], daughter[s]) and other covariates, ascertained through questionnaires and computerized databases. Of the cases 70.9% with recurrent cystitis and 75.2% with pyelonephritis, and of the controls 42.4% reported a urinary tract infection history in 1 or more female relative (p <0.001 for each case group vs controls). In both case groups odds ratios were significantly increased for women reporting a urinary tract infection history in their mother, sister(s) or daughter(s). Risk increased with a greater number of affected relatives. In women with 1 vs 2 or more relatives the ORs for recurrent cystitis were 3.1 (95% CI 2.1, 4.7) and 5.0 (3.1, 8.1), and the ORs for pyelonephritis were 3.3 (2.2, 5.0) and 5.5 (3.4, 9.0), respectively. In these community dwelling women a urinary tract infection history in female relatives was strongly and consistently associated with urinary tract infection recurrence and pyelonephritis. Risk estimates increased with stronger family history indices, suggesting a genetic component for increased susceptibility to these infections.

Xanthogranulomatous Pyelonephritis

A 52 year-old man was brought to our emergency department because of fever with chills and right abdominal pain for 1 week. He had a history of type 2 diabetes mellitus, right renal stones with recurrent pyelonephritis, and end-stage renal disease on regular hemodialysis. The initial vital signs showed body temperature 38.5°C, pulse 102 beats per minute, respiratory rate 24 breaths per minute, and blood pressure 150/88 mm Hg. Physical examination showed tenderness over right upper quadrant of the abdomen. In addition, right costophrenic angle knocking pain was detected. Hemogram showed leukocytosis (white blood cell: 14,400/μL, 90% neutrophils). X-ray of the kidneys, ureters, and bladder showed several radiolucent spots at the right upper abdomen. Abdominal computed tomography (CT) showed a well-encapsulated huge hypodense multicystic lesion with calcifications involving the psoas muscle (Figure 1). Coronary view of abdominal CT showed destruction of the right renal parenchyma replaced by multiple fluid-filled cavities extended into the liver, with postcontrast rim enhancement and thickening of Gerota’s fascia (Figure 2). The attenuation values in these masses varied from −5 to 23 Hounsfield Units (HU) because of its lipid content. Right nephrectomy confirmed the diagnosis of xanthogranulomatous pyelonephritis. Figure 2 View Large Image Figure Viewer

Toll-Like Receptor 4 Promoter Polymorphisms: Common TLR4 Variants May Protect against Severe Urinary Tract Infection

BackgroundPolymorphisms affecting Toll-like receptor (TLR) structure appear to be rare, as would be expected due to their essential coordinator role in innate immunity. Here, we assess variation in TLR4 expression, rather than structure, as a mechanism to diversify innate immune responses.Methodology/Principal FindingsWe sequenced the TLR4 promoter (4,3 kb) in Swedish blood donors. Since TLR4 plays a vital role in susceptibility to urinary tract infection (UTI), promoter sequences were obtained from children with mild or severe disease. We performed a case-control study of pediatric patients with asymptomatic bacteriuria (ABU) or those prone to recurrent acute pyelonephritis (APN). Promoter activity of the single SNPs or multiple allelic changes corresponding to the genotype patterns (GPs) was tested. We then conducted a replication study in an independent cohort of adult patients with a history of childhood APN. Last, in vivo effects of the different GPs were examined after therapeutic intravesical inoculation of 19 patients with Escherichia coli 83972. We identified in total eight TLR4 promoter sequence variants in the Swedish control population, forming 19 haplotypes and 29 genotype patterns, some with effects on promoter activity. Compared to symptomatic patients and healthy controls, ABU patients had fewer genotype patterns, and their promoter sequence variants reduced TLR4 expression in response to infection. The ABU associated GPs also reduced innate immune responses in patients who were subjected to therapeutic urinary E. coli tract inoculation.ConclusionsThe results suggest that genetic variation in the TLR4 promoter may be an essential, largely overlooked mechanism to influence TLR4 expression and UTI susceptibility.

V1999 ROBOT-ASSISTED LAPAROSCOPIC RIGHT CALYCEAL DIVERTICULECTOMY

You have accessJournal of UrologyTransplantation, Urolithiasis & Hydronephrosis1 Apr 2010V1999 ROBOT-ASSISTED LAPAROSCOPIC RIGHT CALYCEAL DIVERTICULECTOMY Matthew Paszek, James Hoskins, and Ramakrishna Venkatesh Matthew PaszekMatthew Paszek More articles by this author , James HoskinsJames Hoskins More articles by this author , and Ramakrishna VenkateshRamakrishna Venkatesh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Symptomatic renal calyceal diverticulum can be managed by ureteroscopic, percutaneous endoscopic, or laparoscopic approaches. Robotic assistance can facilitate the closure of the neck of the diverticulum and obliterate the diverticular cavity. This video demonstrates a technique to ablate renal calyceal diverticulum. A 35-year-old female with history of recurrent pyelonephritis underwent percutaneous drain placement for a suspected abscess. Further work-up revealed a calyceal diverticulum. After a failed ureteroscopic procedure, she was referred for definitive treatment. She presented to us with a perinephric drain and an indwelling ureteral stent. METHODS A retrograde ureteral catheter was positioned for pyelography and for later injection of indigo carmine to identify the diverticular neck. In view of the posterior upper pole location, an intermediate robotic camera position was chosen. Intra-operative laparoscopic ultrasound was performed to identify the diverticulum and to find the thin area of renal cortex overlying it. The diverticulum was entered sharply without clamping of the hilar vessels. Argon beam coagulator was used to fulgurate the lining. The neck of the diverticulum was oversewn and the diverticular cavity was obliterated by renorrhaphy using sliding clip technique with 10mm Hem-o-loks (Weck Closure Systems, NC, USA). RESULTS Total operative time was 220 minutes. Estimated blood loss was 100ml. Retrograde pyelography at the end of the case revealed no contrast entry into the previously seen diverticulum. Patient was discharged on post-operative day 2 with no evidence of urine leak (JP fluid creatinine was 0.7mg/dl). CONCLUSIONS Robot-assistance provided for easier access and reconstruction of the posterior upper pole of the kidney. The sliding clip renorrhaphy technique described for laparoscopic/robotic partial nephrectomy can be performed to obliterate the renal calyceal diverticular cavity. Lexington, KY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e776 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Paszek More articles by this author James Hoskins More articles by this author Ramakrishna Venkatesh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Endoscopic treatment of vesicoureteral reflux in an adult population: Can we teach our adult urology colleagues?

Vesicoureteral reflux (VUR) is not well described or understood in adults. Since endoscopic correction of VUR has become a first-line therapy in children, we aimed to evaluate the efficacy of this technique in adult patients. In 1988-2008, 49 adult patients (6 males, 43 females) with a mean age of 33.6 years (range 18-64) underwent endoscopic treatment of VUR. Reflux was unilateral in 17 (34.7%) and bilateral in 32 (65.3%) patients, comprising 81 renal refluxing units (RRU). Of these, 71 (87.7%) were primary VUR. Reflux was Grade I in 14 (17%), Grade II in 46 (56.8%), Grade III in 17 (21%) and Grade IV in 4 (4.9%) RRU. Median renal function at surgery was 41.2%. Endoscopic correction utilized polytetrafluoroethylene (Teflon) in 38 (77.6%) and dextranomer/hyaluronic acid copolymer in 11 (22.4%) patients. Recurrent febrile urinary tract infection (UTI) was the only indication for surgery. Grade I VUR was treated only in patients with contralateral high-grade VUR. The reflux was corrected in 63 (77.8%) RRU after a single injection, after second injection in 9 (10.6%) and after third in 4 (4.8%) RRU. In 3 (3.5%) RRU, VUR improved to Grade I. In 2 (2.4%), endoscopic correction failed, leading to open reimplantation. One patient with corrected VUR underwent nephrectomy due to non-functioning kidney and recurrent pyelonephritis. Fourteen (28.6%) patients suffered afebrile UTI. Five (10.2%) developed febrile UTI following successful endoscopic correction, leading to a diagnosis of VUR recurrence in two (4.1%) patients. Endoscopic correction of VUR in adults is a simple and effective procedure, as in pediatric practice.

Long‐term outcome of ureterosigmoidostomy: an analysis of patients with &gt;10 years of follow‐up

Therapy (case series). 4. To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques. We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention. The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study. USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

Genetic Variation of the Human Urinary Tract Innate Immune Response and Asymptomatic Bacteriuria in Women

BackgroundAlthough several studies suggest that genetic factors are associated with human UTI susceptibility, the role of DNA variation in regulating early in vivo urine inflammatory responses has not been fully examined. We examined whether candidate gene polymorphisms were associated with altered urine inflammatory profiles in asymptomatic women with or without bacteriuria.MethodologyWe conducted a cross-sectional analysis of asymptomatic bacteriuria (ASB) in 1,261 asymptomatic women ages 18-49 years originally enrolled as participants in a population-based case-control study of recurrent UTI and pyelonephritis. We genotyped polymorphisms in CXCR1, CXCR2, TLR1, TLR2, TLR4, TLR5, and TIRAP in women with and without ASB. We collected urine samples and measured levels of uropathogenic bacteria, neutrophils, and chemokines.Principal FindingsPolymorphism TLR2_G2258A, a variant associated with decreased lipopeptide-induced signaling, was associated with increased ASB risk (odds ratio 3.44, 95%CI; 1.65–7.17). Three CXCR1 polymorphisms were associated with ASB caused by gram-positive organisms. ASB was associated with urinary CXCL-8 levels, but not CXCL-5, CXCL-6, or sICAM-1 (P≤0.0001). Urinary levels of CXCL-8 and CXCL-6, but not ICAM-1, were associated with higher neutrophil levels (P≤0.0001). In addition, polymorphism CXCR1_G827C was associated with increased CXCL-8 levels in women with ASB (P = 0.004).ConclusionsTLR2 and CXCR1 polymorphisms were associated with ASB and a CXCR1 variant was associated with urine CXCL-8 levels. These results suggest that genetic factors are associated with early in vivo human bladder immune responses prior to the development of symptomatic UTIs.

Treatment Strategies to Minimize or Prevent Chronic Allograft Dysfunction in Pediatric Renal Transplant Recipients

Long-term allograft survival poses a major problem in pediatric renal transplantation, with allograft nephropathy being the principal cause of graft failure after the first post-transplant year. The mechanisms of nephron loss resulting in graft dysfunction are multiple, comprising both immunologic factors such as acute and chronic antibody- or T-cell-mediated rejection and non-immunologic components. The latter include peri-transplant injuries and renovascular lesions (renal artery stenosis, thrombosis) as well as cardiovascular risk factors such as arterial hypertension and hyperlipidemia. Another relevant issue leading to progressive nephron loss and declining kidney transplant function is acute and chronic nephrotoxicity induced by the calcineurin inhibitors (CNIs) ciclosporin (cyclosporine microemulsion) and tacrolimus. Furthermore, the presence of an abnormal lower urinary tract as well as bacterial (recurrent pyelonephritis) and viral (cytomegalovirus [CMV], polyomavirus [BK virus; BKV]) infections are crucial factors involved in the incidence of chronic allograft dysfunction and graft failure. Renovascular lesions and lower urinary tract obstruction are typical indicators for surgical intervention. The aim of treatment in pediatric patients with renal failure secondary to a dysfunctional lower urinary tract is to create a sterile, continent, and nonrefluxive reservoir. Surgical techniques such as bladder augmentation and the introduction of intermittent catheterization and anticholinergic therapy have significantly improved graft outcome. Arterial hypertension, another factor responsible for graft function deterioration in pediatric renal transplant recipients, is controlled preferably by the use of angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists, which are known to possess nephroprotective properties in addition to their potent antihypertensive effects. Although treatment of subclinical rejection with augmented immunosuppression has been associated with better graft survival, an increase of the immunosuppressive level to avoid subclinical rejection should be weighed against the risk of infection. The majority of viral infections affecting kidney allografts are caused by CMV and BKV. Antiviral CMV prophylaxis or pre-emptive therapy with ganciclovir has been shown to have beneficial effects in the pediatric renal transplant population. Treatment of BKV-induced nephropathy is based on reduction of the immunosuppressant therapy, although specific antiviral agents such as cidofovir and leflunomide are known to inhibit BKV. However, cidofovir itself is nephrotoxic and should therefore be administered cautiously to pediatric renal transplant patients. Since CNIs are likewise known for their nephrotoxic effects, especially with long-term use, alteration of the immunosuppressant regimen is necessary in case of deteriorating graft function due to CNI-induced histopathologic changes. Complete CNI avoidance seems inappropriate because, in this situation in pediatric renal transplant recipients, other relatively potent immunosuppressant agents such as lymphocyte-depleting antibodies, which are frequently accompanied by a higher incidence of infections, are needed for rejection prophylaxis. CNI withdrawal and switching of the immunosuppressant regimen from CNI therapy to sirolimus may be an option for some pediatric renal transplant patients with less advanced graft function deterioration. Nevertheless, potential adverse events such as aggravation of proteinuria, hyperlipidemia, myelosuppression, and hypergonadotropic hypogonadism have to be considered, and controlled studies are lacking. At present, an immunosuppressant maintenance therapy composed of low-dose tacrolimus or ciclosporin (CNI minimization) and mycophenolate mofetil with low-dose corticosteroids appears to be the most promising strategy to adopt in pediatric renal transplant recipients at low or normal immunologic risk.

Transmission of an Extended-Spectrum-Beta-Lactamase-Producing Escherichia coli (Sequence Type ST131) Strain between a Father and Daughter Resulting in Septic Shock and Emphysematous Pyelonephritis

Probable transmission of an extended-spectrum-beta-lactamase-producing Escherichia coli strain (sequence type ST131) between a father and daughter was documented. The father developed severe, recurrent pyelonephritis with multiple small abscesses; the daughter later developed septic shock, bacteremia, and extensive emphysematous pyelonephritis. This multidrug-resistant E. coli clone appears to be highly pathogenic and transmissible.

Recurrent pyelonephritis as a sign of ‘sponge kidney’

Intravenous urography is the gold standard for the diagnosis of medullary sponge kidney. Computed tomography and ultrasonography have limited ability to clearly show tubular ectasia.

Neurogenic bladder in twins: question

A 20-month-old boy was hospitalized at our institution with acute pyelonephritis. He had a history of two previous episodes of urinary tract infection (UTI) treated at an other center. Radiographic imaging and cystoscopy revealed no obstructive lesions such as posterior urethral valve (PUV), and dimercaptosuccinic acid (DMSA) scintigraphy was normal. Bilateral ureteral reimplantation was performed for repair of bilateral vesicoureteral reflux (VUR) when he was 12 months of age. He used antimicrobial prophylaxis irregularly during the follow-up period, and he had no constipation. Consanguinity was present between his parents. His weight, height, physical examination findings, and renal function tests were normal. Ultrasonography showed normal-sized kidneys with grade 4 hydronephrosis in the left side and dilatation in the left ureter and a mild hydronephrosis in the right kidney. The bladder wall was severely trabeculated with a thickness of 5 mm, and a DMSA scan revealed hypoactivity in the pelvic region of the left kidney without any cortical scars in either kidneys. Voiding cystourethrography (VCUG) showed grade 4 reflux on the left side and grade 3 reflux to the right kidney. His monozygotic twin was also admitted to our hospital with acute pyelonephritis and was treated accordingly. He had suffered from recurrent acute pyelonephritis episodes since 3 months of age. Subureteric injection was performed when he was 9 months old due to the presence of grade 3 VUR on the right side. He also had irregular antimicrobial prophylaxis and had stopped taking the drug 1 month prior to admission. Constipation was not present. His physical examination was normal. Renal ultrasound was unremarkable, with normal-sized kidneys without any dilatation. Dimercaptosuccinic acid scan showed a normal left kidney. The right kidney was inferiorly located and smaller than the left kidney; renal scars were seen in the upper and lower parts of the kidney. Voiding cystourethrography revealed grade 4 reflux to the right kidney and, interestingly, similar to his twin, a trabeculated bladder wall (Fig. 1).

Is continuous antibiotic prophylaxis in children with vesicoureteral reflux really ineffective in preventing pyelonephritis?

Sirs, Although long-term antibiotic prophylaxis (AP) has been used for patients with vesicoureteral reflux (VUR) in order to prevent urinary tract infections for many years, recent randomized controlled trials (RCTs) revealed that AP with sulfametoxazole/trimethoprim (SMX/TMP) or nitrofurantoin was ineffective in reducing the rate of recurrence of pyelonephritis in children with low grade VUR and was associated with an increased risk of resistant infections [1– 3]. On the other hand, because of the increase in organisms resistant to SMX/TMP, conventional AP using low-dose cephalosporins, such as cefaclor (CCL), has been favored by many pediatric nephrologists and urologists in Japan for more than 10 years. Although we previously reported the efficacy and safety of the strategies of AP using low doses of CCL for children with VUR in this journal, since then there has been a paucity of evidence for the agent [4]. To investigate whether long-term use of CCL could effectively reduce the risk of recurrent pyelonephritis in comparison with SMX/TMP, we therefore reviewed retrospective data from children with VUR, including grade IV or V, in our hospital. Two hundred and forty-two children (168 male, 74 female) with VUR who had been diagnosed by voiding cystourethrography after acute pyelonephritis and had received AP (CCL or SMX/TMP) for more than 6 months in Saitama Children’s Medical Center from April 1994 to December 2008 were enrolled in this study. The VUR grade was based on the maximum grade on either side of the urinary collecting system (grade I, 7; II, 41; III, 64; IV, 82; V, 48). Of the 242 patients, 184 (76%) had received AP with CCL (5–10 mg/kg per day), while the remaining 58 (24%) had received SMX/TMP (5–10 mg/kg per day SMX and 1–2 mg/kg per day TMP). The choice of antibiotics and the duration of AP depended on the decisions of different physicians. The children’s ages at the first episode of acute pyelonephritis varied from 0.5 months to 127 months (median 4 months). The mean duration of treatment for patients who had received AP was 21±13.5 months. Forty patients (17%) developed breakthrough infections (total 70 episodes) during a total of 5,028 months of treatment (one recurrent pyelonephritis in approximately 72 months). Of these 40 patients, 29 (73%) had high grade VUR (grade IV or V). Table 1 shows the demographic characteristics of the patients who received AP with CCL or SMX/TMP. Although there were no significant differences between the two groups in terms of the gender ratio, the duration of treatment, VUR laterality, or VUR grade, the predicted months for one recurrent episode of pyelonephritis per patient was significantly longer for children on CCL than for those on SMX/TMP (P<0.05). However, children who had received AP with low doses of CCL were more likely to have had breakthrough infections of cephalosporinresistant bacteria other than Escherichia coli, such as Pediatr Nephrol (2009) 24:1431–1432 DOI 10.1007/s00467-009-1161-6

Urogenital history in veterans exposed to high-dose sulfur mustard: a preliminary study of self-reported data.

To date, little information exists regarding urogenital diseases in those who have been exposed to sulfur mustard (SM). We report the self-reported history of urologic conditions and findings on physical examination in a group of male veterans 19 to 26 years after exposed to high-dose sulfur mustard. Data on urologic health conditions of a nationwide health survey were used in this study. This survey included all 289 Iranian male veterans who had been exposed to high doses of SM between 1983 and 1989. Demographic data, exposure-related data, health status, and also self-reported lifetime history of urologic conditions were analyzed. History of benign prostatic hyperplasia, recurrent urinary tract infections, pyelonephritis, urinary calculi, kidney failure, and urogenital neoplasms were specifically concerned. The mean age of the veterans was 45.0 ? 7.5 years (range, 30 to 75 years). An interval of 19 to 26 years had passed from exposure to SM. Fifty veterans (17.3%) had a positive history of urinary calculi, 25 (8.7%) had recurrent urinary tract infections, 5 (1.7%) had BPH, and 2 (0.7%) had kidney failure. None of them had experienced urogenital malignancies. Neither recurrent urinary tract infections nor urinary calculi were significantly associated with age, medications and their doses, or SM-induced late complications in other organs. This study adds the prevalence of self-reported urologic conditions to our limited knowledge on SM-exposed veterans' health condition, without finding any link neither to demographic, nor to the severity of health complications related to the SM exposure.

Two Stage Complex Embolization of an Arteriovenous Fistula between the Right Common Iliac Artery and the Inferior Vena Cava

We present an interesting case of a symptomatic high flow AV fistula between the right common iliac artery (CIA) and the inferior vena cava (IVC), successfully treated by endovascular coil embolization. The patient was found to have a right lower polar renal artery crossing the ipsilateral ureter arising from the CIA, causing pelvi-ureteric junction (PUJ) obstruction and recurrent pyelonephritis. It is hypothesized that this fistula arising from the lower polar renal artery and entering the IVC, may have occurred as a result of trauma during a previous pyeloplasty, or a pathologically induced process of angiogenesis stemming from recurrent pyelonephritis.

Enterovesical Fistula: A Rare Complication of Urethral Catheterization

This report describes the case of an eighty-two-year old lady with an indwelling urethral catheter inserted eight years prior to her presentation to manage her urinary incontinence. She underwent radiotherapy for muscle-invasive bladder cancer (stage T2b) in 1991 and had a laparotomy and drainage of an appendicular abscess in her early twenties. She presented with a short history of fecaluria, pneumaturia, and passage of urine per rectum. On laparotomy she was found to have an inflated catheter balloon that has eroded through the bladder wall into the lumen of a terminal ileal segment. To our knowledge this is the first reported case in literature of a patient developing an enterovesical fistula as a result of a urethral catheter eroding through the bladder wall into the bowel lumen. There are numerous known complications of long-term urethral catheterization. They include recurrent urinary tract infections, recurrent pyelonephritis, sepsis, urethral stricture, blocked and retained catheters, among many other reported complications. This case describes an unusual presentation secondary to an even more unusual complication. This should be considered when handling patients with indwelling urethral catheters inserted in unhealthy bladders.

Kidney Transplantation Into Urinary Conduits With Ureteroureterostomy Between Transplant and Native Ureter: Single-Center Experience

To evaluate the functional outcomes and complications after allogeneic kidney transplantation into recipients with a urinary conduit using ureteroureterostomy between the transplant and native ureter. We performed a retrospective study of 6 patients with a pre-existing urinary conduit undergoing kidney transplantation at a single tertiary academic center from May 1982 to February 2007. The study included 1 female and 5 males aged 16 to 65 years. Two patients received a living donor transplant. The indications for pretransplant conduit formation were neurogenic bladder in 3 and bladder contraction with vesicoureteral reflux in 3. One patient received a colon conduit. All patients underwent kidney transplantation into a urinary conduit using ureteroureterostomy between the transplant ureter and the ipsilateral native ureter. The average interval between conduit formation and kidney transplantation was 83.5 months and the average time of requiring hemodialysis was 56.3 months. The mean follow-up was 5.3 years. The patient and graft survival rate was 100% and 83.3%, respectively. The 3-year serum creatinine averaged 1.4 mg/dL. One graft was lost because of chronic rejection. Transplant ureter obstruction occurred in 2 patients and required endoscopy or open revision. Four patients underwent post-transplant native nephrectomy for recurrent pyelonephritis. Three patients were hospitalized for treatment of graft pyelonephritis. In our experience, ureteroureterostomy between the transplant and native ureter is technically feasible and provides good functional results despite a high incidence of urinary tract infection. We recommend this approach in renal transplant recipients with a short contracted conduit or in those in whom the donor ureter is too short to warrant a tension-free ureteroileal anastomosis.

Leiomyosarkom der Vena cava inferior

In a 34-year-old woman who underwent ultrasound investigation because of recurrent pyelonephritis a space-occupying lesion in the liver was an incidental finding. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed a tumour in segment I of the liver. The patient had been on contraceptives for 12 years. She had no symptoms. Laboratory tests, including tumour markers, were unremarkable. Diagnostic tests to exclude malignant tumour with metastases were negative (thyroid scintigraphy, mammography, coloscopy and gastroscopy). Further tests (ultrasound, coeliaco-mesentericography, hydro-CT and spiral CT, MRI) revealed a tumour, 5 x 4 x 4 cm, in segment I of the liver, most likely an adenoma. Surgical intervention was indicated by the size and questionable malignancy of the tumor. At operation a tumour was found which originated from the inferior vena cava (IVC) and displaced segment I of the liver. The tumour was resected and the venous wall reconstructed with a Goretex patch. Histological examination indicated a poorly differentiated leiomyosarcoma of the IVC. Adjuvant radiotherapy was undertaken postoperatively. There has been no evidence of recurrence after 10 months. Leiomyosarcoma of the IVC can be mistaken, both by ultrasound and tomographic diagnostic procedures, for a tumour in segment I of the liver, especially an adenoma. A leiomyosarcoma of the IVC should be included in the differential diagnosis of an hepatic tumour that lies close to segment I of the liver.

Tratamiento endoscópico del reflujo vesico ureteral III-V complicado en lactantes menores de 1 año

Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritis and high grade (G) Vesicoureteral Reflux (VUR).infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibiotic prophylaxis (AP). N = 27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: G II (control without AP); Persistence: III-V Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings.34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6%), Improved 1, OS 3 (33.3%). Overall results: Solved: 24 U (70.58%), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery.ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.

Clinical and Functional Results after Continent Cutaneous Urinary Diversion with the Ileal Double-T-Pouch

Introduction: The aim of the study was to assess the clinical and functional results after continent cutaneous diversion with the ileal double-T-pouch. Patients and Methods: Between July 1998 and July 2006, 19 patients underwent continent urinary diversion with a cutaneous ileal double-T-pouch. Follow-up investigations included blood chemistry, renal ultrasound and evaluation of the outlet function. The median follow-up was 24 months (range 3–76). Results: There were no intraoperative complications and no perioperative mortality. Early postoperative complications not related to urinary diversion occurred in 6 patients (31.6%). Five patients developed complications related to the urinary diversion (26.3%). The mean operating time was 580 min (420–840). Including the patients who had good results after reoperation, 16 out of the 19 patients (84.2%) were continent day and night without any catheterization difficulties. The average pouch capacity was 490 ml (range 250–1,100). A mild acidosis was the only metabolic disorder observed. During follow-up renal function remained stable in all patients, urinary reflux, recurrent pyelonephritis or stone formation were not found. Three patients with a body mass index >30 developed a necrosis of the efferent loop resulting in pouch cutaneous fistulas. Conclusions: Continent cutaneous urinary diversion with the ileal double-T-pouch led to good intermediate functional and clinical results. However, construction of the pouch is sophisticated, resulting in a long operation time. The double-T-pouch is not recommended in obese patients.