Retrograde Urogram Research Articles

A Case of Duodenoureteral Fistula Formation

Duodenoureteral fistulas are rare occurrences. They are most often seen with trauma, ingestion of foreign body, chronic renal infections, duodenal ulcer disease, or ureteral calculi. This is the case of a 63-year-old male with a history of polysubstance abuse, COPD and heart failure with reduced ejection fraction and diastolic dysfunction admitted to the hospital with a nine day history of right sided abdominal pain. The patient denied any fevers, chills, nausea, vomiting, changes in bowel habits, dysuria, or hematuria associated with the pain. CT imaging on admission demonstrated mild-moderate right hydronephrosis with abrupt narrowing of the right proximal ureter, irregularities in the duodenal lumen suspicious for duodenitis, and pericholecystic fluid (Figure 1). Follow-up right upper quadrant ultrasound demonstrated no gallbladder or liver abnormalities. Blood cultures and urinalysis were done and empiric ceftriaxone and metronidazole were started. A retrograde urogram identified a fistula between the right ureter and duodenum with extravasation of dye into the small bowel (Figure 2). A right ureteral stent was placed. Initial blood cultures and HIV testing returned negative. With continued fevers to 103, repeat blood cultures were drawn and the patient's antibiotics were then broadened to Zosyn. EGD performed the following day demonstrated a toothpick penetrating the wall of the descending duodenum (Figure 3). The toothpick was removed via forceps and clips were applied to close the fistula. Blood cultures drawn at the time of the fever spike grew Candida krusei, attributed to a GI source with translocation of the organism to the blood stream via the toothpick. The patient improved following a 21-day course of micafungin. This case is an instance of foreign body ingestion resulting in penetration of the duodenum with formation of a duodenoureteral fistula. Course was complicated by hydronephrosis and Candida krusei bloodstream infection. Candida krusei septicemia is rare in immunocompetent patients and should prompt a search for an etiology.1894_A Figure 1. CT Abdomen1894_B Figure 2. Retrograde Urogram1894_C Figure 3. Endoscopic View of Foreign Body

Management of Ureterouterine Fistula

A 29-year-old female is presented as paradoxical incontinence. As per speculum vaginal examination, there was continuous urine dribbling from external os. Computed tomography urogram showed that there was extravasation of dye from left ureter into a uterus. Cystoscopy examination showed no evidence of vesicovaginal fistula. On left retrograde urogram, there was extravasation of dye into the uterus. Lt ureterorenoscopy was done and left double-J stenting was done after negotiating guidewire into an upper ureter. She was advised for continuous bladder drainage and left double-J stent in situ for 6 weeks. Postoperation, there was no urinary incontinence. After 6 weeks, Foley's catheter and left double-J stent were removed, and intravenous urogram showed no evidence of urogenital fistula.

Laparoscopic Ureteroneocystostomy for Iatrogenic Ureteral Insult—Early and Delayed Repairs

Introduction: Ureteral rehabilitation after iatrogenic ureteral insult poses dual challenges—satisfactory restoration of ureteral continuity and limiting the procedural morbidity. In cases refractory to endourologic approach, the laparoscopic approach may be attempted in view of its favorable morbidity profile. The procedural performance may be considerably affected by the time interval between the primary insult and the restorative procedure.1 We present a video demonstration of this approach in different scenarios. Methods: All patients are evaluated in detail. Imaging included ultrasonography, magnetic resonance urogram or computed tomography urogram, cystoscopy, and retrograde urogram. Patients refractory to endourologic approach with a salvageable renal unit were planned for laparoscopic approach. All procedures were attempted through transperitoneal access utilizing four ports. After familiarizing with the pelvic anatomy, the lower ureteral course was identified. Dissection was continued till the pathological segment. Periureteral adventitia was meticulously preserved during ureteral handling, and thermal energy was utilized selectively. Ureter was dismembered proximal to the pathological segment. The ureter edge was refreshened and spatulated to ensure wide anastomosis. The vesical unit was then mobilized to ensure tension-free approximation. Additional psoas hitch was employed when tension was apprehended during ureterovesical approximation and Boari flap in long-segment defects. Ureteroneocystostomy was conducted with 3-0 polyglactin. Ureteral stent was inserted intracorporeal. Postoperative course was recorded. Ureteral stents were removed at 6 weeks postprocedure. Subsequent follow-ups were scheduled 3 monthly. Imaging was repeated at 6 months postprocedure. Resolution of hydronephrosis and a satisfactory drainage pattern were appraised as a successful outcome. Results and Discussion: Forty-five laparoscopic ureteroneocystostomies were performed between June 2006 and December 2011. Mean±SD age was 37.4±3.5 years. Two were men and 43 women. Etiologies included gynecological surgeries (41 cases), colorectal surgeries (2 cases), and urological surgeries (2 cases). Injuries involved right side in 35 cases, left side in 8 cases, and bilateral in 1 case. All procedures were completed successfully by a laparoscopic approach. Twenty-four patients underwent laparoscopic ureteroneocystomy with psoas hitch, and 19 patients underwent laparoscopic ureteroneocystomy and 2 patients laparoscopic Boari flap. Twenty-five procedures were undertaken within 7 days of the primary event, and 20 procedures were performed after 2 weeks of the primary event. The mean±SD operation duration was 155±10.2 minutes. The mean±SD blood loss was 120±22.5 mL. The operation duration in early and delayed repairs differed significantly (187.05±12.8 minutes, vs. 113.27±17.7 minutes, p = 0.00). No remarkable intraoperative complications were encountered. The mean±SD hospital stay was 3.5±1.2 days. Forty-three patients completed 6-month follow-up and revealed satisfactory outcome. No patients required any additional intervention. Laparoscopic ureteroneocystostomy after iatrogenic ureteral insult is feasible in different scenarios and offers durable outcome with limited morbidity. Diligent handling of the ureter and anastomosis without tension are key aspects of this exercise. The operator should be sufficiently versed with laparoscopic anatomy and intracorporeal suturing exercises. No competing financial interests exist. Runtime of video: 7 mins 35 secs

Early diagnosis of primary ureteral neoplasms:report of 28 cases

Objective To evaluate the choice of early diagnosis method of primary ureteral neoplasms in or-der to improve the ratio of clinical diagnosis. Methods 28 cases with primary ureteral neoplasms were retrospectively analyzed. Ultrasonic examination, IVU, retrograde urogram, spiral CT, MRI, ureteroscopy and exfoliative cell examina-tion of urine were compared in this study. Results The most useful methods of detecting tumors preoperation were retrograde urogram, spiral CT, MRI, ureteroseopy. All the 28 patients underwent surgical treatment. Among them, nephroureterectomy and bladder cuff or partial resection were performed in 19 cases. Postoperative pathology showed transitional cell carcinoma in 27 cases,and adenoma in 1 case. 8 cases were T1-2 tumours. Of the 14 cases during 1990 ～1999 period, 1,5,3,2,2 and 1 cases had survival time of 1,2,3,4,5 and 6 years ,respectively. Of the 14 cases during 2000～2007,4 were lost to follow-up;2 survived for 3 years and 2 for 1 year;the other 6 who have survived near 5 years have been followed till now. Conclusions To improve the early diagnosis rate,B-ultrasonic examination, IVU,retrograde urogram,3D spiral CT and MRI examination were necessary in the early stage. The patients should be opeiated as early as possible after diagnosis. Key words: Ureteral neoplasms; Diagnostic techniques,surgical

Unusual Complication of Urethral Catheterization: A Case Report

We report an unusual complication caused by urethral catheterization. During a routine urethral catheter change in a 38-yr-old woman, a 14-Fr Foley catheter was accidentally placed into the right ureter through the ureteral orifice. The position of the catheter was confirmed by retrograde urogram through urethral catheter. Percutaneous nephrostomy was performed with subsequent proper replacement of a urethral catheter. Two weeks later, the injured ureter had healed without leakage or obstruction.

Uretero‐uterine fistula following dilatation and curettage

A 22-year-old woman presented with a urinary leak per vaginum for 4 months; she also voided normally. Prior to the onset of her symptoms she had undergone a termination of pregnancy by dilatation and curettage (D&C) at 12 weeks gestation at another hospital. On the first postoperative day following the procedure she had developed a urinary leak per vaginum with fever and left flank pain. An intravenous urogram showed a left hydroureteronephrosis with contrast in the vagina. Cystoscopy revealed a normal bladder and on vaginoscopy urine was seen leaking from the cervix. A retrograde urogram showed a stricture 3 cm proximal to the ureterovesical junction where contrast was leaking into a cavity and then delineating the uterus and subsequently the vagina. With a diagnosis of left uretero-uterine fistula a left ureteric reimplant with psoas hitch was undertaken. The postoperative period was uneventful with complete cessation of the urinary leak. (excerpt)

Clinical analysis of 174 cases of primary ureteral carcinoma

To analyse the clinicopathological features and discuss the diagnosis, therapy and prognosis of primary ureteral carcinoma. One hundred and seventy four cases of primary ureteral carcinoma diagnosed pathologically between January 1971 and July 2002 in our institution were followed up and retrospectively studied. The incidence of primary ureteral carcinoma was increasing during the last 30 years. The mean age of occurrence was 63.7 years. The most useful methods of detecting tumors preoperatively were retrograde urogram, CT, magnetic resonance urography and ureteroscopy, with positive percentage of 87.8% (86/98), 96.0% (48/50), 95.8% (23/24), 87.0% (20/23) respectively. 131 (75.3%) cases underwent nephroureterectomy with a cuff of bladder. 171 (98.3%) cases were transitional cell carcinoma. T(a-2) and G(1, 2) tumors account for 70% of all respectively. The 5 year and 10 year survival rates were 53.1% (52/98) and 30.5% (18/59) respectively. The subsequent bladder cancer occurred in 38 cases (23.8%), and the subsequent contralateral ureteral carcinoma occurred in 6 cases (3.8%). The prognosis of primary ureteral carcinoma is poor. Tumor stage and grade are both the prognostic factors. Precise preoperative diagnosis and more effective adjuvant therapy may improve the prognosis.

Ureteral pseudodiverticulosis: The case for the retrograde urogram

Ureteral pseudodiverticula are small outpouchings along the length of the ureter diagnosed primarily by the retrograde urogram. They are associated with hematuria and urinary tract infections, although it is not known whether they cause these associated symptoms or are a result of them. Herein we report 2 cases that highlight the characteristic clinical correlates of ureteral pseudodiverticulosis and review the pertinent literature.

Extracorporeal shock-wave lithotripsy of middle ureteral stones: Are ureteral stents necessary?

To ascertain whether insertion of a ureteral stent improves the outcome of middle ureteral (overlying the pelvic bone) stones treated with extracorporeal shock-wave lithotripsy (ESWL). Thirty-three patients with middle ureteral stones were treated with ESWL at our institution between October 1991 and October 1994. Twenty-six patients were available for follow-up; 14 patients were treated with stent bypass, 8 were treated in situ, and 4 patients were treated after percutaneous nephrostomy (PCN). All patients were treated initially on an unmodified Dornier HM-3, and all but 4 patients were treated in the prone position on a modified Stryker frame. Follow-up consisted of a plain abdominal radiograph, intravenous urogram, occasionally a retrograde urogram, and a telephone interview. The overall stone-free rate for ESWL alone was 73%, and the efficiency quotient was 69. The stone-free rates after a single treatment for the stent bypass, in situ, and PCN groups were 71%, 63%, and 75%, respectively. Overall, 4% of patients required retreatment, 19% of patients required an auxiliary procedure, and 8% of the patients required hospital or emergency room admissions for renal colic. For stones 10 mm or greater (9), stone-free rates after one treatment for the stent bypass, in situ, and PCN groups were 33%, 33%, and 67%, respectively; for stones less than 10 mm (17), success rates were 82%, 80%, and 100%, respectively. Pretreatment stinting provides no advantage over in situ ESWL for middle ureteral calculi (Fisher's exact test, P = 1.0). ESWL is a reasonable initial therapy for middle ureteral stones less than 10 mm.

Clinical radiological management of an uncommon perinephric abscess

The authors describe an uncommon case of a huge perinephric abscess with a gas-fluid level occupying the upper left abdomen. A rational sequence of radiological diagnostic methods such as plain film, ultrasound, CT, and combined retrograde urogram with contrast filling of percutaneous drainage led to correct management.

Renal infarction

A 43-year-old woman complaining of left flank pain was found to have renal infarction. New-onset atrial fibrillation suggested thromboembolism, which was confirmed by retrograde urogram and intravenous pyelogram. The patient was treated with heparin and was discharged on coumadin after evaluation of her cardiac disease.

A rare case of a bifid ureter with a blind end--"h" shaped ureter with calculi (author's transl)

A 51-year-old man was admitted on April, 18, 1972, to our hospital to comfirm the diagnosis of calculi in the left ureter. A plain X-ray film showed 4 calculi in the left side of the pelvis. An excretory urogram showed normal function of both kidneys and of the right ureter. The left ureter appeared Y-shaped. However, a retrograde urogram showed clearly that the left ureter was an h-shaped blindending ureter with calculi. An operation was performed under general anesthaesia. The bifurcation was found just below the iliac vessels. The abnormal ureter, which almost reached to the seminal vesicle behind the bladder, was separated from the surrounding tissues, and was removed with calculi inside. No kidney tissues were demostrated near the blindending ureter either by gross or by histologic examinations. Such a blindending bifid ureter with stones in h-shape seems to be extremly rare.