Tomography Urogram Research Articles

Can Renal and Bladder Ultrasound Replace Computerized Tomography Urogram in Patients Investigated for Microscopic Hematuria?

PurposeComputerized tomography urogram is recommended when investigating patients with hematuria. We determined the incidence of urinary tract cancer and compared the diagnostic accuracy of computerized tomography urogram to that of renal and bladder ultrasound for identifying urinary tract cancer.Materials and MethodsThe DETECT (Detecting Bladder Cancer Using the UroMark Test) I study is a prospective observational study recruiting patients 18 years old or older following presentation with macroscopic or microscopic hematuria at a total of 40 hospitals. All patients underwent cystoscopy and upper tract imaging comprising computerized tomography urogram and/or renal and bladder ultrasound.ResultsA total of 3,556 patients with a median age of 68 years were recruited in this study, of whom 2,166 underwent renal and bladder ultrasound, and 1,692 underwent computerized tomography urogram in addition to cystoscopy. The incidence of bladder, renal and upper tract urothelial cancer was 11.0%, 1.4% and 0.8%, respectively, in macroscopic hematuria cases. Patients with microscopic hematuria had a 2.7%, 0.4% and 0% incidence of bladder, renal and upper tract urothelial cancer, respectively. The sensitivity and negative predictive value of renal and bladder ultrasound to detect renal cancer were 85.7% and 99.9% but they were 14.3% and 99.7%, respectively, to detect upper tract urothelial cancer. Renal and bladder ultrasound was poor at identifying renal calculi. Renal and bladder ultrasound sensitivity was lower than that of computerized tomography urogram to detect bladder cancer (each less than 85%). Cystoscopy had 98.3% specificity and 83.9% positive predictive value.ConclusionsComputerized tomography urogram can be safely replaced by renal and bladder ultrasound in patients who have microscopic hematuria. The incidence of upper tract urothelial cancer is 0.8% in patients with macroscopic hematuria and computerized tomography urogram is recommended. Patients with suspected renal calculi require noncontrast renal tract computerized tomography. Imaging cannot replace cystoscopy to diagnose bladder cancer.

The effects of recreational ketamine cystitis on urinary tract reconstruction - a surgical challenge.

To identify the rate of postoperative complications in patients who require surgical reconstruction for ketamine-induced urinary tract dysfunction and to identify any predictors for poor postoperative outcome with subsequent management strategies. A retrospective review of data collected between 2007 and 2017 of all patients with ketamine-induced urinary tract disease was performed. Evaluation included computed tomography urogram, cystoscopy, and biopsy. Indications and outcomes for surgical intervention were assessed. In all, 44 patients were identified of which 68% were male. The mean (range) age at presentation was 31 (23-55) years. All bladder biopsies confirmed an eosinophilic inflammatory infiltrate. A significant proportion of patients (81.8%) were found to have reduced cystoscopic bladder capacity of <300 mL (mean 196, range 25-550 mL). In all, 29 patients were treated conservatively with a view to symptom resolution. Two patients underwent dilatation for urethral strictures. Four patients underwent repeated intra-detrusor onabotulinum toxin injection with minimal subjective symptom relief. Two of these patients proceeded to have major reconstruction. Indications for urinary tract reconstruction included intractable symptoms, high-pressure compliance loss with renal compromise and ureteric obstruction. Patients were advised to abstain from ketamine use for a minimum of 6 months prior to consideration of surgical intervention. A total of 14 patients underwent major reconstruction. Surgical intervention included ileal conduit urinary diversion, augmentation cystoplasty with or without Mitrofanoff channels, ureteric re-implantation, and cystectomy with neobladders. Complications included anastomotic leaks, ureteric strictures, adhesional small bowel obstruction, renal failure, and sepsis. Overall, complications occurred in 10/14 patients. In a tertiary high-volume reconstructive unit, ketamine patients were at high risk of significant perioperative complications. There did not appear to be any other common factor apart from their use of ketamine, and the significant inflammatory change associated with this. We recommend meticulous preoperative evaluation and multidisciplinary consultation for all patients to determine optimal treatment strategies.

Urolithiasis secondary to primary obstructive megaureter in an adult: a case report

BackgroundPrimary obstructive megaureter is relatively uncommon in adults. This condition usually regresses spontaneously or is treated during infancy. It can remain asymptomatic for decades until adulthood when symptoms may manifest in the event of complications or during a routine radiologic imaging. Primary obstructive megaureter has been reported to favor stone formation in the upper urinary tract.Case presentationWe present the case of a 35-year-old Moroccan man who had a 10-year history of intermittent left flank pain and hematuria. A computed tomography urogram revealed a left megaureter with giant ureteral and renal calculi.ConclusionsPrimary obstructive megaureter should be a differential diagnosis in an adult with hydroureteronephrosis associated with urolithiasis especially when there is kidney impairment. Through this case report we will discuss the diagnosis and management of primary obstructive megaureter associated with urolithiasis in adults.

The morphology and treatment of coexisting ureteropelvic junction obstruction in lower moiety of duplex kidney

BackgroundDuplex kidney is a common congenital anomaly of the urinary tract, while ureteropelvic junction obstruction (UPJO) in lower unit of duplex kidney is rare. Surgical treatment can be challenging in such cases. The aim was to report our experience in managements of UPJO in lower moiety of duplex kidney. MethodsAmong the pediatric patients with duplex system from 2007 to 2013, 7 children were diagnosed with UPJO in lower moiety. Their medical records were retrospectively analyzed, mainly focused on anatomic aspects and operation details. ResultsThe lower pole UPJO associated with incomplete duplex systems were identified in 6 patients on the left side and 1 on the right side. Median patient age at surgery was 11 months (range 6–84 months). Prenatal hydronephrosis was detected in 4 patients, and 3 had intermittent abdominal pain. Hydronephrosis, thin parenchyma and presence of UPJO in lower moiety could be shown on computed tomography urogram (CTU). The ureters were fused in a “Y” shape without any dilation. Based on the length between UPJO to the confluence in retrograde ureteropyelography, patients were classified into group 1 (5 cases,≤3 cm) and group 2 (2 cases, >3 cm). In group 1, surgical procedure involved end-to-side pyeloureterostomy of the lower pelvis to the ureteral confluence in 4 cases and laparoscopic pyeloureterostomy in one case. The two patients in group 2 underwent laparoscopic pyeloplasty of lower moiety. In all of these patients hydronephrosis gradually improved and no complications were detected during follow-up. ConclusionsUPJO in a duplex kidney requires careful evaluation and treatment should be individualized. Ureteropyeloanastomosis is a feasible treatment for duplex kidneys associated to a functioning lower moiety with UPJO. With the technical improvements in laparoscopic pyeloplasty, this procedure can be performed using laparoscopy.

Assessing the Costs of Extraurinary Findings of Computed Tomography Urogram in the Evaluation of Asymptomatic Microscopic Hematuria

To assess the costs associated with incidental extraurinary findings on computed tomography urogram (CTU) in patients with asymptomatic microscopic hematuria. A retrospective review was performed to identify all CTUs performed for asymptomatic microscopic hematuria at our institution from 2012 to 2014. All genitourinary (GU) and incidental extraurinary findings were documented. Further clinical follow-up to May 2015 was reviewed to determine if any referrals, tests, imaging, and/or procedures were ordered based on the initial CTU. Cost estimates were determined using the Medicare physician reimbursement rate. Two hundred two patients were evaluated with CTU for asymptomatic microscopic hematuria. GU malignancy was documented in 2 patients (0.99%), both renal masses suspicious for renal cell carcinoma. Sixty patients were found to have kidney stones, of which 26 had stones ≥5 mm. Incidental extraurinary findings were found in 150 (74.3%) patients, requiring further imaging costs of $17,242 or $85.35 per patient screened. Twelve patients required a total of 20 procedures for a cost of $54,655. The total cost related to extraurinary findings was $140,290 or $694.50 per initial patient screened. The incidental extraurinary findings detected on CTU can lead to expensive and invasive testing and treatment. Whereas costs associated with further workup were high, the overall outcomes in both GU and non-GU cancer diagnosis were low. Future analysis should focus on limiting the cost and invasiveness of our evaluation for this condition.

Case Presentation: Vesicovaginal Fistula Following a Total Abdominal Hysterectomy

2405-4569/# 2016 Published by Elsevier B.V. on behalf of European Associ A 43-yr-old woman underwent a total abdominal hysterectomy for benign disease. The procedure appeared to be straightforward, although heavy bleeding around the left ovarian vascular pedicle was encountered. This needed additional sutures for control. Postoperatively the patient developed left loin pain and was found to have new-onset left-sided hydronephrosis on an abdominal ultrasound scan. A percutaneous nephrostomy was inserted into the left kidney and renal pelvis, and 2 d later this was followed by percutaneous antegrade ureteric stenting. The patient then developed continuous urinary leakage per vagina despite a period of catheterisation. A vesicovaginal fistula was diagnosed and she was referred to our specialist centre for repair. We performed a cystogram (Fig. 1) and upper tract imaging via a computed tomography urogram. We then performed an examination under anaesthesia, including cystoscopy with bilateral retrograde studies (Fig. 2).

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.

Wilms tumour with intracardiac extension - multimodal approach to a challenging case.

Sir, Anaesthesia for surgery for Wilm's tumour in advanced stage is a great challenge as the condition is often seen in young children with limited reserve further complicated by disease process, prior chemotherapy and paraneoplastic associations such as hypertension and coagulopathy.[1] A 2-year-old child was admitted to our institution with a biopsy proven right nephroblastoma that did not respond to neoadjuvant chemotherapy. Computerised tomography scan revealed a large right renal tumour with a cavoatrial thrombus [Figure 1]. Echocardiogram revealed a large tumour thrombus (20 mm × 15 mm) in the right atrium encroaching the tricuspid valve and mild pericardial effusion. The treatment plan was right radical nephrectomy with inferior vena caval (IVC) thrombectomy and right atriotomy under cardiopulmonary bypass. Figure 1 Pre-operative computerised tomography urogram demonstrates large right renal tumour with extension of tumour thrombus into right atrium Pre-anaesthetic evaluation revealed an emaciated child weighing 13 kg with a disproportionately protuberant abdomen, pallor, pedal oedema and tachycardia. Her coagulation profile and renal function tests were normal. The day before surgery, right renal artery angioembolisation was undertaken to decrease tumour vascularity and ease surgical extirpation. Anaesthesia was induced with fentanyl 2 μg/kg, ketamine 2 mg/kg and vecuronium 0.08 mg/kg. Monitoring included electrocardiogram, pulse oximetry, end-tidal carbon dioxide, central venous pressure, intra-arterial blood pressure, temperature and urine output. Mechanical ventilation with a tidal volume of 6 ml/kg was instituted with airway pressure maintained around 28 mmHg and the end-tidal carbon dioxide maintained at around 42 mmHg. Anticipating haemodynamic fluctuations, two arterial lines and one central venous catheter were secured after induction. Through a right thoraco-abdominal incision, right radical nephrectomy, cavotomy and extraction of vena caval thrombus was performed [Figure 2]. Blood loss encountered was about 100 ml. Moderate degree of hypotension was experienced which responded to volume replacement. Intraoperative echocardiography demonstrated the persistence of right atrial thrombus. Right atriotomy was then undertaken under deep hypothermic circulatory arrest (DHCA) with a core body temperature of 18°C and the thrombus was extracted. The total circulatory arrest time was 3 min. After clearance of tumour, circulation was restored, and atrial reconstruction was completed during the rewarming phase. The patient required inotropic support (adrenaline 0.03 μg/kg/min) during the procedure. Approximately 300 ml of packed red blood cells and 350 ml of fresh frozen plasma were transfused. The total duration of the procedure was 8 h. The child was electively ventilated and extubated on the following day. By the 5th day, she was moved out of the Intensive Care Unit and discharged on the 14th day. Post-operative period was fairly uneventful except for mild renal dysfunction which responded to conservative management. Figure 2 Intraoperative appearance of tumour Wilm's tumour is the fourth most common paediatric malignancy.[2] Complete surgical clearance improves the prognosis but may be demanding in advanced lesions as it has the propensity to extend into the cardiac chambers along the inferior vena cava. A multidisciplinary approach will facilitate favourable outcome in such situations.[3] Intraoperative course may be stormy and the anaesthesiologist should be equipped to tackle this. The major intraoperative concerns are heat loss, fluid balance, inadequate ventilation due to raised intra-abdominal pressure, haemodynamic fluctuations in the face of intermittent IVC compression, tumour embolisation and major haemorrhage. Cardiopulmonary bypass is employed to avoid tumour embolisation.[4] DHCA enabled excellent surgical exposure, but the duration of circulatory arrest had to be limited to ward off complications.[5] The disproportionate size of the tumour in comparison to the weight of the child and its physiological consequences made this case unique. A multidisciplinary approach and close coordination between various specialties is what saw the child through the technically demanding procedure and convalescence. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Is Ureteroscopy Needed Prior to Nephroureterectomy? An Evidence-Based Algorithmic Approach

To develop an evidence-based approach to the diagnostic workup of suspicious upper urinary tract lesions. The PubMed database was searched using the following terms with a filter for English language: "upper tract urothelial carcinoma" and "upper tract transitional cell carcinoma," along with the following corresponding terms: "cost," "epidemiology," "diagnosis," "ureteroscopy," and "workup." A total of 404 articles were returned, and 33 were reviewed in full based on relevance. Computed tomography urogram is both sensitive and specific (96% and 99%). Cytology is utilized for its specificity (89%-100%). Ureteroscopy and biopsy of an upper tract lesion can be helpful in equivocal cases but can pose challenges in terms of yield and eventual pathologic upstaging. Due to the high sensitivity and specificity of other noninvasive tests, ureteroscopy can be obviated in select cases. We assess the available evidence and devise an algorithm for the evaluation of an upper tract urothelial carcinoma lesion. Ureteroscopy can be omitted as part of the diagnostic workup in appropriately selected cases of upper tract urothelial carcinoma.

Unfriendly Filter: An Unusual Cause of Hydronephrosis and Hematuria

A 67-year-old woman was referred to the urology clinic for abdominal pain and hematuria. Urine analysis showed microscopic hematuria. Computed tomography urogram revealed a misplaced inferior vena cava (IVC) filter in the right gonadal vein causing right hydronephrosis. Retrograde pyelography revealed a 3-cm ureteral narrowing at the level of the IVC filter. A double-J ureteral stent was placed in the right ureter prior to exploratory laparotomy, which revealed partial erosion of the IVC filter into the right ureter and a thrombosed right ovary. The patient underwent a right oophorectomy and removal of the misplaced IVC filter. Her postoperative course was uncomplicated.

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi: long-term follow-up results from a case series.

Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes. From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2-9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar. The average operative time was 140 min (range, 90-190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5-0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2-6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence. Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75-100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons.

Does Side Make a Difference? Anatomical Differences Between the Left and Right Ureter.

Seventy to eighty percent of iatrogenic ureteral injuries involve the left ureter. We sought to evaluate potential anatomical differences between the left and right ureters that may contribute to this discrepancy. A retrospective image review was undertaken of women who underwent computed tomography urograms between 2012 and 2013. The distance to the ureters from the midline was measured at the level of the sacral promontory (S1) and the cervix. Cervical deviation from the midline was measured, and distance between the cervix and ureters was calculated. The anterior-posterior distance between ureters was also measured. Ninety-five computed tomography urograms were analyzed. The mean age was 56 years (range, 23-92 years). Mean cervical deviation was 2.9 mm left of the midline (P = 0.028). The left ureter was 4.2 mm more lateral than the right at S1 and 2.7 mm more lateral at the cervix (P = 0.000 and 0.001). There was no significant difference when accounting for cervical deviation (P = 0.220). The left ureter was 1.9 mm more anterior than the right at the cervix (P = 0.012). Age, body mass index, and ethnicity did not affect the ureteral position. Based on midline measurements, the left ureter courses 2 to 4 mm more lateral and anterior than does the right ureter. The cervix is also positioned 2 to 4 mm to the left side, and as a result, the ureters are actually symmetric to the cervix. Although seemingly small, 2 to 4 mm is the width range of a Heaney clamp. These anatomic differences may be a contributing factor to the increase in ureteral injuries on the left side compared with the right.

Quiz: A middle-aged lady with intermittent turbid urine

A 51-year-old lady complained of on and off turbid urine for two months. Her symptom was aggregated after meals and disappeared upon fasting. She enjoyed good past health. She had no fever, dysuria, abdominal pain nor history of recent injury. Urine test strip showed presence of red blood cells and protein. Patient's urine specimens were collected (Figure 1). Urine investigations including white cell count, cast, cytology, bacterial and acid-fast bacillus cultures were all negative. Her complete blood picture, liver and renal function blood tests were normal. Her fasting lipid profile was abnormal with total cholesterol of Figure 1. Turbid and clear urine specimen collected from the patient. 7.09 mmol /L and low-density lipoprotein of 4.38 mmol/L. Computed tomography urogram showed no specific finding.

The Difficult Ureter: Clinical and Radiographic Characteristics Associated With Upper Urinary Tract Access at the Time of Ureteroscopic Stone Treatment

To evaluate the association between clinicoradiographic features and need for prestenting (PS) because of inability of the ureter to accommodate the ureteroscope, or ureteral access sheath, at the time of stone treatment. From 2009 to 2013, 120 consecutive nonstented patients underwent ureteroscopic stone treatment with preoperative computerized tomography urogram. Acute stone events with obstruction or infection were excluded. Preoperative radiographic imaging underwent radiologist review. Clinicoradiographic features were characterized, and multivariable logistic regression models were used to identify covariates independently associated with need for PS. Of the 154 renal units treated, 25 (16%) required PS for failed primary access. PS ureters were less likely to have a history of prior ipsilateral ureteral stent (4% vs 31%) or surgery (8% vs 36%; P <.05). Radiographically, PS ureters had a narrower ureteropelvic junction (4 mm vs 5 mm) and were more likely to have <50% ureteral opacification on computerized tomography urogram (32% vs 9%; P <.05). On multivariable analysis, prior ipsilateral ureteral stent (odds ratio [OR] = 0.11) and stone surgery (OR = 0.15) reduced the need for PS; meanwhile, <50% ureteral opacification (OR = 4.41) was independently associated with an increased risk of access failure. We report a 16% incidence of access failure requiring PS at time of ureteroscopy. Clinically, there was an 89% and 85% risk reduction in the need for PS with prior history of ipsilateral ureteral stent or surgery. Radiographically, there was a 4.4-fold increased risk of PS with <50% ureteral opacification. Accordingly, our findings may assist in counseling and operative management of the difficult ureter.

Loopography after ileal conduit urinary diversion – a useful investigation?

Purpose A loopogram has historically been used to demonstrate the anatomy and patency of the ureteroileal anastomosis following ileal conduit urinary diversion. We review the place of routine postoperative loopography and other imaging modalities in the assessment of asymptomatic ureteroileal conduit obstruction. Methods and materials An audit of all routine loopograms over a period of five years (December 2008 to June 2013) to diagnose asymptomatic ureteroileal obstruction following radical cystectomy and ileal conduit formation using the Wallace refluxing technique. Results A total of 47 loopograms were performed in 90 renal units between six to 12 weeks postoperatively. Of these, 82 renal units showed free reflux while eight units had no or slow reflux. Subsequent computed tomography (CT) urogram revealed that only one or the non/slow refluxing units was obstructed. Conclusion We conclude that postoperative loopography is a useful to demonstrate anatomy and show contrast leak but insensitive in the diagnosis of asymptomatic ureteroileal obstruction. We propose routine follow-up with ultrasound at three months to detect asymptomatic obstruction and a six monthly cancer follow-up CT scan.

Laparoscopic Pyeloplasty with Intracorporeal Flexible Ureteroscopy: A Management Option for Pelviureteric Junction Obstruction and Multiple Caliceal Calculi

Introduction: Laparoscopic pyeloplasty (LP) is a well-accepted minimally invasive approach for the management of pelviureteric junction obstruction (UPJO).1 In patients presenting with UPJO and multiple calculi, calculi located in renal pelvis can be cleared following pyelotomy during LP. However, multiple caliceal calculi are difficult to extract by pyelotomy alone. Usage of intracorporeal flexible ureteroscopy (IFURS) for clearance of caliceal calculi during laparoscopic pyelolithotomy for large staghorn calculus has been previously described.2 We present a video demonstration of LP and IFURS for simultaneous addressal of UPJO and multiple caliceal calculi. Materials and Methods: Preoperative assessment included present history, clinical and biochemical profiles, and imaging (radiography [XR], ultrasound [USG], computed tomography urogram [CTU], diuretic renogram [DR], and retrograde pyelogram [RGP]). Patients with significant UPJO and multiple caliceal calculi comprised the study cohort. All procedures were conducted through transperitoneal access. After dismemberment of pathological segment and pyelotomy, FURS with access sheath was inserted through a 5-mm working port and directed into the pelvicaliceal system under direct supervision. Flexible ureteroscopy was then carried out, all calices inspected, and caliceal calculi were retrieved using entrapment basket. The retrieved calculi were immediately transferred to the intraperitoneal retrieval bag. Pyeloplasty was then completed, pelviureteric approximation with interrupted sutures and pelvic edge approximation in continuous manner. Ureteral stent was placed in an antegrade manner. Operative and postoperative parameters were noted. Stent removal was undertaken at 6 weeks. Follow-up assessment included USG and XR for calculi clearance. Drainage was assessed by RGP and DR at 6 months postoperatively. Results: Between July 2012 and January 2013, five similar procedures were conducted. The mean age was 32.2 years (range, 8–55 years). The mean number of caliceal calculi was 18.8 (range, 5–59). Pathology involved the left side in four and the right side in one. One unit was malrotated. The mean preoperative glomerular filtration rate (GFR) was 30.2 mL/minute (range, 22.2–34.8 mL/minute). The mean operative duration was 280 minutes (range, 240–330 minutes). The mean blood loss was 75 mL (range, 50–100 mL). No major intraoperative or postoperative events were noted. The mean hospital stay was 3.8 days (range, 3–5 days). Complete clearance of calculi at pyeloplasty was possible in four patients (80%). One patient required additional flexible ureteroscopy during stent removal. Till last follow-up, all patients were symptom free. The mean 6-month postoperative GFR was 42.2 mL/minute (range, 40.4–44.6 mL/minute) (p < 0.001). Conclusion: Intracorporeal usage of FURS during LP enables simultaneous addressal of multiple caliceal calculi and UPJO, preserving the goals of minimally invasive access. The procedure is well tolerated and renders satisfactory outcome. No competing financial interests exist. Runtime of video: 7 mins 51 secs

Asymptomatic proteinuria, renal cysts and dorsal pancreas agenesis

A 28-year-old woman was referred to our institution for evaluation of asymptomatic proteinuria. She had no significant past medical history and no family history of diabetes mellitus or kidney disease. Physical examination was unremarkable: blood pressure was 108/70 mmHg and she had no edema. Laboratory investigations found serum creatinine 74 μmol/L and normal electrolyte levels. Serum albumin was 38 g/L and liver enzymes were normal. Fasting glucose was 5.7 mmol/L. Serum complements were normal. Anti-nuclear antibody and anti-doublestranded deoxyribonucleic acid antibody were negative. Urine protein-creatinine ratio was 0.51 g/g. Urine examination under high-power field microscopy found three white blood cells and no red cells. Kidney ultrasonography found normal sized kidneys with simple subcentimeter subcortical cysts bilaterally. A computer tomography urogram found mild cortical scarring in the upper pole of the right kidney but no hydronephrosis. The urinary bladder was unremarkable. Incidentally, most of the body and tail of the pancreas was not visualized although the head and uncinate process appeared normal (Figure 1). The uterine endometrial cavity appeared to diverge at the fundus, suggesting an arcuate uterus. What is the diagnosis?

Trends in the utilization of diagnositics for upper-tract urothelial carcinoma.

348 Background: The evolution and adoption of better endoscopes and imaging allow for improved diagnostic capacity for upper tract urothelial cancer (UTUC). We evaluated the changes in diagnostic modalities used to establish a diagnosis of UTUC. Additionally, we assessed how these changes affected the stage of patients receiving definitive surgery. Methods: Using linked SEER-Medicare data from 1992-2009, we identified patients between the age of 66-90 who underwent surgical treatment for UTUC. Among this cohort we assessed the types of diagnostics: endoscopy, computed tomography urogram (CTU), magnetic resonance urography (MRU), intravenous pyelogram (IVP), and retrograde pyelogram (RGP), used to evaluate their disease. Additionally, we dichotomized the final stage at surgery as lower stage disease (Ta, CIS, or unknown stage) or higher-stage disease (T1 or greater). Tests for trend were calculated for the five diagnostic modalities. Logistic regression models were fit to determine the impact of diagnostic modalities on stage at surgery. Results: We found a downward trend in utilization of IVP and RPG over time (p &lt; 0.001, p = 0.011) with IVP having largest decline in use. Endoscopy, CTU and MRU all demonstrated increased utilization over time (p &lt;0.0001). The incidence of lower stage disease was not found to be changing over time (p = 0.123). Logistic regression analysis demonstrated that among modern use (2000-2009), only the use of endoscopy and IVP were associated with smaller tumors (CI 1.310-1.996, CI 1.150-1.720). Conclusions: Modern diagnostics (endoscopy, CTU, MRU) have supplanted traditional methods of establishing a diagnosis of UTUC. Although these newer adopted technologies have a greater sensitivity in diagnosis of UTUC, only the use of endoscopy prior to definitive management has been associated with the diagnosis of smaller tumors.

A New Model with an Anatomically Accurate Human Renal Collecting System for Training in Fluoroscopy-Guided Percutaneous Nephrolithotomy Access

Obtaining renal access is one of the most important and complex steps in learning percutaneous nephrolithotomy (PCNL). Ideally, this skill should be practiced outside the operating room. There is a need for anatomically accurate and cheap models for simulated training. The objective was to develop a cost-effective, anatomically accurate, nonbiologic training model for simulated PCNL access under fluoroscopic guidance. Collecting systems from routine computed tomography urograms were extracted and reformatted using specialized software. These images were printed in a water-soluble plastic on a three-dimensional (3D) printer to create biomodels. These models were embedded in silicone and then the models were dissolved in water to leave a hollow collecting system within a silicone model. These PCNL models were filled with contrast medium and sealed. A layer of dense foam acted as a spacer to replicate the tissues between skin and kidney. 3D printed models of human collecting systems are a useful adjunct in planning PCNL access. The PCNL access training model is relatively low cost and reproduces the anatomy of the renal collecting system faithfully. A range of models reflecting the variety and complexity of human collecting systems can be reproduced. The fluoroscopic triangulation process needed to target the calix of choice can be practiced successfully in this model. This silicone PCNL training model accurately replicates the anatomic architecture and orientation of the human renal collecting system. It provides a safe, clean, and effective model for training in accurate fluoroscopy-guided PCNL access.

Retroperitoneoscopic left upper moiety heminephroureterectomy for dribbling incontinence

A 7-year-old girl underwent a prone, retroperitoneoscopic left upper moiety heminephroureterectomy for a non-functioning upper moiety associated with a dilated, ectopic ureter. The dilated ureter was noted prenatally, but postnatal investigations failed to demonstrate the duplex system. The child remained asymptomatic until she represented at 6 years of age, with dribbling of urine. She went on to have an ultrasound scan, dimercaptosuccinic acid and magnetic resonance urogram, which identified a grossly-dilated fluid-filled structure in proximity of the left kidney, but failed to demonstrate the small non-functioning left upper moiety. A computed tomography urogram was more helpful in establishing the diagnosis. Retroperitoneoscopy via three 5-mm ports allowed clear visualisation of both the left duplex ureters, as well as the small non-functioning upper moiety, which had been challenging on the pre-operative imaging. The procedure is described in the accompanying video. The child was discharged home the following day and has been completely well and dry at 6 months' follow-up.