Ureteral Anatomy Research Articles

Assessment of Outcomes andAnatomical Changes in the Upper Urinary Tract Following Flexible Ureteroscopy With a Flexible and Navigable Suction Ureteral Access Sheath: 3-Month Results From a Multicenter Study.

To study the long-term outcomes of the flexible and navigable suction ureteral access sheath (FANS) in flexible ureteroscopy (FURS). FANS has well-established efficiency and 30-day perioperative safety; however, its influence on pelvicalyceal and ureteric anatomy remains to be investigated. This was a prospective study of patients with normal renal anatomy who underwent FURS with FANS for renal stones from April 2023 to August 2024 in 16 centers worldwide. Thirty-day postoperative stone-free rate and delayed complications after 3 months were analyzed with a non-contrast CT scan and contrasted CT urogram respectively. The primary aim was to report if FANS could potentially cause pelviureteric junction, pelvicalyceal or ureteric complications. Three hundred-tenpatients were analyzed. Median age was 51; median stone volume was 1584mm3. Disposable scopes were used in 58.1%. Predominant laser energies were Thulium fiber laser (56.1%) followed by Thulium-YAG laser (20.6%). Median laser time was 14minutes, median ureteroscopy time was 30minutes, and median total operation time was 45minutes. Ureteric injury occurred in 11 patients (3.5%), of which 10 were Traxer-Thomas Grade 1. On 30-day NCCT, 63.5% of patients had zero residual fragments; overall stone-free status was seen in 95.1%. Thirty-day reintervention rate was 4.2% (13 cases). Three-month CT urogram showed ureteric stenosis in only 1 patient (0.3%) who was managed by dilatation and stenting. No other anatomical anomalies were recorded. The extremely low rates of 3-month adverse outcomes, high immediate SFR, and low 30-day reintervention rates further strengthen the evidence for safety and effectiveness of FANS.

‘Out of Scope’ – Operative Challenges in Ureteric Stone Management for Patient With Abnormal Ureteric Anatomy Post Multiple Urinary Diversion Procedures for Posterior Urethral Valves

‘Out of Scope’ – Operative Challenges in Ureteric Stone Management for Patient With Abnormal Ureteric Anatomy Post Multiple Urinary Diversion Procedures for Posterior Urethral Valves

Ureteral stricture formation after endoscopic removal of obstructing stones: could it be predicted with well-assessed radiological parameters?

The possible role of well-assessed radiological parameters in the prediction of ureteral stricture formation in cases with impacted obstructive ureteral calculi has been evaluated. 46 adult patients with or without ureteral stricture formation after ureteroscopic stone management were included. In addition to stone size and some certain radiological parameters including ureteral wall thickness (UWT) of the involved ureter at the impacted stone site was also measured and noted on computed tomography (CT) images. Parameters were evaluated in two subgroups of cases, namely: Group 1: patients in whom a ureteral stricture formed after endoscopic stone removal and Group 2: patients normal ureteral anatomy without any stricture formation. The possible relationship between the UWT values and degree of hydronephrosis (HN) with subsequent stricture formation was comparatively evaluated. All of the stones were proximal ureteral calculi in both groups. Both the degree of HN and proximal ureteral diameter (PUD) parenchymal was higher in cases with stricture formation. In addition, mean parenchymal thickness was lower and mean values of UWT measurements at the stone site were 3.70 ± 0.97mm and 2.17 ± 0.26mm in Groups 1 and 2, respectively. A cutoff value 2.49mm for UWT was found to be highly predictive for stricture formation. UWT value calculated at the obstructing stone site was found to be predictive enough for the likelihood of ureteral stricture formation with high sensitivity and specificity . This evaluation along with some other radiological parameters may enable the urologists to follow such cases on this aspect with necessary measures taken.

Receiver operating characteristics of computed tomography (CT) compared to cystoscopy in diagnosis of canine ectopic ureters: Thirty-five cases.

The aim of the study was to determine receiver operating characteristics (ROC) of computed tomographic excretory urography (CTEU) in predicting cystoscopic findings of ureteral anatomy. Retrospective cohort study. Thirty-five client-owned dogs. The medical records of dogs referred for suspected ectopic ureters were reviewed. Inclusion criteria included CTEU findings reported by board-certified radiologists, followed by rigid cystoscopy with or without ureteral cystoscopic laser ablation (CLA). Data included signalment, urinary incontinence degree, body condition score, weight, degree of colon distension, CTEU and cystoscopy findings. ROC analysis was used to compare CT-predicted ureteral orthotopia/ectopia to cystoscopy findings. Additionally, ROC of CT predicted ureteral orifice locations was analyzed. Regression covariate analysis was performed to identify factors that may have influenced accuracy of diagnosis. The ability of CT to identify a normal and intra-or extramural ectopic ureters conclusively and correctly was 13/26 (50%) and 32/41(78%), respectively. Sensitivity and specificity of identifying extramural versus intramural ureters was 2/7 versus 30/46 (29 vs. 65%) and 61/63 versus 17/24 (97 vs. 71%), respectively. Ectopic orifice determination sensitivity and specificity varied widely depending on location from 0% to 76% and 67% to 97%, respectively. Covariate analysis failed to identify interfering factors. CT did not accurately predict anatomy of ureters; CT findings may need confirmation by cystoscopy and possibly intraoperative fluoroscopy prior to determining if CLA is indicated or not. Our results may be of importance for surgeons interpreting the CTEU findings. CTEU prediction of the location of the ureteral orifice shows low sensitivity especially in or close to the urethral sphincter area.

OPTIMALISASI KUALITAS CITRA ANATOMI DENGAN VARIASI IDOSE DAN INTERATIVE MODEL RECONTRUCTION (IMR) PADA MSCT UROGRAPHY NON KONTRAS DENGAN TEKNIK TRACKING

Background: The urinary tract (urinary system) consists of the two kidneys and ureters, the urinary bladder, and the ureters. There are several ways to examine abnormalities in the urinary tract radiologically. including the current CT scan, CT Scan (MSCT) is one of the modalities to evaluate and diagnose urinary tract disorders. MSCT of the urinary tract without using positive contrast media is able to identify images of the urinary tract in cases of urolithiasis. iDose and Interative Model Reconstruction (IMR) are the second generation of IR algorithms from the previous generation, namely iDose. This technology can also lower the dose to the patient and also improve the quality of the resulting image.
 Method: This type of research is an experiment with an observational approach with comparisons. This type of research is an experiment with data obtained from a comparison of noise values and the quality of anatomical images from tracking images with iDose and IMR variations. And an assessment was carried out by 3 radiologists. Place of data collection in radiology RSUD RAA Soewondo Pati. Time for data collection From April to November 2022. in assessing anatomical images using statistical tests. Data analysis was carried out using the Wilcoxon statistical test method because the data were ordinal with paired groups. The Wilcoxon statistical test was used to test the hypothesis and see the level of difference in anatomical image information. The level of significance (level of significance) is 95% or α> 0.05 and is done by assessing the p-value. For a significant level of assessment p <0.05 then Ho is rejected and p> 0.05 then Ho is accepted.
 Results: Friedman test on each anatomical part of the urinary tract system on Non-Contrast Urography MSCT images with Tracking Techniques with iDose 1-6 and IMR 1-3 variations, there are differences in anatomical image information with a p value of .000 (p <0.05). In the anatomy of the renal parenchyma, the highest mean rank is iDose 3 with a value of 8.15. In pelvic anatomy and kidney calices, the highest mean rank is at iDose 6 with a value of 8.05. In ureteral anatomy, the highest mean rank is iDose 3 with a value of 8.05. In the anatomy of the perirenal space, the highest mean rank is iDose 3 with a value of 8.20. Based on the results of the mean rank Friedman test to find out the optimal I Dose and IMR values, it was obtained iDose 1 with a mean rank value of 4.65, iDose 2 with a mean rank value of 4.95, iDose 3 with a mean rank value of 8.3, iDose 4 with a mean rank value of mean rank 6.4, iDose 5 with a mean rank value of 6.55, iDose 6 with a mean rank value of 7.75, IMR 1 with a mean rank value of 1.65, IMR 2 with a mean rank value of 2.05, and IMR 3 with a mean value rating 2.7.
 Conclusion: Changes in the values of iDose and IMR variations affect the anatomical image information of Non-Contrast MSCT Urography with Tracking Techniques, this is based on the results of the mean rank Friedman test performed on each anatomy of the renal parenchyma, pelvic calices, ureters and perirenal space which shows a difference. Based on the results of Friedman's mean rank test conducted on the entire anatomy of the renal parenchyma, ureters, and perirenal space, it showed that the optimal iDose and IMR variation values were iDose 3 with a mean rank value of 8.3.

Robot-Assisted Laparoscopic Ureteroureterostomy of an Obstructive Retrocaval Ureter

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

Prevention of ureteral injury during laparoscopic colorectal cancer surgery with horseshoe kidney using fluorescent ureteral catheters: a case report

BackgroundHorseshoe kidney is one of the most common congenital renal fusion anomalies and is characterized by abnormalities in the position, rotation, vascular supply, and ureteral anatomy of the kidney. When performing surgery for colorectal cancer in patients with horseshoe kidneys, anatomical identification is important to avoid organ injuries. Several reports on surgery for colorectal cancer with horseshoe kidneys have described the usefulness of three-dimensional (3D) computed tomography (CT) angiography for detecting abnormalities in vascular supply. However, few reports have focused on the prevention of ureteral injury in surgery for colorectal cancer with horseshoe kidney, despite abnormalities in the ureteral anatomy. Here, we report a case in which laparoscopic sigmoid colon resection for sigmoid colon cancer with a horseshoe kidney was safely performed using fluorescent ureteral catheters.Case presentationA 60-year-old Japanese man presented to our hospital testing positive for fecal occult blood. Colonoscopy revealed sigmoid colon cancer, and CT confirmed a horseshoe kidney. The 3D-CT angiography showed aberrant renal arteries from the aorta and right common iliac artery, and the left ureter passed across the front of the renal isthmus. A fluorescent ureteral catheter was placed in the left ureter before the surgery to prevent ureteral injury. Laparoscopic sigmoid colon resection with D3 lymph node dissection was performed. The fluorescent ureteral catheter enabled the identification of the left ureter that passed across the front of the renal isthmus and the safe mobilization of the descending and sigmoid colon from the retroperitoneum. The operative time was 214 min, with intraoperative bleeding of 25 mL. The patient’s postoperative course was good: no complications arose and she was discharged on the seventh postoperative day.ConclusionIn patients with horseshoe kidney, the use of fluorescent ureteral catheters and 3D-CT angiography enables safer laparoscopic surgery for colorectal cancer. We recommend the placement of fluorescent ureteral catheters in such surgeries to prevent ureteral injury.

Outcome of Upper Ureteric Stone Management by in Situ Extracorporeal Shock Wave Lithotripsy and Intracorporeal Pneumatic Lithotripsy

Background: Ureteric stone disease is a common urological problem throughout the world. Treatment of ureteral stones depends on stone size, composition and degree of obstruction, pain, presence of infection, single kidney and abnormal ureteral anatomy. The aim of the present study is to evaluate and compare in situ ESWL and URS with pneumatic lithotripsy in terms of Stone clearance, duration of procedural time, duration of hospital stay and complications (fever, haematuria, ureteral injury, stone migration, stone clearance, steinstrasse, UTI, ureteral perforation). Methods: A total of 80 patients were included in the study. 42 of them enrolled in ESWL group and 38 in pneumatic lithotripsy group. This is a Prospective Observational study. ICPL were done as day case surgery and ESWL were done as outpatient basis. Results: Intracorporeal pneumatic lithotripsy is better than in situ ESWL for the treatment of small non-impacted upper ureteric stone because it has more stone clearance rate and less complication like fever, haematuria, steinstrasse, UTI, ureteral injury and ureteral perforation. Conclusion: At the end of the study, it can be concluded that for the management of upper ureteric stones ICPL is a better option than in situ ESWL considering its greater stone clearance and less complications.

Successful management of an intraoperative electric burn broken ureteral stent: A case report

In the treatment of some gynecological diseases, ureteral stents (double J stents) have been generally utilized in the prevention of ureteral injury. Nevertheless, if the ureteral stent is retained as a protective reminder during gynecological surgery, severe ureteral injury can be avoided. Hence, it is very essential to be familiar with the anatomy of ureter in gynecological surgery to prevent complications and morbidity. We demonstrate a case of a 49-year-old woman who presented with an electric burn broken ureteral stent in the gynecological surgery, but the ureter is only burned but not broken. This resulted in no abnormality being found during surgery. So, ureteroscopy is necessary to extract the ureteral stent and the patient is inserted with another new ureteral stent to repair the ureteral injury. The electric burn broken ureteral stent is difficult for discovering during the operation. And ureteroscopy is very crucial for the special situation of the ureteral injury.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n=13), complete ureteral duplication (n=2), periureteral diverticulum (n=2), ectopic megaureter requiring dismembering (n=1). The median operative time was 155min for unilateral and 211.5min for bilateral repairs. The clinical+radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n=5, 8.7%), febrile urinary tract infection (UTI) (n=6, 10.5%) and gross hematuria (n=3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p=0.002] and bilateral repair [p=0.001] and post-operative urinary retention was more frequent in simple cases [p=0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p=0.001] (Table). This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

The Complication of Ureteral Injury Induced by Gynecological Laparoscopic Surgery

Compared with traditional laparotomy, laparoscopic surgery has obvious advantages (smaller incisions, shorter hospital stays, and reduced blood loss). At present, more and more gynecological surgeries can be completed under laparoscopy. With the increasement of clinical treatment of gynecological laparoscopic surgery, the complications related to gynecological laparoscopic surgery and their prevention measures have become a continuous concern in the field of gynecology. The risk of injury to the lower urinary tract, consisting of the bladder and ureters, is inherent to gynecologic surgery regardless of operative technique, because the bladder and ureters lie adjacent to other critical structures. Ureteral injury caused by gynecological laparoscopic surgery is a relatively rare complication. Clinicians do not pay enough attention to it because of its low incidence. However, once it happens, the consequences are often serious. The clinical manifestations of ureteral injury caused by gynecological laparoscopic surgery vary greatly according to the location and severity of the injury. Patients with mild injury can heal themselves after conservative treatment, and patients with severe injury can have serious consequences such as peritonitis and acute renal insufficiency, and even lead to death. This paper will focus on ureteral anatomy, common causes, clinical manifestations, key points of diagnosis, treatment measures and prevention strategies of ureteral injury caused by laparoscopic surgery.

Renal Vascular and Ureteral Anatomic Variations in 1859 Potential Living Renal Donors

Renal vascular and ureteral anomalies detected by preoperative computed tomography angiography (CTA) are important for determining the side of the donor nephrectomy and the optimal surgical technique. In the present study, we aimed to examine the renal vascular and ureteral variations in living kidney donor candidates. A retrospective analysis was made of 1859 patients who were examined in our clinic as donor nephrectomy candidates between November 2008 and December 2019. Renal CTA images were acquired using a 64-channel multidetector computed tomography scanner, and renal vascular and ureteral variations were evaluated. The prevalence rates of multiple renal arteries on the right and left sides were 18.3% and 22.6%, respectively. The prevalence rates of early branching of the renal arteries, in turn, were 6.3% on the right side and 6.5% on the left side. The overall rate of renal artery variations on both the right and left sides was significantly higher in male individuals than in female individuals (P < .001). Multiple renal veins rates were 28.2% and 2.3% on the right and left sides, respectively, and the short renal veins rates on the right and left sides were 10.1% and 4.35%, respectively. Among the 941 cases undergoing donor nephrectomy, the procedure was completed by laparoscopy in 815 and by conversion from laparoscopic to open surgery in 36. The rate of vascular variations was higher in the conversion to open surgery group than in the laparoscopy group (P=.015). Careful preoperative assessments of donor renal vascular and ureteral anatomy and variations in CTA are essential for successful and safe renal transplant.

Research progress of ureteral injury in oblique lumbar interbody fusion

To summarize the research progress of ureteral injury in oblique lumbar interbody fusion (OLIF). The literature about incidence, clinical manifestations, diagnosis, and treatment of ureteral injury complications in OLIF was reviewed. OLIF surgery poses a risk of ureteral injury because its surgical approach is anatomically adjacent to the left ureter. Ureteral injuries in OLIF are often insidious and have no specific clinical manifestations. CT urography is a common diagnostic method. The treatment of ureteral injury depends on a variety of factors such as the time of diagnosis, the location and degree of injury, and the treatment methods range from endoscopic treatment to replacement reconstruction. Surgeons should pay attention not to damage the ureter and find the abnormality in time during OLIF. High vigilance of abnormalities is conducive to the early diagnosis of ureteral injury. Furthermore, it is important to be familiar with ureter anatomy and gentle operation to prevent ureteral injury.

Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties.

We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney. A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups. Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis. Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

24: Ureteral anatomy for the junior learner

This educational video will highlight the ureteral anatomy from a transperitoneal approach with a focus on the learning objectives of the junior learner. Educational video. An understanding of ureteral anatomy is essential to avoid operative injury during gynecologic procedures. This video will assist the junior in identification and visualization of the course of the ureter from a transperitoneal approach highlighting relevant anatomic landmarks and common locations for injury.

Transection of Duplex Ureter During Vaginal Hysterectomy

Duplex ureter, an embryological developmental anomaly, can lead to intra-operative injuries, even by surgeons with a stronghold on normal ureteric anatomy. We describe the first case of an ectopic ureter transected during vaginal hysterectomy performed for pelvic organ proplase, due to its abnormally low implantation into the bladder, worsened by cystocoele. The injury was recognised, and the duplex ureter was diagnosed with cystoscopy and retrograde pyelography. A post-operative computed tomography urogram allowed us to map the exact course. In this case, there was injury to the ectopic, non-functional ureter, thus averting any further intervention. However, lower urinary tract injuries are serious complications with high morbidity, especially during delayed diagnosis. Knowledge of the ureter variants, meticulous tracing of the course, and use of post-operative cystoscopy could reduce these complications, particularly in face of increasing minimally invasive approaches.

Laparoscopic Management of Vaginal Vault Fibroids

Video Objective To demonstrate a rare case of vaginal vault fibroids post hysterectomy presenting 7 years after primary surgery. Setting Tertiary Care University recognised Endoscopy Referral Unit. Case Details 49 year old patient who underwent Total laparoscopic hysterectomy 7 years back with intermittent spotting and frequency of urination with ultrasound demonstrating multiple well defined hypo-echoic masses at the vault region. Interventions Laparoscopic management of multiple parasitic fibroids at the vaginal vault. Pre-operative cystoscopy was undertaken and it was found that the fibroid was bulging into the posterior wall of the bladder with close association to the right ureter. Use of dilute vasopressin as in normal myomectomy was done. Fibroids were enucleated which remained hidden in the recto-vaginal and vesico-vaginal plane. As one fibroid was enucleated another came into view representing a tip of the iceberg phenomenon. Vault which got opened during fibroid enucleation was sutured back with standard techniques. Conclusion Such a rare entity like vaginal vault fibroids can pose a diagnostic dilemma with confusing differentials like stump carcinoma, vault granulomas, chronic infections or endometriotic nodules. Dealing with such fibroids is usually easy but can pose a challenge if large in size distorting the ureteric anatomy and its close association with bladder or the rectum. It also highlights the non-sarcomatous hazards of uncontained morcellation, be it trans-abdominal or vaginal morcellation.

Robotic excision and ureteroureterostomy of blind-ending ureteral ‘Duplication’

Duplicated ureteral anatomy can be a reconstructive challenge. Blind-ending ureteral duplication has been reported with recommendations for surgical excision. This video reviews the importance of exposure of anatomic landmarks in surgical excision of a blind-ending ureteral duplication. This is a retrospective case report of a patient who presented with a blind-ending ureteral duplication. A 13-year-old female presented with a right-sided abdominal mass. Abdominal and pelvic imaging revealed a tubular structure adjacent to and below the right kidney, possibly connecting to the right lower pole. While initially observed, the patient re-presented with urosepsis. A retrograde pyelogram showed no connection between the right ureter and this structure. The patient underwent robotic-assisted excision of this structure. Intra-operatively, it was connected to the right lower pole calyces. A ureteroureterostomy to the orthotopic ureter was performed. Although the structure was adjacent to the bladder dome, there was no communication distally. Postoperatively, the patient did well; follow-up imaging showed a non-dilated lower pole. The pathology of this structure was benign urothelium. Surgical management of aberrant ureteral duplications should focus on identifying known landmarksand should be considered to prevent symptomatic infections and renal scarring.

Ureteral Anatomy for the Junior Learner

Ureteral Anatomy for the Junior Learner

Implementation and validation of a retroperitoneal dissection curriculum

Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency. Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance. A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation. Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P< .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r= 0.53, P= .01). The ureter was identified intraoperatively by 91% (n= 21/23) of participants. The majority of residents (81%, n= 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n= 17/26). A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.