Ureteral Lesions Research Articles

Combined Removal of Stones with Resection of Concurrent Pathologic Ureter May Be a Preferred Treatment for Impacted Ureteral Stones with Stricture Lesions

We investigated ureteral lesions associated with impacted stones and compared the long-term outcomes after ureteroscopic lithotripsy (URSL) with a holmium laser with open ureterolithotomy, resection of concurrent pathologic ureter, and ureteroureterostomy (OUU) for patients with impacted ureteral stone. Between January 2004 and December 2007, 86 patients with impacted ureteral stones were treated with URSL (61) or OUU (25) because of tortuous ureter or failed access to stones. The stone size, location, impaction, ureteral lesions, and long-term outcomes were recorded. Mean stone size for the URSL group and the OUU group was 11.8 +/- 2.6 mm and 15.3 +/- 4.2 mm, respectively (P = 0.078). The impaction duration was 8.5 +/- 1.1 months for the URSL group and 17.2 +/- 3.8 months for the OUU group (P < 0.001). Endoscopic observation revealed two types of ureteral lesions that were defined as villous or polypoid protrusion (type 1) and edematous hemispheric lesions (type 2). Stone-free rates for the URSL group and the OUU group were 91.8% and 100%, respectively (P = 0.140). URSL was associated with a higher incidence of stricture (26.2% v 4.0%; P = 0.019) and worse recovery of hydronephrosis (P < 0.001). Stricture occurred more frequently in patients with type II lesions in the URSL group (P = 0.022). Stone recurrence for the URSL group and the OUU group were 13.1% and 4%, respectively (P = 0.210). Chronically impacted stones are frequently associated with ureteral polyp or stricture lesions. Our results reveal that combined removal of stones with resection of the pathologic ureter may achieve better long-term outcomes for patients with impacted stones with stricture lesions.

The use of JJ stent in the management of deep endometriosis lesion, affecting or potentially affecting the ureter: a review of our practice

Objective With the increasing number of operative laparoscopies performed for the treatment of deep pelvic endometriosis, technical difficulties and risk of complications inevitably increase. We report our experience using JJ stents, in women treated for deep pelvic endometriosis, with regard to prevention and management of ureteral lesions. Design Descriptive retrospective analysis between March 2004 and March 2007. Setting Department of Obstetrics and Gynaecology, University Hospital, Strasbourg, France. Population and methods Cases of women who underwent laparoscopic surgery for severe endometriosis and who needed a JJ stent in their management were recorded. Laparoscopic surgery was performed at the Department of Obstetrics and Gynaecology at CMCO-SIHCUS and Hautepierre Hospitals, Strasbourg, which are referral centres in the treatment of deep endometriosis. Main outcome measures To evaluate the contribution of JJ stent in the prevention and management of ureteral lesions from endometriotic origin and/or iatrogenic origin in women treated for deep pelvic endometriosis. Results A total of 145 women had surgery for deep pelvic endometriosis. Seventeen (11.7%) women had a JJ ureteral stent inserted. In 82.4% of women, the stent was inserted pre- or peroperatively. We noted three ureteral complications, of which only one needed management by laparotomy. Conclusions Except in extreme cases, management of ureteral endometriosis should be performed laparoscopically. Ureteral lesions whether iatrogenic, or secondary to endometriotic disease, can be treated by cystoscopy, JJ stent and laparoscopy. The combination of these three elements is the optimal management and is unlikely to cause subsequent complications. Laparotomy and its associated morbidity should be avoided.

Beyond haematuria in uro oncology: imaging biomarkers lag behind needs

Haematuria is the presence of red blood cells in the urine, and it is an important symptom in the diagnosis and treatment of renal and urological disease. Haematuria, which can be suspected on the basis of urine colour, is confirmed by the use of qualitative and/or semiquantitative urine strips to test for occult blood and by microscopic examination of urine sediment. Haematuria can be either microscopic or gross. Microscopic haematuria is the finding of more than three red blood cells per high-powered field in at least two out of three different urine samples collected at different times, whereas gross haematuria is the term used when blood present in urine is visible to the naked eye. Haematuria can originate from the kidneys or urinary tract and bladder [1]. A prospective analysis of the diagnostic yield from over 4,000 patients attending a protocol-driven haematuria clinic demonstrated that 1,950 (48.5%) had microscopic haematuria and 2,073 (51.5%) had macroscopic haematuria. Of the 1,950 patients with microscopic haematuria, 153 (7.8%) had urinary tract calculi, 19 (1.0%) had renal cell cancer (RCC), 3 (0.2%) had upper tract transitional cell cancer (TCC), 73 (3.7%) had bladder TCC, while 87.3% had no detectable cause of the haematuria. The overall prevalence of malignancy in patients with microscopic haematuria was 4.8%. Of the 2,073 patients with macroscopic haematuria, 183 (8.8%) had urinary tract calculi, 41 (2.0%) had RCC, 10 (0.5%) had upper tract TCC, 342 (16.5%) had bladder TCC, while 1,497 (72.2%) had no identifiable cause of their haematuria [2]. Most RCCs are discovered incidentally during CT imaging performed for other reasons. Around 70% of renal cortical tumours are confined to the kidney and 30% will develop into metastatic disease at some time during their course. Of these tumours, one in four will be benign, another one in four will be indolent (with limited metastatic potential), and approximately two in four will be malignant carcinomas. As reported by O’Connor et al. of the Department of Radiology, Cork University Hospital, Republic of Ireland [3], RCC is the most common malignant neoplasm of the kidney, accounting for up to 90% of renal neoplasms and up to 3% of all neoplasms. It is more common in men than in women (3:2 ratio), has a peak incidence between 60 and 70 years of age, and is associated with smoking, obesity, and antihypertensive therapy. TCC accounts for 10% of upper urinary tract neoplasms. Although TCC is most likely to occur in the bladder, the ureters have been reported to be involved in 2%, and the renal pelvis in 5% of patients. TCC may also have a multifocal presentation. Synchronous tumours occur in up to 2% of renal and 9% of ureteric lesions, with metachronous lesions typically occurring in the bladder in up to 50% of patients with upper ureteric tumours on presentation. Imaging is required for primary diagnosis of TCC and is commonly used for the detection of synchronous and metachronous lesions. Bladder neoplasia is the fifth most common cancer in Europe and the fourth most common in the United States. TCC of the bladder also occurs more commonly in men than in women, is associated with smoking (incidence up to fourfold greater than in nonsmokers), exposure to chemicals such as benzene and 2

Segmental Ureteral Resection and Termino-Terminal Anastomosis

On the video we show a 24-year-old patient, who has suffered a Ureter lesion after a laparoscopic oforectomy. We first recognized the injury and prepared it so we can suture it with 4 stitches of vycril 5.0 and finally we insert a ureter double j catheter and an abdominal drainage.

Laparoscopic management of ureteral lesions in gynecology

To investigate the outcome of laparoscopic repair of ureteral injury in laparoscopic gynecologic surgery. Prospective trial. University hospital. Forty patients with a ureteral lesion in laparoscopic surgery between 1991 and 2007. Laparoscopic ureteral repair, laparoscopic-assisted or blind stent insertion. Treatment outcome of ureteral lesion analyzed by type of injury, time of diagnosis, and management. In 4,350 consecutive laparoscopic gynecologic interventions, 42 lesions occurred, 5 during hysterectomy, 1 during adnexectomy, and 36 during deep endometriosis surgery. In the latter group (n = 1,427), the incidence was 1.5% and 21% in women without and with hydronephrosis, respectively. In eight women in whom a stent was inserted after surgery without laparoscopic guidance, five were uneventful and three needed a second intervention. In all 34 women in whom a laparoscopic repair over a stent was performed, the outcome was uneventful, whether diagnosed and treated during surgery (n = 25) or after surgery (n = 9). Laparoscopic repair over a stent was uneventful for all lacerations, transections, and fistulas, whether performed during or after surgery, and was superior to blind stent insertion. In women with hydronephrosis and deep endometriosis, a preoperative stent insertion seems to be mandatory.

The use of JJ stent in the management of deep endometriosis lesion, affecting or potentially affecting the ureter: a review of our practice

With the increasing number of operative laparoscopies performed for the treatment of deep pelvic endometriosis, technical difficulties and risk of complications inevitably increase. We report our experience using JJ stents, in women treated for deep pelvic endometriosis, with regard to prevention and management of ureteral lesions. Descriptive retrospective analysis between March 2004 and March 2007. Department of Obstetrics and Gynaecology, University Hospital, Strasbourg, France. Cases of women who underwent laparoscopic surgery for severe endometriosis and who needed a JJ stent in their management were recorded. Laparoscopic surgery was performed at the Department of Obstetrics and Gynaecology at CMCO-SIHCUS and Hautepierre Hospitals, Strasbourg, which are referral centres in the treatment of deep endometriosis. To evaluate the contribution of JJ stent in the prevention and management of ureteral lesions from endometriotic origin and/or iatrogenic origin in women treated for deep pelvic endometriosis. A total of 145 women had surgery for deep pelvic endometriosis. Seventeen (11.7%) women had a JJ ureteral stent inserted. In 82.4% of women, the stent was inserted pre- or peroperatively. We noted three ureteral complications, of which only one needed management by laparotomy. Except in extreme cases, management of ureteral endometriosis should be performed laparoscopically. Ureteral lesions whether iatrogenic, or secondary to endometriotic disease, can be treated by cystoscopy, JJ stent and laparoscopy. The combination of these three elements is the optimal management and is unlikely to cause subsequent complications. Laparotomy and its associated morbidity should be avoided.

Ureteral endometriosis: clinicopathological and immunohistochemical study of 7 cases

Ureteral endometriosis is a rare yet important entity that can lead to renal failure due to silent obstruction of the ureter. Awareness of clinical and morphologic features can help in early detection and treatment. We analyzed the clinical, pathologic, and immunohistochemical findings of 7 cases of ureteral endometriosis. Mean age of patients was 51 years. All patients presented with hydroureter, accompanied in the most cases by hydronephrosis. Superimposed pyelonephritis was experienced by 2 of 7 patients. Most patients (4 of 7) had previously undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy. In 6 of 7 cases, endometriosis involved the left ureter. The distal one third of the ureter was involved in 6 cases, whereas the middle third was involved in 1 case. In 4 cases, endometriosis was located extrinsic to the ureter, whereas in 3 cases, the ureter showed intrinsic involvement by endometriosis. One case showed simple endometrial hyperplasia. Surgical management included nephrectomy in 2 cases, distal ureterectomy with reimplantation in 3 cases, ureteral stent placement followed by ureteroureterostomy in 1 case, and relief of ureteral obstruction by resection of pelvic endometrioma in 1 case. Immunostains for cytokeratin-7 (CK7) and progesterone receptor (PR) were positive in all of the cases, whereas immunostains for estrogen receptor (ER) were positive in 83% of cases and immunostains for CK20 were negative in all cases. CA125 immunostains were positive in 67% of cases. The stromal cells were positive for CD10, ER, and PR immunostaining. Our findings suggest that the diagnosis of ureteral endometriosis is preceded in most cases by hysterectomy and bilateral salpingo-oophorectomy, possibly because of prior symptoms related to adenomyosis or pelvic endometriosis and that ureteral endometriosis has a strong predilection for involvement of the lower third of the left ureter. Ureteral endometriosis should be included in the differential diagnosis of obstructive ureteral lesions in women, particularly those involving the lower third of the left ureter, even in postmenopausal patients. Immunostains for ER, PR, CK7, CA125, and CD10 can be helpful in challenging cases.

Résultats des néphrostomies à ballonnet dans le traitement des fistules urinaires basses

To study the results of balloon nephrostomy urine drainage in the treatment of lower urinary tract fistula. A series of 10 patients with lower urinary tract fistula was treated by balloon nephrostomy for tumour in eight cases and trauma in two cases with a palliative indication in two patients. The duration of diversion ranged from seven to 210 days (mean: 55 days). The only incidents observed were three cases of urinary sepsis and four cases of nephrostomy tube or balloon migration. On removal of the nephrostomy, there were no signs of stenosis or other ureteric lesion. Balloon nephrostomy drainage achieved cure of the fistula in four cases, and allowed successful surgical repair in the other cases. Balloon nephrostomy placement appears to constitute an alternative to surgical repair for lower urinary tract fistula. In the case of failure, it appears to allow surgical repair to be performed under better conditions than in the case of immediate surgery. However, these preliminary results need to be confirmed on larger series.

Uretero-Fallopian Fistula After Gynecological Surgery for Endometriosis: A Case Report

Urinary tract injuries are unfortunate complications of pelvic surgery. These frequently involve the bladder. The incidence of iatrogenic ureteral lesions ranges from 0.05% to 30%. Even though some lesions are observed intraoperatively, most remain undiscovered and reveal themselves later. Fistulas of ureteral origin usually involve the vagina or more rarely the uterus. Uretero-fallopian fistulas are even more rare. We report a case of uretero-fallopian fistula that developed after surgery for endometriosis.

Technical Complications in Organ Procurement

It is of crucial importance that harvested organs are not discarded because of lesions inflicted during the procurement operation. From January 2005 to January 2006, a total of 395 organs were procured: 266 kidneys, 102 livers, and 27 pancreate. Two kidneys were lost due to vascular lesions, and 1 liver could not be transplanted because of a severe parenchymal injury (0.75% total organ losses). In 33 of 198 cases (16.7%) despite lesions to renal vessels or to the ureter, the kidneys were transplanted after back-table repair procedures. Vascular lesions were observed in 10% of the evaluated livers (8 of 102) and in 3 of 18 pancreatic grafts. In the literature, a total organ loss of 0.75% because of technical problems demonstrates a high standard of visceral organ procurement in our region. Hence, reparable vascular and ureteral lesions in 10% to 16.4% indicated the need for better surgical training and standardization in procurement techniques. We believe that double-checking both the organ and quality reports and giving immediate feedback to the procurement surgeons in cases of technical problems are effective ways to perform quality control. It must be our goal to increase the response rate of the quality forms.

VID-04.01: Reconstructive laparoscopy for ureteral lesions: a single institute experience

VID-04.01: Reconstructive laparoscopy for ureteral lesions: a single institute experience

A comparison of urinary complications following total laparoscopic radical hysterectomy and laparoscopic pelvic lymphadenectomy to open abdominal surgery

Objective The objective of this study was to compare total laparoscopic radical hysterectomy (TLRH) and laparoscopic pelvic lymphadenectomy (LPS) to total abdominal radical hysterectomy (TARH) and pelvic lymphadenectomy (LPT) in terms of urinary tract lesions and postoperative urinary retention. Methods Starting in 2004, we treated all early stage cervical cancer patients with TLRH and LPS. The control group for this analysis was a historical cohort of patients treated with TARH + LPT. Within the TLRH + LPS group, we assessed whether the width of parametrial tissue removed was a risk factor for urinary tract injuries or postoperative urinary retention. Results Fifty women were included in the TLRH + LPS group and forty-eight were included in the TARH + LPT group. There were no conversions from laparoscopy to laparotomy. There was no statistically significant difference in intraoperative urinary complications between the groups. Four (8%) intraoperative urinary tract injuries in the LPS (3 cystotomies and 1 ureteral lesions all repaired laparoscopically) and 2 (4.2%) in the LPT group (2 cystotomies) occurred ( p = 0.68). Similarly, there was no statistically significant difference in postoperative urinary complications between groups. Urinary postoperative complications were: 1 (2%) ureterovaginal and 1 vesicovaginal fistulas, 1 delayed ureteric fistula in LPS group vs. 0 in LPT group ( p = 0.24). Urinary retention was complained by 7 (14%) and 7 (14.6%) patients in LPS and LPT groups respectively ( p = 1.00). The average width of parametrial tissue removed in the LPS group was 32.2 + 14.0 mm in patients with vs. 39.5 + 13.6 mm in patients without urinary complications ( p = 0.11). Conclusions A laparoscopic approach is comparable to the laparotomy in terms of urinary lesions and postoperative retention. The width of parametrium removed does not affect the risk of urinary lesions or postoperative retention.

Management of ureteral endometriosis: areas of controversy

In this review we critically evaluate what we know and what we still do not know about pathogenesis, diagnosis and treatment of ureteral endometriosis, highlighting areas of controversy. Recent studies have produced new insights into diagnostic and management options for ureteral endometriosis. The diagnosis of ureteral endometriosis entails a high index of suspicion for the disorder. Imaging techniques are of limited value in providing an accurate depiction of extension of ureteral lesions. Preliminary results suggest that magnetic resonance urography is accurate in differentiating between intrinsic and extrinsic forms of ureteral involvement, but further studies are required to define its role in directing better treatment. Current controversies in the treatment of ureteral endometriosis are over whether segmental resection and anastomosis or ureterolysis are indicated, and whether minimal-access procedures are equally effective than their traditional open counterparts. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis but that recurrence rates are not negligible, as suggested in pioneering works. Successful application of laparoscopic surgery, even for procedures that have traditionally necessitated laparotomy, has been reported. Extensive experience with endourological techniques is prerequisite for success.

Rapid, Economical Treatment of Large Impacted Calculi in the Proximal Ureter With Ballistic Ureteral Lithotripsy and Occlusive, Percutaneous Balloon Catheter: The High Pressure Irrigation Technique

We describe our innovative technique for the treatment of large calculi (greater than 1.5 cm) of the proximal ureter. Between 2003 and 2005 we positioned an 8Ch pyelostomy in 25 patients diagnosed with impacted calculi of the proximal ureter greater than 1.5 cm on ultrasound, direct x-ray of the abdomen, and/or computerized tomography and subsequent retrograde pyelography. After 30 days all patients underwent combined treatment in the Valdivia supine position, including positioning a 0.035-inch guidewire through the pyelostomy into the ureter up to above the calculus, pyelostomy removal and insertion onto the guide of a 7Ch balloon occlusion catheter, which was inflated in the ureter immediately above the calculus. Ureteral lithotripsy was done with an 8.5 to 11.5Ch ureteroscope (Wolf, Dudley, Massachusetts) with a 6Ch operating channel and a Calcusplit ballistic probe, alternating high antegrade pressure by the balloon catheter and retrograde pressure using the ureteroscope, as required. After lithotripsy and fragment dislocation the ureteroscope was retracted with rapid flow antegrade irrigation. At the end of the procedure after antegrade contrast medium followup the balloon catheter was retracted as far as the pelvis as a nephrostomy. We analyzed operative time, the number of postoperative recovery days, the incidence of complications during and after surgery, and the stone-free rate immediately, after 5 days and after 1 month. Average calculus size was 1.7 cm. Ten patients presented with multiple ureteral bending upon diagnosis, which was no longer found at surgery with a consequent lack of difficult ureteroscope feeding. Significant edema downstream of the calculus was present in all cases. High pressure irrigation, a rigid ballistic probe and retrieving forceps enabled the dislocation of even larger fragments from the original calculous site in all cases. Antegrade high pressure irrigation after lithotripsy enabled the complete clearance of calcareous fragments as far as the bladder without the need for ancillary maneuvers. We observed no cases of calcareous fragment push-back. No retroperitoneal extravasation, or pyelolymphatic or pyelovenous backflow was observed. Average procedure time was 33 minutes. The renal-ureteral stone-free rate was 100% at the end of the procedure and all calcareous fragments were in the bladder. We did not observe any ureteral lesions. In no case was there onset of fever. Average postoperative hospitalization was 2 days. Followup with contrast material after 5 days showed a renal-ureteral stone-free rate of 100% and a bladder stone-free rate of 84%. The nephrostomy was removed at an average of 5.5 days. Compared to the techniques described in the medical literature our method appears to have certain advantages, including a mini-invasive approach to the renal pelvis compared to that of percutaneous nephrolithotomy with protection of the renal parenchyma from high pressure, rigid ureteroscope use, which provides a high level of maneuverability and low operating costs, ballistic probe use, which provides lower costs and higher speeds than the laser, and balloon catheter use, which removes the risk of push-back and enables push-down of the fragments without any further ancillary maneuvers. The balloon catheter also enables contrast medium followup and immediate postoperative drainage. The speed of the procedure and the ability to adjust antegrade or retrograde flow with variable pressure and direction make this technique highly suitable for the complete resolution of large, impacted calculi of the proximal ureter.

Singuläres Ileuminterponat mit beidseitiger Harnleiterimplantation nach Wertheim-Meigs-Operation

Ileum or colon interpositions are qualified procedures for functional ureteral replacement in case of extended ureteric lesions. In most cases, a unilateral interposition is sufficient. Rarely, it is necessary to perform bilateral procedures. We report the case of a 41-year-old female patient with bilateral ureter implantation into a singular ileum segment.

Autotrasplante renal: Una alternativa válida en la resolución de casos complejos

To analyze the current indications for renal autotransplantation, as well as the technical features, complications and long-term follow-up of the technique. From 1990 to 2005 we have performed autotransplantation in 10 patients, 7 adults and 3 children. The indication was established due to vascular pedicle pathology in 8 cases and ureteral lesion in 2. The cause of vascular pathology was: atherosclerotic stenosis (4), dysplastic stenosis (2), Takayasu's disease stenosis (1), and renal artery aneurysm (1). The patients with ureteral lesion had ureteral stenosis secondary to Crohn's disease in one case, initially solved by ureteral stent and subsequently obstructed by lithiasic encrustation, and ureteral avulsion in the other case. The vascular grafts employed in the 8 cases with vascular reconstruction were: hypogastric artery 7 cases, and sophena vein in one case. Ureteral reimplantation was necessary in 5 cases after bench surgery; in other five cases vascular reconstruction was performed without ureteral division. All grafts were perfused with 4 degrees C lactate ringer or Wisconsin solution and protected with surface cold ischemia. Ischemia times ranged from 42 to 89 minutes. Nine kidneys (90%) functioned after autotransplantation, 8 of them had immediate function, and one had delayed graft function after a six-day period of acute tubular necrosis. The kidney with arterial stenosis secondary to Takayasu's disease never functioned. The cause of graft loss was renal vein thrombosis. Postoperative mortality was zero. After a mean follow-up of 72+/- 13 months mean serum creatinine is 1.6+- 0.4 mg/dl (1.1-2.4) and 70% (7/10) of the patients have normal blood pressure without antihypertensive medication. Currently, renal autotransplantation, with or without extracorporeal vascular reconstruction, is a complex technique with exceptional indications, but it allows recovering renal units with vascular pathology not amenable to angioplasty or in situ revascularization. It is also a valid alternative to ileal ureteral substitution in cases of extensive ureteral lesion.

Penetrating ureteral trauma

The purpose of this series is to report our experience in managing ureteral trauma, focusing on the importance of early diagnosis, correct treatment, and the impact of associated injuries on the management and morbid-mortality. From January 1994 to December 2002, 1487 laparotomies for abdominal trauma were performed and 20 patients with ureteral lesions were identified, all of them secondary to penetrating injury. Medical charts were analyzed as well as information about trauma mechanisms, diagnostic routine, treatment and outcome. All patients were men. Mean age was 27 years. The mechanisms of injury were gunshot wounds in 18 cases (90%) and stab wounds in two (10%). All penetrating abdominal injuries had primary indication of laparotomy, and neither excretory urography nor computed tomography were used in any case before surgery. The diagnosis of ureteric injury was made intra-operatively in 17 cases (85%). Two ureteral injuries (10%) were initially missed. All patients had associated injuries. The treatment was dictated by the location, extension and time necessary to identify the injury. The overall incidence of complications was 55%. The presence of shock on admission, delayed diagnosis, Abdominal Trauma Index > 25, Injury Severity Score > 25 and colon injuries were associated to a high complication rate, however, there was no statistically significant difference. There were no mortalities in this group. A high index of suspicion is required for diagnosis of ureteral injuries. A thorough exploration of all retroperitoneal hematoma after penetrating trauma should be an accurate method of diagnosis; even though it failed in 10% of our cases.

Vertebromedullary Wound with Ureteral Fistula

We report a case of associated vertebromedullary and ureteral lesions in a severely injured patient, a victim of a gunshot aggression in Africa. Urine extended from the ureteral fistula through the third lumbar vertebral body, blended with cerebrospinal fluid from the dural attrition, and flowed very slowly through the dorsal exit ballistic hole. This is to our knowledge the first such case described in the literature. Uro-computed tomography scan finally made the diagnosis of ureteral fistula after two neurosurgical procedures determined that initially presumed dural persistent fistula needed to be closed.

A case of ureteral lesions in a renal transplant recipient with a co-infection of BK virus and JC virus

Sir, Most cases of Polyomavirus-associated nephropathy are due to BKV, although Randhawa [1] demonstrated the co-infection of JCV and BKV in renal transplant recipients with interstitial nephritis and Kazory [2] and Wen [3] described two cases of interstitial nephritis associated with JCV in the absence of BKV. We report a 65-year-old female who developed ureteral lesions with a co-infection of BKV and JCV. This patient underwent cadaver renal transplantation in November 2005, after four years of haemodialysis for chronic renal failure secondary to diabetes mellitus. The patient received immunosuppressive therapy with tacrolimus, mycophenolate mofetil and corticosteroids. On day 9 post-transplant, cystography showed a urinary fistula, for which a conservative management was initially chosen. On day 12, PCR assay showed a negative result for serum BKV-DNA and JCV-DNA and urine BKV-DNA and demonstrated a viral load of 10 2 JCV-DNA copies/ml on urine. On day 51 a pyeloureteral anastomosis was performed, as no definitive resolution of the leakage was achieved. During surgery, ureteral stricture and detachment were observed. Histological investigation showed cystic ureteritis and mild chronic inflammation of the wall. Neither nuclear findings consistent with viral infection nor positive reaction for SV40 antibody (Lee Biomolecular Res. Labs, CA) were present. PCR on ureteral specimen showed a viral load of 10 3 and 10 8 BKV- and JCV-DNA copies/m go f extracted DNA, respectively. The patient’s clinical conditions and allograft function worsened; a transplantectomy was performed on day 65. Histological investigation of the explanted kidney revealed an acute microabscessual pyelonephritis due to Candida albicans, a small infarction and cystic pyelitis. Notwithstanding immunosuppression withdrawal, transplantectomy, and anti-fungal therapy, clinical conditions did not improve and the patient died on day 83. No autopsy was performed. Some authors have suggested that BKV and JCV reactivation are controlled by distinct mechanisms, hypothesising a protective effect of BKV with regard to JCV [4]. In our patient, both BKV- and JCV-DNA were detected on ureteral specimen, with JCV load being higher than BKV load. However, a histological examination of the explanted kidney did not show the presence of viral inclusions in uroepithelial cells. The discrepancy between morphological and molecular findings could be due to sampling, although it cannot be excluded that the affected cells were detached in the ulcerated areas. However, we could not unequivocally prove a cause and effect relationship between ureteral damage, PCR positivity and allograft dysfunction and failure. Based on these observations, we think a close monitoring of polyomaviruses DNA serum and urine levels should be recommended, to diagnose a viral reactivation in its early stages in kidney graft recipients and to perform a quantitative PCR on tissue samples when a biopsy is executed, even if serum and urine have previously tested negative.

Solitary ureteral metastases of renal cell carcinoma

Metachronous presentation of metastatic renal cell carcinoma (RCC) to the ureter is extremely rare. We report a solitary metachronous metastatic RCC in the contralateral ureter 14 months after right radical nephrectomy for Fuhrman grade 2 pT3a clear cell disease after the patient re-presented with gross hematuria. The proximal left ureteral lesion was excised followed by ileal-ureteral interposition. Pathologic examination confirmed metastatic RCC. To date, only 51 cases of metastatic RCC to the ureter have been reported, with only 6 occurring metachronously in the contralateral ureter. Also, we report the presence of focal extramedullary hematopoiesis occurring within this metastatic lesion.