Ureteral Pathology Research Articles

Perioperative and functionnal outcomes of robot-assisted laparoscopic versus open ureterovesical reimplantation for benign lower ureteral pathologies: a single-center comparative study.

The robot-assisted laparoscopic(RALUVR) and open(OUVR) approaches have both been described for ureterovesical reimplantation to treat benign lower ureteral pathologies. Thus, we aimed to compare the perioperative and functional outcomes of RALUVR vs. OUVR. We performed a retrospective comparative study including all consecutive patients treated with RALUVR or OUVR for benign lower ureteral pathologies between January 2013 and December 2022 at our center. Logistic regression analyses were used to assess the predictors of complication ≥ Clavien-Dindo(CD)III within 90 days, prolonged length of stay(LOS), and 90-day overall success. The Kaplan-Meier method and Cox regression analyses were used to assess vesicoureteral reflux-free(VU-RFS) and stenosis-free(SFS) survivals. Overall, 44 patients underwent RALUVR(n = 19; 43%) and OUVR (n = 25; 57%). In univariable logistic regression analyses, the use of RALUVR vs. OUVR was not significantly associated with postoperative complications ≥ CDIII (OR = 0.98; 95% CI=[0.17-5.09]; p = 0.98), and 90-day overall success (OR = 1.43; 95% CI=[0.24-11.28]; p = 0.7). Despite a shorter median LOS after RALUVR vs. OUVR (4 vs. 10 days, respectively; p < 0.001), multivariable logistic regression analysis showed no impact of the surgical approach on prolonged LOS (OR = 0.51, 95% CI=[0.03-13.86]; p = 0.65). No significant difference was observed in 2-year VU-RFS (72.9% vs. 100%, respectively; p = 0.2) and 2-year SFS between the RALUVR and OUVR groups (85.7% vs. 87.7%, respectively; p = 0.8). In Cox regression analysis, the use of RALUVR vs. OUVR was not significantly associated with VU-RFS (HR = 4.26; 95% CI=[0.38-47.84]; p = 0.24) or SFS (HR = 1.32; 95% CI=[0.22-8.01]; p = 0.76). We observed that RALUVR provides similar perioperative and functional outcomes as compared to OUVR, except for potentially shorter LOS.

Diagnosis and Management of Ureteropelvic Obstruction in Kidney Transplant Recipients and Outcomes of Foley Y-V Pyeloplasty.

To evaluate the etiology and diagnostic tools for ureteropelvic obstruction in kidney transplant recipients, we investigated the short-term and long-term outcomes of Foley Y-V pyeloplasty. We retrospectively reviewed 10 patients who underwent kidney transplant followed by additional interventions to treat obstructive ureteral pathologies between 2016 and 2020. We enrolled 4 patients who had received intervention to treat ureteropelvic obstruction. For these 4 patients, serum creatinine and estimated glomerular filtration rate levels were recorded at baseline, during the symptomatic period, and long-term. In this single center study, we investigated diagnostic tools and management strategies for ureteropelvic obstruction and assessed performance of Foley Y-V nondismembered pyeloplasty in kidney transplant recipients. Among 4 patients, graft function (assessed by serum creatinine and estimated glomerular filtration rate) worsened significantly (P = .03) in the symptomatic period of ureteropelvic obstruction in all patients; however, graft function levels improved rapidly to levels similar to baseline (P = .07) after Y-V pyeloplasty. In addition, no statistically significant difference was detected between baseline and longterm graft functions afterY-V pyeloplasty in follow-up (P = .28). Diagnosis and management of ureteropelvic obstruction in kidney transplant recipients are challenging due to rarity and lack of an ideal management algorithm.There is no specific diagnostic tool to discriminate this pathology from other ureteral pathologies; therefore, a regimen of conventional imaging modalities and diuretic renogram combined with endoscopic evaluation is more reliable. Moreover, nondismembered Foley Y-V pyeloplasty is effective and safe for graft function in the short-term and long-term.

Is fluoroscopy-free single-use flexible ureteroscopy a feasible treatment for kidney stones with abnormal renal anatomy?

ObjectiveTo evaluate the feasibility of fluoroscopy-free single-use flexible ureteroscopy procedure in the treatment of kidney stones with abnormal renal anatomy compared to normal renal anatomy. MethodsForty patients with abnormal (Group A) and 80 patients with normal (Group B) renal anatomy who had 10–20 mm renal stones were included. They were treated with LithoVue single-use flexible ureteroscopy (Boston Scientific, Marlborough, MA, USA) after ureteric dilatation by two different size semi-rigid ureteroscopes. This technique was chosen as the aim was to exclude any ureteric pathology (e.g., stone or stricture), confirm the placement of a safe guidewire, avoid balloon dilatation of the ureter, and achieve safe insertion of a 12 Fr, 35/45 cm ureteric access sheath with optical and tactile sign and without fluoroscopy image for guidance. ResultsThe mean ages were 43 years and 45 years in group A and group B, respectively. The mean stone burden was 14.62 (standard deviation: 5.35) mm3 and 14.79 (standard deviation: 4.58) mm3 in Group A and Group B, respectively. There is no significant difference between both groups according to the mean operative time, hospital stay, or stone-free rate. The stone-free rate was about 93% in both groups when the stone size was between 10 mm and 15 mm, and less than 54% when the stone size was more than 15 mm to 20 mm. In the majority of cases (80% in Group A and 92.5% in Group B), we completed the procedure without fluoroscopy. The perioperative complication rates were comparable in the two groups. ConclusionFluoroscopy-free single-use flexible ureteroscopy, when performed by expert urologist, is a feasible treatment for pre-stented patients with kidney calculi of ≤15 mm with abnormal renal anatomy.

Applications of Indocyanine Green-Guided Near-Infrared Fluorescence Imaging in Pediatric Minimally Invasive Surgery Urology: A Narrative Review.

Background: Indocyanine green (ICG) is a fluorescent dye used for several indications in adult surgery, and, more recently, adopted also in the pediatric patients. This study aimed to review the literature published on the use of ICG near-infrared fluorescence (NIRF) in pediatric urology, to address its shortcomings and disadvantages and to detect the future perspectives. Materials and Methods: An electronic literature search of PubMed on all studies reporting use of ICG-NIRF in pediatrics was performed. We included only studies reporting ICG-NIRF application in minimally invasive surgery (MIS) for pediatric urology indications. Results: Forty-two articles reporting MIS procedures performed using ICG-NIRF in children were obtained, but only 15 studies that focused on urological applications of ICG-NIRF in children were included in this review. The included studies described use of ICG-NIRF for kidney malformations such as duplex system, kidney tumors, renal cysts, ureteral pathology, bladder malformations, varicocele, and lymph node sampling in tumors. The pediatric urological applications in which ICG-NIRF provided significant advantages included partial nephrectomy, lymphatics sparing varicocele repair, and oncological procedures. The ICG-NIRF use was clinically safe, without reported adverse systemic reactions in all pediatric series. The main drawback of this technology is the need of specific laparoscopic equipment such as camera system, light sources, and telescopes or the da Vinci Xi Robot, with the software for ICG-NIRF, Firefly®, already integrated within. Conclusions: ICG-enhanced fluorescence-guided surgery is gaining growing popularity among pediatric surgeons due to the excellent results that have been published until now. ICG-NIRF technology has proven to be safe, easy to use, not time-consuming, cheap, and very effective to improve intraoperative view and surgical ability. Nonetheless, further evidence, including larger series, longer follow-up, and more specific assessments, is necessary to confirm the preliminary results and enlarge the applications.

Kidney Autotransplantation and Orthotopic Kidney Transplantation: Two Different Approaches for Complex Cases.

Introduction Transplantation surgery teams often have to face complex cases. In certain circumstances, such as occlusion of the iliac vessels or prior pelvic surgery, heterotopic kidney transplantation may not be feasible and orthotopic kidney transplantation (OKT) could be a good alternative. Kidney autotransplantation (KAT) has been described as a potential treatment for complex renovascular, ureteral, or neoplastic conditions. There are scarce data regarding the complications and outcomes of these procedures; therefore, we present our experience. Materials and Methods We retrospectively analysed the medical records of both 21 patients who had received OKT and 19 patients who underwent KAT between 1993 and 2020. We collected demographic features and data regarding surgical technique, complications, and graft outcomes. Kidney graft survival was calculated using Kaplan–Meier survival analysis. Results Regarding OKT, in 15 (71.43%) cases, it was the first kidney transplantation. The most common indication was the unsuitable iliac region due to vascular abnormalities (57.14%). The early postoperative complication rate was high (66.67%), with 23.81% of Clavien grade 3b complications. During the follow-up period (mean 5.76 -SD 6.15- years), we detected 9 (42.85%) graft losses. At 1 year, the survival rate was 84.9%. Concerning KAT, the most frequent indication was ureteral pathology (52.63%), followed by vascular lesions (42.11%). The overall early complication rate was 42.11%. During the follow-up period (mean of 4.47 years), 4 (15.79%) graft losses were reported. Conclusions Although OKT and KAT have high complication rates, these techniques can be considered as two valuable approaches for complex cases, in the absence of other therapeutic options.

Bioengineering solutions for ureteric disorders: clinical need, challenges and opportunities.

ObjectivesTo summarise the causes of ureteric damage and the current standard of care, discussing the risks and benefits of available therapeutic options. We then focus on the current and future solutions that can be provided by ureteric bioengineering and provide a description of the ideal characteristics of a bioengineered product.MethodsWe performed a literature search in February 2021 in: Google Scholar, Medline, and Web of Science. Three searches were conducted, investigating: (a) the epidemiology of ureteric pathology, (b) the current standard of care, and (c) the state of the art in ureteric bioengineering.ResultsThe most‐common causes of ureteric damage are iatrogenic injury and external trauma. Current approaches to treatment include stent placement or surgical reconstruction. Reconstruction can be done using either urological tissue or segments of the gastrointestinal tract. Limitations include scarring, strictures, and infections. Several bioengineered alternatives have been explored in animal studies, with variations in the choice of scaffold material, cellular seeding populations, and pre‐implantation processing. Natural grafts and hybrid material appear to be associated with superior outcomes. Furthermore, seeding of the scaffold material with stem cells or differentiated urothelial cells allows for better function compared to acellular scaffolds. Some studies have attempted to pre‐implant the graft in the omentum prior to reconstruction, but this has yet to prove any definitive benefits.ConclusionThere is an unmet clinical need for safer and more effective treatment for ureteric injuries. Urological bioengineering is a promising solution in preclinical studies. However, substantial scientific, logistic, and economic challenges must be addressed to harness its transformative potential in improving outcomes.

Therapeutic Living Donor Nephrectomy for Proximal Ureteral Pathology: A Longitudinal Case Series

ObjectiveTo raise awareness that patients with proximal ureteral stricture who elect for nephrectomy can consider donating the kidney. We present a series of patients undergoing therapeutic living donor nephrectomy (TLDN), a scenario in which a patient undergoing nephrectomy for an underlying medical problem donates the kidney to a person with end-stage renal disease. This practice is underutilized, and only a single TLDN with proximal ureteral stricture has been previously described. We aim to help define the indications, risks, and benefits for patients. MethodsThis is a retrospective case series of seven therapeutic donors with proximal ureteral pathology and stone disease. Patient characteristics, donor work up, operative details, and donor and recipient outcome were collected. ResultsAll seven donors had proximal ureteral pathology, and six of the seven had nephrolithiasis or ureterolithiasis. After electing for nephrectomy, the mean time to TLDN was 57.9 days. No recipients experienced delayed graft function . Mean follow up was 40.1 months (range 8-131), and the most recent follow-up mean creatinine was 1.08 (mg/dL). Graft and recipient survival is 100%. No recipients developed recurrence of ureteral stricture or stones. ConclusionThis is the first series demonstrating patients with proximal ureteral stricture, even with concomitant stone disease, may donate kidneys for transplantation. Recipient outcomes suggest this practice is safe, and appropriately selected patients that have already elected for nephrectomy should receive counseling about this opportunity. Importantly, patients who donate a kidney receive waiting list priority if they ever need a kidney transplant in the future.

A novel tattooing technique for ureteric strictures in robotic ureteroureterostomy: a non-inferiority analysis.

A novel tattooing technique for ureteric strictures in robotic ureteroureterostomy: a non-inferiority analysis.

EP.TH.112The Use Ex-Vivo Renal Autotransplantation to Treat Hypertension Secondary to Renal Artery Disease: Two Case Reports

Abstract Renal Auto transplantation (RAT) is the surgical procedure in which the kidney is initially removed and subsequently re-implanted in a different position, allowing for improved outcomes in conditions involving ureteral pathology, renovascular and neoplastic disease primarily. In this paper, we aim to build upon the understanding of RAT and especially its effectiveness in treating patients with hypertension secondary to renal artery disease, intolerant to previous treatment approaches. In particular, the ex-vivo technique will be focused upon as introduced by Ota et al. in 1967 whereby the use of the workbench is frequently applied for patients requiring in excess of 45 minutes of ischaemic time. We, therefore, put forth two cases managed in co-operation by the University of Arkansas vascular and urology departments. The first of which was a 52-year-old woman with an aneurysmal Lesion reaching the renal artery at the hilum. The second was an 18-year-old woman with Takayasu arteritis. The use of vasopressin had preserved some renal function however at the time of the diagnosis, they were experiencing difficulty in controlling their hypertension, and thus RAT was performed, and the subsequent patient postoperative outcomes and effectiveness have been recorded and analysed as part of this study.

Psoas hitch procedure in 166 adult patients: The largest cohort study before the laparoscopic era.

ObjectivesTo present the short‐term and long‐term outcomes of the psoas hitch procedure in a large cohort with long‐term follow‐up.Patients and methodsA multicenter, retrospective cohort study was conducted. Patients were included if they had undergone an open psoas hitch procedure with ureteral reimplantation for different types of distal ureteral pathology between 1993 and 2017. Clinical failure was defined as radiologically‐proven obstruction of the ureteroneocystostomy and/or post‐operative complaints requiring additional surgery. Pre‐operative demographic data and post‐operative radiological imaging were collected. Complications were categorized as peri‐operative, acute (<30 days), and long‐term complications.ResultsA total of 166 patients had undergone a psoas hitch procedure, with a median follow‐up of 15 months (IQR 6‐45). Indications for the procedure included intra‐operative injury of the ureter during gynecological, urological or general surgery, transitional cell carcinoma of the distal ureter, fistulae, (radiation) fibrosis, and trauma. There was no significant difference in pre‐ and post‐operative estimated glomerular filtration rate. Post‐operative complications included urinary leakage, recurrent urinary tract symptoms, recurrent malignancy, and kidney failure. Postoperative imaging was available in 143 patients. Failure of the psoas hitch procedure was seen in 8% (11/143) of the patients. In 55% (6/11) of these patients, radiation fibrosis was the indication for the psoas hitch procedure.ConclusionThis study provides greater insight into the long‐term complications of the open psoas hitch procedure in adults. The psoas hitch procedure can be considered a safe procedure for restoring the continuity of the ureter for different types of ureteral pathologies in adult patients. However, patients with a history of radiation therapy causing retroperitoneal fibrosis might be more prone to failure after the procedure.

Возможности пневмовезикоско-пического доступа при коррекции патологии уретеровезикального сегмента мочеточника и мочевого пузыря у детей

Background pneumovesicoscopic approach gives new possibilities for endovideosurgical correction of congenital ureteral and bladder pathology. Aim To increase the efficiency of ureteral reimplantation in patients with vesicoureteral reflux (VUR), obstructive megaureter and bladder pathology by using pneumovesicoscopic access. Materials and methods For the period 2014 - 2020 a total of 52 children aged from 10 months up to 15 years (median 2.5 years) were treated. In all patients, pneumovesicoscopic ureteral reimplantation according to the Cohen technique was performed, and in six cases bilateral procedure was done. 30 patients with obstructive megaureter (32 ureters) were treated, and intravesical suturing with ureteral plication was performed in 9 patients. Reimplantation for grade 3-5 VUR was performed in 22 patients (26 ureters), in combination with excision of the bladder diverticulum was done in 3 patients, while 3 children were undergone to simultaneous excision of the ureterocele. An original technique for fixation of the mobilized dilated ureter with a ligature to the bladder neck is proposed to simplify its intravesical suturing according to the Starr technique. Results The mean operation time was 142 (83-235 minutes). Conversion to open surgery was required in 1 (1.9%) child during the learning curve. The length of stay was 5-6 days, with an average of 5.21 days. According to ultrasound data, after 1, 3, 6 months there was a decrease in the size of the collecting system and ureter in all cases. At cystography after 6-12 months, VUR was detected in 3 (5.7%) children: in 2 (9%) patients with grade 3-5 VUR and in 1 (3.3%) patient with obstructive megaureter and ureteral suturing. Conclusion Pneumovesicoscopic access for ureteral reimplantation in patients with VUR, obstructive megaureter, bladder diverticulum and ureterocele has proven its efficiency and reliability with a minimal complication rate (5.7%). Our proposed method of fixing the mobilized ureter with a ligature to the bladder neck helps to simplify the suturing of the ureter and to shorten the operation time.

Non-obstructive, non-refluxing uretero-colonic anastomosis by colonic sero-muscular excision and extra mural peri-ureteric wrap – A new technique in 17 children

Uretero-enteric anastomosis with concomitant neobladder/augmentation/conduit becomes necessary when the bladder is unavailable or unfit for reimplantation or the ureters are short after high diversion or resection of lower ureteric pathology. Aiming to prevent both obstruction and reflux, we report a novel technique of sero-muscle denuded extra mural uretero-colic anastomosis. (Fig 1) The ureter was brought through the colonic mesentery. An adjacent zone of colon "abcd" was chosen to receive the ureter and colonic sero-muscular layer was excised from this zone. The ureter was placed on the raw area and uretero-colic anastomosis was done (a-d).The edges of the sero-muscular layer (ab and cd) were sutured over the ureter to complete a submucosal tunnel. The augmentation/neo bladder was completed such that the implanted ureter lay within it between two regions of re-configured bowel, this adding to the anti-reflux mechanism created by the extra mural peri-ureteric wrap. Surgical audit of this technique. 17 children (exstrophy - 8, ectopic ureter with bladder agenesis/hypoplasia - 3, prune belly - 2, neurogenic bladder -2, eosinophilic cystitis -1 and posterior urethral valve -1) underwent colonic implantation of 23 ureters while 6 ureters were drained via a trans uretero-ureterostomy into the reimplanted ureter. Nine augmentation, seven neo bladders and one sigmoid conduit was performed. The colon was available for ureteric re-implant in all patients. Pre-operatively 21 had hydroureteronephrosis. The bladder was agenetic/hypoplastic, small and fibrosed or poorly compliant. Eleven ureters had been diverted. Post operatively (mean follow up - 3.4 years) 16 of 30 renal units were normal, 11 had mild and three had moderate residual hydronephrosis, with no new hydronephrosis. Cystogram showed no reflux in 14 children and unilateral reflux in three (one re-diverted). Of 29 renal units drained directly or via trans uretero-ureterostomy by the uretero-colic reimplantation, none are obstructed, 26 have no vesico-ureteric reflux while three (10%) have reflux. We report results comparable to other extra mural techniques into the bowel, mainly from adult literature. Pediatric refluxing ureters are often large megaureters with or without preliminary diversions. The technique described avoids obstruction although having a slightly higher incidence of recurrent VUR. The ureters with recurrent reflux were massively dilated preoperatively and showed decrease in ureteric diameter postoperatively. The wrap, made for a larger ureter could have become too roomy and allowed reflux. This technique of non refluxing non obstructive uretero-colonic anastomosis has proven useful in selected situations.

Spontaneous bilateral renal pelvis rupture during CT in the absence of urinary tract obstruction: case report

BackgroundAtraumatic renal pelvis rupture without pre-existing renal or ureteric pathology is an uncommon event. It is reported in the setting of acute urinary tract obstruction, most often secondary to ureteric calculi. Typical symptoms include acute flank pain and nausea, mimicking pyelonephritis or other causes of acute abdomen. Spontaneous rupture occurring bilaterally without identifiable urinary tract obstruction is exceedingly rare, and has yet to be reported in current English literature. Possible contributing pathophysiological mechanisms can be postulated from reported cases of rupture with observed obstruction.Case presentationA 58-year-old woman undergoing multiphasic computed tomography (CT) for evaluation of asymptomatic microscopic haematuria developed on-table bilateral renal pelvis rupture seen only after contrast administration, on the delayed phase. There was no significant past medical history of note. The patient remained asymptomatic throughout and after the study, and was managed conservatively. Follow-up radiographical imaging over a month showed resolution of urinoma and no further contrast extravasation. No complications or recurrence was subsequently noted.ConclusionsSpontaneous rupture of the renal pelvis can be a rare complication of intravenous contrast administration even in cases without identifiable urinary tract obstruction, and it can occur bilaterally. Cases can uncommonly be asymptomatic but typical symptoms should prompt evaluation of the kidneys, particularly when they are not included in the initial study or no delayed phase is protocolled. Interval imaging for resolution of urinoma and contrast extravasation is clinically relevant to monitor for and avoid infective sequelae.

CME Sonography 91: Differential Diagnosis of Lower Abdominal Pain

CME Sonography 91: Differential Diagnosis of Lower Abdominal Pain Abstract. Pain in the lower abdomen is a frequent reason for further imaging clarification by sonography. The most frequent causes are appendicitis and diverticulitis, in addition to ureteral stones, ovarian and tubal pathology as well as various hernias. Appendicitis has a characteristic clinical presentation and can be diagnosed by CT or ultrasound. In children, the differential diagnosis is that of mesenteric lymphadenitis. Diverticulitis, often right-sided, can also be reliably diagnosed with CT or ultrasound. Not to be forgotten is the left-sided diverticulitis, which occurs more frequently in Asian persons. Appendicitis epiploica should be recognized to avoid unnecessary operations. The iliopsoas syndrome, which is diagnosed by sonopalpation, often remains undetected.

Особливості лікування дітей із вродженою патологією сечоводу

Особливості лікування дітей із вродженою патологією сечоводу

Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus. ResultsDuring the 1993–2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2–12). Successful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%). DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of patients is small and there are few studies, hindering the agreement on the most appropriate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus ResultsDuring the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction. This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris®, and performed clinical and histological review of these patients. The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux® (1790) and Vantris® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls. Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2±0.6cc (mean±SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

PD25-09 RISK FACTORS FOR TECHNICAL FAILURE OF RENAL AUTOTRANSPLANT: RESULTS OF 103 CASES FROM A SINGLE INSTITUTION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2018PD25-09 RISK FACTORS FOR TECHNICAL FAILURE OF RENAL AUTOTRANSPLANT: RESULTS OF 103 CASES FROM A SINGLE INSTITUTION Mohamed Eltemamy, Ahmed Elshafei, Rathika Ramkumar, Alvin Wee, Stuart Flechner, and Venkatesh Krishnamurthi Mohamed EltemamyMohamed Eltemamy More articles by this author , Ahmed ElshafeiAhmed Elshafei More articles by this author , Rathika RamkumarRathika Ramkumar More articles by this author , Alvin WeeAlvin Wee More articles by this author , Stuart FlechnerStuart Flechner More articles by this author , and Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1336AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal autotransplantation (RA) is an accepted therapeutic option for select indications. We sought to analyze factors associated with technical failure in RA patients. METHODS We reviewed 103 patients who underwent RA from 2004 to 2017. Satisfactory outcome (SO) was defined as post-operative patent vasculature on ultrasound and/ or normal nuclear scan. Unsatisfactory outcomes (UO) included Compromised grafts (CG) (partial infarction on radiographic studies more than 20%) and lost grafts (LG) (nephrectomy or absent perfusion on radiographic studies). RESULTS Median age was 39 years (IQR: 32-47). Females were 71 (69%) and males were 32 (31%). Median follow up time was 9.5 months (IQR: 2.5-30) Indications for RA were renovascular diseases (n=27), Ureteric pathology (n=30), intractable nephrolithiasis (n=30), flank pain (n= 15) and pancreatic neoplasm (n=1). 89 (86.4%) patients had a SO while 14 (13.6%) had a UO (CG= 7, LG= 7). There was no statistically significant difference between UO and SO in median preoperative creatinine (p=0.2), preoperative positive urine culture (p=0.32), history of stone disease (P=0.27) and prior urinary tract instrumentation (p=0.11). However, presence of ureteric stent or nephrostomy tube (PCN) at time of RA was significantly higher in UO (42.9% vs. 16.9%, p=0.04). Also, multiple arterial anastomoses were more frequent in UO (42.9% vs 18.2%, p=0.03). Other operative variables including median blood loss (p=0.23) and type of urinary reconstruction (p=0.6) were not significantly different. Median creatinine at last follow up was higher in UO compared to SO (1.08 mg/dl vs 0.86 mg/dl, p= 0.005). On logistic regression model, the presence of a stent or PCN at time of surgery (OR 4.19, 95% CI 1.2-14.71, p=0.03) and multiple arterial anastomoses (OR 3.89, 95 CI 1.11-13.63, p=0.03) were independent predictors of UO. CONCLUSIONS The presence of a stent or PCN at time of surgery and multiple arterial anastomoses were associated with graft compromise or loss. While the correlation between number of arteries and outcomes is sound, the stronger correlation of stents and PCN at time of surgery with worse outcomes is unclear. Our hypothesis is that ureteric stents and PCNs harbor infections despite appropriate antibiotic treatment. Consequently, these kidneys are more prone to technical failure after RA suggesting the need for an alternative approach with respect to those indwelling devices. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e549-e550 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Mohamed Eltemamy More articles by this author Ahmed Elshafei More articles by this author Rathika Ramkumar More articles by this author Alvin Wee More articles by this author Stuart Flechner More articles by this author Venkatesh Krishnamurthi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pattern of Ureteric Pathology Presenting to a Fistula Centre in Western Kenya.

Background Ureteric pathology arises from surgical misadventures, trauma, and congenital anomalies. Early detection and treatment is of the essence. Objectives To determine the types/etiology and outcome of ureteric pathology presenting to Gynocare Fistula Centre, Eldoret, Kenya. Methods Descriptive retrospective study that evaluated patients presenting with ureteric pathology at Gynocare between 1st January 2012 and 31st December 2016. We pulled out patient charts and extracted and analyzed relevant data using STATA 13E statistical software. Results We analyzed 33 charts, and their age ranged from 10 to 58 years. Annual proportion for 2012, 2013, 2014, 2015, and 2016 was 2.5%, 2.8%, 1.2%, 1.4%, and 3.0% respectively among all the fistula patients treated in the hospital. All the patients presented with urinary incontinence, and 7 (21.2%) had flank pain. Iatrogenic injuries contributed 84.8% (28), and 3 (9.1%) were congenital while trauma and infection had 1 each. Of those resulting from surgical misadventures, 17 (60.7%) were from obstetric while 11 (39.2%) were from gynecological surgery. All the injuries were in the distal third of the ureter; 5 were bilateral; and 11 were left sided while 17 were right-sided. Repair and/or reimplantation was successful in 31 (93.93%) of the patients. Conclusion Highest proportion of ureteric pathologies was accounted for by iatrogenic causes and surgical repair and/or reimplantation has a high success rate.