Ureteral Pathology Research Articles

Early complications of diagnostic and therapeutic ureteroscopy

Objective: The aim of this study is to report early complications of diagnostic and therapeutic ureteroscopy and to grade each complication according to modified Clavien classification system (MCCS). Materials and Methods: Through a prospective study conducted from March to September 2017, all patients who underwent diagnostic and therapeutic semirigid ureteroscopy were evaluated. The procedure was performed by different surgeons. The recording data included patient demographics, ureteroscopy site (left, right, or bilateral), aim of ureteroscopy (diagnostic or therapeutic), operative time, additional intervention, stone-free rate, double J stent placement, and complications which were graded according to the modefied clavien classification system with their management. Results: One hundred and fifty patients were included in the study. The average age was 39.9 years and male-to-female ratio 2.3/1. The number of patients who underwent right, left, and bilateral ureteroscopy was 74 (49.3%), 64 (42.3%), and 12 (8%), respectively, so the overall number of ureteroscopy procedures was 162. Diagnostic ureteroscopy was done in 20 (13.3%) patients and therapeutic ureteroscopy in 130 (87.7%). Complications occurred in 37.3% of patients. According to MCCS, Grade I, II, IIIa, IIIb, IVa, IVb, and V complications were detected in 40 (26.6%), 6 (4%), 10 (6.7%), 14 (9.3), 0 (0.0%), 2 (1.3%), and 0 (0.0%) of cases, respectively. Conclusion: Ureteroscopy becomes the prevailing procedure for different ureteral pathologies mainly stones with a good safety and efficacy. It is important to adopt a precise classification system for reporting the complications of ureteroscopy. Most of the complications are of low grade and they are amenable to conservative management. The complications of ureteroscopy will continue to decline as the ureteroscopic technology evolved.

Ultrasound Diagnosis of Clinically Unsuspected Ureteral Stone Presenting as Acute Scrotum

Ureteral colic is not generally included in the differential diagnoses of acute scrotal pain, although ureteral pathology is a recognized cause of pain referred to the scrotum. We report 3 patients presenting with acute scrotal pain who had normal scrotal color Doppler ultrasound scans; subsequent ultrasound of the ipsilateral kidney revealed hydronephrosis, which ultimately led to the clinically unsuspected diagnosis of ureteral colic. We conclude that ureteral colic should be included in the differential diagnosis of acute scrotal pain, and we further suggest that a survey ultrasound of the kidney on the side of the pain should be performed in patients presenting with acute scrotal pain and a normal color Doppler ultrasound examination of the scrotum.

Robotic Ureteroplasty with Buccal Mucosa Graft for the Management of Complex Ureteral Strictures.

Surgical management of proximal and mid ureteral strictures that are not amenable to primary excision and anastomosis is challenging. Although a buccal mucosa graft is commonly used during substitution urethroplasty, its use in substitution ureteroplasty is limited. We describe our technique of robotic ureteroplasty with a buccal mucosa graft to manage complex ureteral strictures and we report our outcomes. We retrospectively reviewed the records of 12 patients who underwent robotic ureteroplasty with a buccal mucosa graft between September 2014 and June 2016. The indication for the procedure was a proximal or mid ureteral stricture not amenable to primary excision and anastomosis. The primary outcomes were clinical success, absent symptoms on ureteral pathology and radiological success, defined as absent ureteral obstruction on retrograde pyelography, renal scan and/or computerized tomography. Four of the 12 patients (33.3%) had a ureteropelvic junction stricture, 4 (33.3%) had a proximal stricture and 4 (33.3%) had a mid ureteral stricture. Eight of the 12 patients (66.7%) had previously undergone failed ureteral reconstruction. Median stricture length was 3 cm (range 2 to 5). Median operative time was 217 minutes (range 136 to 344) and mean estimated blood loss was 100 ml (range 50 to 200). Median length of stay was 1 day (range 1 to 6). At a median followup of 13 months (range 4 to 30) 10 of the 12 cases (83.3%) were clinically and radiologically successful. Robotic ureteroplasty with a buccal mucosa graft is associated with low inherent morbidity. It is an effective way to manage complex proximal and mid ureteral strictures.

Antegrade Ureteral Stenting is a Good Alternative for the Retrograde Approach

Background/Aims: Double J (JJ) stents for treating obstructive ureteral pathology are generally inserted through a retrograde route with cystoscopic guidance. Antegrade percutaneous insertion using fluoroscopy can be performed alternatively but is less known. Indications, success rate and complications of antegrade ureteral stenting were evaluated. Methods: Data of consecutive patients in which antegrade ureteral stenting was performed were retrospectively analysed using the radiology information system and patient records. Patient characteristics, details of the antegrade JJ stent insertion procedure and registered complications were collected. Furthermore, it was investigated if prior to the antegrade procedure a retrograde attempt for JJ stent insertion was performed. Results: Total 130 attempts for antegrade JJ stent insertion were performed in 100 patients. A percutaneous nephrostomy catheter had already been placed in the majority of kidneys (n = 109) for initial treatment of hydronephrosis. Most prevelant indication for a JJ stent was obstructive ureteral pathology due to malignancy (n = 63). A JJ stent was successfully inserted in 125 of 130 procedures. In 21 cases, previous retrograde ureteral stenting had failed but, subsequent antegrade ureteral stenting was successful. There were 8 procedure related complications; 6 infections, 1 false tract and 1 malposition. Conclusion: Antegrade percutaneous insertion of a JJ stent is a good alternative for retrograde insertion.

Long Term Outcomes of Laparoscopic and Open Modified Lich-Gregoir Reimplantation in Adults: A multicentric comparative study.

Background & Objective:Obstructive ureteral pathologies in adult patients are most commonly due to ureteral strictures and secondary to surgical interventions. In this study, we aimed to compare open and laparoscopic modified Lich-Gregoir ureteral reimplantation with regards to outcomes in benign ureteral pathologies in adult patients.Methods:Between December 2008 and December 2014, 32 open cases and 29 laparoscopic cases were performed as per the data retrieved from surgical databases. All laparoscopic procedures were performed in Bakirkoy Dr. Sadi Konuk Training and Research Hospital(BEAH) and all open ureteral reimplantation procedures in Kartal Dr Lutfi Kirdar Training and Research Hospital(KEAH) and Okmeydani Training and Research Hospital(OEAH).Results:The mean operation time was significantly lower in the group of patients operated with open group (142.5 minutes versus 188.9 minutes; P< 0.0001). The mean duration of follow-up was longer in the laparoscopy group (31 versus 28 months; p< 0.0001). The mean amount of operation associated blood loss was significantly lower in patients operated laparoscopically (93.7 mL versus 214 mL; P< 0.0001). The mean VAS score obtained six hours after surgery was 6.6 ± 0.8 in open group, and 5.8 ± 0.7 in laparoscopic group (p=0.0004). The mean VAS scores measured at post-operative day 1 was 4.5 ± 0.7 in open group and 3.7 ± 0.9 in laparoscopy group. Time required to achieve the pre-operative capability of daily activities was significantly longer in open group (15 ± 1.4 days vs 11 ± 1.4 days; p< 0.0001).Conclusion:Despite open techniques provide shorter operation time and laparoscopic techniques require long learning curve, we think that laparoscopic techniques are superior to open ones since that they provide a better post-operative comfort and are better tolerated in terms of complications.

MP51-12 COST SAVINGS WITH SELECTIVE GUIDE WIRE USE DURING RETROGRADE URETERAL ACCESS

You have accessJournal of UrologyStone Disease: Surgical Therapy V1 Apr 2016MP51-12 COST SAVINGS WITH SELECTIVE GUIDE WIRE USE DURING RETROGRADE URETERAL ACCESS Mike Fascelli, Scott Hubosky, Kelly Healy, Mihir Shah, and Demetrius Bagley Mike FascelliMike Fascelli More articles by this author , Scott HuboskyScott Hubosky More articles by this author , Kelly HealyKelly Healy More articles by this author , Mihir ShahMihir Shah More articles by this author , and Demetrius BagleyDemetrius Bagley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.467AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiple guide wires exist for retrograde endourologic access to the upper urinary tract. Hybrid guide wires combine a hydrophilic tip to facilitate access and a polytetrafluoroethylene (PTFE)-coated shaft over a nitinol core to reduce safety wire slippage. Given its multiple advantages, it has been suggested that a hybrid wire be considered a first line choice in all cases of retrograde access. We hypothesize that this strategy is not cost effective. METHODS Over six-months, we prospectively and routinely attempted to gain initial retrograde access up to the level of the renal pelvis, whenever indicated, in a consecutive group of patients with a standard 0.038-inch stainless steel (SS) fixed core PTFE-coated wire with a 5cm flexible tip. A hybrid guide wire was used as second line when the SS wire was not successful. All urinary diversions, renal transplants and cases of ureteroneocystotomies were excluded. Success rates and cost savings were calculated. RESULTS Retrograde access through a cystoscope was attempted in 300 consecutive qualifying cases. The top five indications for surgery were ureteral stones (121), renal stones (74), strictures (53), ureteral compression (33) and ureteropelvic obstruction (7). For the whole group (300): 55% were pre-stented, 10% had radiation history and 74% had active ureteral pathology. Overall, initial SS wire placement was possible in 64% (191/300). Among SS failures, a hybrid guide wire was successful as second line in 60% (65/109) while other means for retrograde access were required in 39% (42/109). Considering indication, 96% (71/74) of renal stones were successfully accessed with the SS wire. Ureteral stones and ureteral strictures were successfully accessed with SS wires in 54% (65/121) and 45% (24/53), respectively. In cases of extrinsic compression, SS wires were successful in 46% (15/33). In cases of active ureteral pathology, SS wires were successful in 52% (115/221). Given the case volume and at a savings of $41 per case, the SS wire saved $7831 over six months, for a projected savings of $15,662 per year over initial hybrid guide wire use alone. CONCLUSIONS Although potentially convenient, exclusive initial use of hybrid guide wires in all patients requiring retrograde upper tract access is unnecessary and not cost effective. Inexpensive SS wires can achieve successful access in almost all cases devoid of ureteral pathology and over half the time when active ureteral pathology exists. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e685 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Mike Fascelli More articles by this author Scott Hubosky More articles by this author Kelly Healy More articles by this author Mihir Shah More articles by this author Demetrius Bagley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP55-07 HISTOPATHOLOGICAL CHANGES ASSOCIATED WITH POLYACRYLATE POLYALCOHOL BULKING COPOLYMER (PPC, VANTRIS) INJECTION FOR PAEDIATRIC VESICOURETERAL REFLUX (VUR)

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-07 HISTOPATHOLOGICAL CHANGES ASSOCIATED WITH POLYACRYLATE POLYALCOHOL BULKING COPOLYMER (PPC, VANTRIS) INJECTION FOR PAEDIATRIC VESICOURETERAL REFLUX (VUR) Boris Chertin, Stanislav Kocherov, Ermelinda Mele, Simona Gerocarni Nappo, and Nicola Capozza Boris ChertinBoris Chertin More articles by this author , Stanislav KocherovStanislav Kocherov More articles by this author , Ermelinda MeleErmelinda Mele More articles by this author , Simona Gerocarni NappoSimona Gerocarni Nappo More articles by this author , and Nicola CapozzaNicola Capozza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.598AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Endoscopic correction of VUR utilizing Vantris has demonstrated high efficacy not only during a short term period, but also during a long term follow up without VUR recurrence. We have hypothesized that the obstruction following endoscopic correction of VUR is related to the anatomical features of the UVJ rather than the type of material used for endoscopic correction. Therefore, we have retrospectively evaluated all cases of obstruction following endoscopic treatment of VUR in both departments over the last 5 years and have performed clinical and histological review of these patients. METHODS Study population comprised 2470 patients who underwent endoscopic correction of VUR utilizing Deflux (1790 children) and Vantris (680 patients). 9(0.5%) children (3 F and 6 M) in Deflux group and 8(1.2%) (4 F and 4 M) in Vantris group developed UVJ obstruction and required ureteral re-implantation. 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. RESULTS All children developed obstruction during the period ranging from 2 to 49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in 7, IV in 6 and V in 4 children respectively. The review of pretreatment VCUG demonstrated the presence of refluxing/obstructive ureter in 10(58.8%) out of 17 obstructive ureters showing true obstruction in 7 ureters (1 from Deflux and 6 from Vantris group). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign body-type 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, Vantris injection and also of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux, Vantris patients and controls. CONCLUSIONS Our data show that Vantris injection does not lead to ureteral fibrosis or inflammatory changes and therefore does not seem to increase the incidence of UVJ obstruction. However, patients with high grade VUR and an initial underlying ureteral pathology should receive appropriate counseling upon surgery concerning the possibility of UVJ obstruction and the need in subsequent ureteral re-implantation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e738 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Boris Chertin More articles by this author Stanislav Kocherov More articles by this author Ermelinda Mele More articles by this author Simona Gerocarni Nappo More articles by this author Nicola Capozza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V11-10 MINI LAPAROSCOPIC PYELOPLASTY OF A RETROCAVAL URETER

You have accessJournal of UrologyAdrenal/Single Port Surgery/LESS/NOTES1 Apr 2015V11-10 MINI LAPAROSCOPIC PYELOPLASTY OF A RETROCAVAL URETER Anibal W. Branco, Luciano C. Stunitz, Sandro Nichele, Julio C. Foiatto, Juliano D. Scheffer, Marcio Gatti, and Kleber Stelmasuk Anibal W. BrancoAnibal W. Branco More articles by this author , Luciano C. StunitzLuciano C. Stunitz More articles by this author , Sandro NicheleSandro Nichele More articles by this author , Julio C. FoiattoJulio C. Foiatto More articles by this author , Juliano D. SchefferJuliano D. Scheffer More articles by this author , Marcio GattiMarcio Gatti More articles by this author , and Kleber StelmasukKleber Stelmasuk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2608AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Mini laparoscopy is an emerging field of minimally invasive surgery that involves the use of 2mm, 3mm and 5mm laparoscopic instruments. This approach causes less abdominal trauma and, consequently, minimizes pain and surgical stress, as well as providing an excellent aesthetic result. Retrocaval ureter is a congenital anomaly, and its golden standard treatment is the laparoscopic pyeloplasty. The aim of this video is to demonstrate a case of a retrocaval ureter approached by mini laparoscopy. METHODS A 23-year old male patient was presented with recurrent right flank pain; the CT scan demonstrated retrocaval ureter with uretero-pelvic junction (UPJ) obstruction. RESULTS A double J catheter was placed endoscopically; after that, a 3mm trocar and two 5mm ones were used to perform the entire laparoscopic procedure. The operative time was 80 minutes, the blood loss 50ml and no external drain was used; the patient was discharged in the first post operative. The Folley catheter was removed in the second p.o. and the double J stent after six weeks. After 3 months, both ureters demonstrated satisfactory kidney bilateral contrast excretion and the patient reported no existence of right flank pain. CONCLUSIONS Conclusively, the main applications of mini laparoscopy in urology are to ureteral pathologies – mainly typical UPJ obstructions. To our knowledge, this was the first description of treatment of retrocaval ureter. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e909-e910 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anibal W. Branco More articles by this author Luciano C. Stunitz More articles by this author Sandro Nichele More articles by this author Julio C. Foiatto More articles by this author Juliano D. Scheffer More articles by this author Marcio Gatti More articles by this author Kleber Stelmasuk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V11-11 TRANS-UMBILICAL LAPAROENDOSCOPIC SINGLE-SITE EXCISION OF URACHAL REMNANT WITH PERITONEAL REPAIR

entire laparoscopic procedure. The operative time was 80 minutes, the blood loss 50ml and no external drain was used; the patient was discharged in the first post operative. The Folley catheter was removed in the second p.o. and the double J stent after six weeks. After 3 months, both ureters demonstrated satisfactory kidney bilateral contrast excretion and the patient reported no existence of right flank pain. CONCLUSIONS: Conclusively, the main applications of mini laparoscopy in urology are to ureteral pathologies e mainly typical UPJ obstructions. To our knowledge, this was the first description of treatment of retrocaval ureter.

MP30-14 UPPER POLE UROLOGIST-OBTAINTED PERCUTANEOUS RENAL ACCESS FOR PCNL IS SAFE AND EFFICACIOUS

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2015MP30-14 UPPER POLE UROLOGIST-OBTAINTED PERCUTANEOUS RENAL ACCESS FOR PCNL IS SAFE AND EFFICACIOUS Amar Patel, Don Bui, John Pattaras, and Kenneth Ogan Amar PatelAmar Patel More articles by this author , Don BuiDon Bui More articles by this author , John PattarasJohn Pattaras More articles by this author , and Kenneth OganKenneth Ogan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Interventional radiologist may be hesitant to obtain upper pole access for percutaneous nephrolithotomy (PCNL) due to a higher complication rate. Renal access gained by a urologist may achieve higher stone-free rates with similar complication rates. We discuss our institution's contemporary results of percutaneous renal access in the upper pole for nephrolithotomy by a urologist. We believe that urologist-obtained upper pole access for PCNL is both safe and efficacious. METHODS We performed a retrospective chart review of PCNL performed by a fellowship-trained endourlogist from 2003 to 2014 at a single institution. The inclusion criteria included patients in which renal access was obtained by the urologist via the upper pole for subsequent nephrolithotomy. Variables analyzed include age, gender, BMI, ASA, operative time, rib level, initial stone size, change in hemoglobin (hgb), length of stay (LOS), and post-operative complications. Stone-free status was determined by either KUB or CT scan on post-operative day (POD) #1. Patients without stones visible on KUB or stones less than 4 mm on CT were considered stone-free. RESULTS A total of 144 renal units were percutaneously accessed via the upper pole for subsequent nephrolithotomy. Baseline demographics included, mean age of 52.7 years, 51 males, 93 females, mean BMI of 29.7, median ASA of 3, mean Hgb change on POD #1 of 1.8 g/dL, and a mean hospital stay of 2.5 days. There were a total of 53 (36.8%) stones classified as a staghorn calculi, or which 35 (24.3%) were partial staghorn stones. Renal access was obtained above 11th rib in 12.5% (n=18), above 12th rib in 57.6% (n=83), subcostal in 14.6% (n=21) and undetermined in the rest. Complications were seen in 18 (12.5%) of patients. Hydropneumothorax requiring chest tube was seen in 8 (4.9%) of patients. Postoperative imaging confirmed 93 (64.6%) patients stone-free, and 35 (24.3%) required a second look PCNL. CONCLUSIONS Our experience with upper pole percutaneous renal access for nephrolithotomy has shown that it has an acceptable complication risk. There is an increased chance of thoracic complications but this can be mitigated with technical maneuvers. It should be a part of an endourologist armamentarium who operate on large burden, complex stones or ureteral pathology. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e352 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amar Patel More articles by this author Don Bui More articles by this author John Pattaras More articles by this author Kenneth Ogan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Treatment of tuberculous ureteritis. What is the appropriate time for invasive treatment? A case report and review of literature.

We report a case of isolated distal ureter tuberculosis who presented with irritative voiding symptoms treated with sole medical therapy and discuss the clinical, imaging, diagnostic and therapeutical features. In case of irritative voiding symptoms and radiological presentation of ureteral pathologies, genitourinary tuberculosis should be considered in the differential diagnosis. We believe that medical therapy should be the main option before the invasive procedures.

Use of Indocyanine Green During Robot-assisted Ureteral Reconstructions

BackgroundAlthough there are reports of robot-assisted ureteral reconstructions (RURs) with excellent safety and efficacy, the procedures remain technically challenging. In the robotic setting the surgeon must rely on visual cues in the absence of tactile feedback. Indocyanine green (ICG) is a dye that can be visualized under near-infrared fluorescence (NIRF). ObjectiveTo describe our novel technique, which utilizes intraureteral injection of ICG and subsequent visualization under NIRF to facilitate RUR, and report our outcomes after these procedures. Design, setting, and participantsThis is a retrospective review of 25 patients who underwent 26 RURs for various ureteral pathologies between June 2012 and October 2013. Surgical procedureAfter full disclosure, all patients consented to off-label use of ICG. A ureteral catheter and/or percutaneous nephrostomy tube were used to inject 10ml of ICG into the diseased ureter, above and below the stricture. Intraoperatively, NIRF was activated to assist in identification of the ureter and to localize the margins of ureteral strictures. MeasurementsPostoperatively, RURs were assessed for clinical success (absence of symptoms attributable to ureteral pathology) and radiological success (absence of a ureteral stricture on imaging). Results and limitationsOur technique provided visual cues and aided in successful performance of 26 RURs in 25 patients. The procedures included ureterolysis (n=4), pyeloplasty (n=8), ureteroureterostomy (n=9), and ureteroneocystostomy (n=5). There were no perioperative complications attributable to ICG use. At a mean overall follow-up of 12 mo, all procedures were clinically and radiologically successful. This study is limited by the small sample size and short-term follow-up. ConclusionsIntraureteral injection of ICG and subsequent visualization under NIRF facilitates RUR by aiding in rapid and accurate identification of the ureter, and precise localization of the proximal and distal ureteral stricture margins. In our experience, our technique is safe, easy to perform, and reproducible. Patient summaryIn this report, we describe a new technique to facilitate robot-assisted ureteral reconstructions using intraureteral injection of ICG and subsequent visualization under near-infrared fluorescence. More specifically, our technique allows for rapid and accurate identification of the ureter, and precise localization of ureteral strictures.

Management of iatrogenic ureteral injury.

Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic, colorectal, and vascular pelvic surgery. There is also potential for considerable ureteral injury during endoscopic procedures for ureteric pathology such as tumor or lithiasis. While maneuvers such as perioperative stenting have been touted as a means to avoid ureteral injury, these techniques have not been adopted universally, and the available literature does not make a case for their routine use. Distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesico-psoas hitch. Mid-ureteral and proximal ureteral injuries can potentially be managed with ureteroureterostomy. If the distal segment is unsuitable for anastomosis then a number of techniques are available for repair including a Boari tubularized bladder flap, transureteroureterostomy, or renal autotransplantation. In rare cases renal autotransplantation or ureteral substitution with gastrointestinal segments may be warranted to re-establish urinary tract continuity. Laparoscopic and minimally invasive techniques have been employed to remedy iatrogenic ureteral injuries.

Single Surgeon Experience with Robot-Assisted Ureteroureterostomy for Pathologies at the Proximal, Middle, and Distal Ureter in Adults

To describe our initial experience with robot-assisted ureteroureterostomy (RUU) at the proximal, middle, and distal ureter. Twelve consecutive patients underwent RUU by a single surgeon (D.D.E.) between July 2009 and November 2012. Indications included three iatrogenic injuries, two impacted stones, two ureterovaginal fistulas, two idiopathic ureteral strictures refractory to conservative treatment, one primary transitional cell carcinoma of the ureter, one colon cancer metastasis to the ureter, and one invasive endometriosis. There were two proximal, three middle, and seven distal ureteral pathologies. Tension-free anastomosis was achieved in all 12 patients. All patients with proximal and middle ureteral pathology received concomitant downward nephropexy (DN) as a standard part of RUU. Mean age of patients at the time of surgery was 52 years (range 30-69), mean body mass index was 30.0 kg/m(2) (range 21-38), mean operative room time was 190 minutes (range 104-354), mean estimated blood loss was 181 mL (range 50-400), and mean length of excised ureter on pathologic analysis was 2.0 cm (range 1.0-4.5). There was one intraoperative complication in which liver and gallbladder laceration occurred during trocar placement. Mean length of hospital stay was 1.4 days (range 1-5), and there were no postoperative complications. Mean follow up was 10 months (range 3-36). One patient had a ureteral stricture recurrence at 7 months postoperatively that led to renal unit loss and eventual nephrectomy. RUU is feasible, safe, and demonstrates good outcomes for pathologies at the proximal, middle, and distal ureter. Concomitant DN during RUU may assist in achieving a tension-free anastomosis for proximal and middle ureteral repairs.

863 NOVEL USE OF INDOCYANINE GREEN FOR INTRAOPERATIVE, REAL-TIME LOCALIZATION OF URETERAL STENOSIS DURING ROBOT-ASSISTED URETEROURETEROSTOMY

You have accessJournal of UrologyTechnology & Instruments: Robotics: Benign & Malignant Disease (I)1 Apr 2013863 NOVEL USE OF INDOCYANINE GREEN FOR INTRAOPERATIVE, REAL-TIME LOCALIZATION OF URETERAL STENOSIS DURING ROBOT-ASSISTED URETEROURETEROSTOMY Ziho Lee, Christopher Reilly, Elton Llukani, David Lee, and Daniel Eun Ziho LeeZiho Lee Philadelphia, PA More articles by this author , Christopher ReillyChristopher Reilly Philadelphia, PA More articles by this author , Elton LlukaniElton Llukani Philadelphia, PA More articles by this author , David LeeDavid Lee Philadelphia, PA More articles by this author , and Daniel EunDaniel Eun Philadelphia, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.431AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Localization of ureteral stenosis during robot-assisted ureteroureterostomy (RAUU) relies largely on visual cues. This may be particularly difficult in the presence of inflammation or fibrosis, which often accompanies the underlying ureteral pathology and obliterates normal dissection planes. Enhancing the ability to visually distinguish healthy versus scarred ureter during RAUU may assist in ureteral dissection and attaining a tension-free anastomosis. Indocyanine green (ICG), a fluorescent dye, is theoretically well suited for this purpose due to its ability to penetrate tissue. ICG has a high signal to noise ratio when viewed under near infrared (NIR) light, a modality available in the da Vinci Si® (Intuitive Surgical, Sunnyvale, CA). We present a novel method to intraoperatively localize ureteral stenosis via ICG injection. METHODS Six patients underwent RAUU for ureteral stricture (2 proximal, 2 middle, and 2 distal) by a single surgeon (DDE) between June and November 2012. Localization of ureteral stenosis was determined by preoperative retrograde pyelography followed by intraoperative instillation of ICG (25 mg in 10 ml distilled water) above and below the level of stenosis through a ureteral catheter or percutaneous nephrostomy tube. Occlusion of the ureteral catheter or nephrostomy tube minimized ICG drainage. Patients were subsequently positioned for robotic ureteral repair in supine lithotomy or flank position depending on the area of ureteral stenosis. The fluorescent tracer was detected as a green color via the NIR modality on the da Vinci Si®. All patients consented to off-label use of ICG after full disclosure. RESULTS Intraoperative ICG injection and visualization under NIR light allowed for definitive identification of healthy ureter which fluoresced green and devitalized ureter which remained un-fluoresced. A spatulated and tension free anastomosis was successful in all 6 RAUU. Mean age of patients was 58 years (range 39-69), mean BMI was 30 kg/m2 (range 22-38), mean operative time was 177 min (range 104-270), and mean EBL was 170 ml (range 50-400). There were no adverse effects attributable to ICG administration. Mean length of stay was 1.7 days (range 1-5), with no postoperative complications. Mean follow up was 1.25 months (range 0.5-3), and all cases were clinically and radiographically successful at the last follow up examination. Follow up in all patients is ongoing. CONCLUSIONS Intraoperative precise localization of ureteral stenosis is safe and feasible through intraureteral ICG injection. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e356 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ziho Lee Philadelphia, PA More articles by this author Christopher Reilly Philadelphia, PA More articles by this author Elton Llukani Philadelphia, PA More articles by this author David Lee Philadelphia, PA More articles by this author Daniel Eun Philadelphia, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Single-Surgeon Experience With Robot-Assisted Ureteroneocystostomy for Distal Ureteral Pathologies in Adults

PurposeTo demonstrate our technical approach for robot-assisted ureteroneocystostomy (R-UNC) for benign and malignant distal ureteral pathologies.Materials and MethodsBetween January 2009 and January 2013, a total of 10 patients underwent R-UNC in the distal ureter by a single surgeon. Indications for R-UNC were as follows: idiopathic (3), fistula (2), iatrogenic (2), malignancy (2), and chronic vesicoureteral reflux (1).ResultsTension-free anastomosis was attained in all 10 R-UNC procedures. A psoas hitch was performed in 6/10 cases (60%). Intravesical and extravesical reimplantations were completed in 5/10 (50%) and 5/10 cases (50%), respectively. A nonrefluxing ureter was constructed in 2/10 cases (20%). The patients' mean age was 52.9±16.6 years, their mean body mass index was 30.8±6.3 kg/m2, the mean operative time was 211.7±69.3 minutes, mean estimated blood loss was 102.5±110.8 mL, and mean length of stay was 2.8±2.3 days. There were no intraoperative complications. There was one Clavien-Dindo grade I and one Clavien-Dindo grade II postoperative complication. The mean postoperative follow-up duration was 28.5±15.5 months. Two patients had recurrence of ureteral strictures at 3 months postoperatively and were managed successfully with balloon dilation.ConclusionsOur technique for R-UNC demonstrates good perioperative outcomes. However, underlying periureteral inflammation and pelvic adhesions may predispose patients for stricture recurrence after R-UNC.

Robot-Assisted Ureteroneocystostomy: Technique and Comparative Outcomes

Ureteroneocystostomy can be used for the treatment of patients with a wide variety of ureteral pathology. Over the last decade, robot-assisted surgery has become more commonly used as a minimally invasive approach for reconstructive upper urinary tract procedures. The aim of this study is to present our experience with robot-assisted ureteroneocystosctomy (RUNC) with a comparison with that of open ureteroneocystostomy (OUNC). Medical records of 25 patients who underwent RUNC and 41 patients who underwent OUNC or at our institution between 2000 and 2010 were retrospectively analyzed. Perioperative and postoperative data including demographics, surgical outcomes, and clinical and radiographic findings at postoperative follow-up were considered in the comparative analysis. Descriptive statistics were used to present the data. The significance of the difference between variables was evaluated using the Wilcoxon rank sum test for continuous and Fisher exact test for categorical variables. No significant differences were detected in terms of baseline patient characteristics between the two groups. The OUNC procedures were performed with a shorter median operative time (200 vs 279 min., P=0.0008), whereas RUNC patients had a shorter hospital stay (median 3 vs 5 days, P=0.0004), less narcotic pain requirement (morphine equivalent, mg 104.6 vs 290, P=0.0001), and less estimated blood loss (100 vs 150 mL, P=<0.0002). There as no significant difference in the rate of reoperation between groups: RUNC 2/25 (7.6 %) vs OUNC 4/41 (9.7%) P=0.8. Limitations include the retrospective nature of the study and the difference in indications for surgery. RUNC provides excellent outcomes with shorter hospital stay, less narcotic pain requirement, and decreased blood loss when compared with the open procedure. Advantages of the robotic platform for dissection and suturing can be useful for complex minimally invasive urologic reconstructive procedures.

Pediatric Standard and Robot-Assisted Laparoscopic Pyeloplasty: A Comparative Single Institution Study

We report our experience and compare the outcomes between standard and robot-assisted laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in children. A retrospective cohort study was performed of all children who underwent standard or robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction at a single institution from October 2007 to January 2012. Indications for surgery included symptomatic obstruction and abnormal diuretic renal scan. A successful outcome was defined as resolution of clinical symptoms, improvement of hydronephrosis on ultrasound, stable ultrasound with resolution of symptoms or improvement of the drainage curve on diuretic renal scan. We reviewed 18 patients (median age 8.1 years) who underwent standard and 46 (8.8 years) who underwent robot-assisted laparoscopic pyeloplasty (p = 0.194). Median operative time was 298 minutes (range 145 to 387) for standard and 209 minutes (106 to 540) for robot-assisted laparoscopic pyeloplasty (p = 0.008). Mean hospitalization was similar between the groups (1 day for standard vs 2 days for robot-assisted laparoscopic pyeloplasty, p = 0.246). Narcotic use was similar between the groups. Median followup was 43 months for standard and 22 months for robot-assisted laparoscopic pyeloplasty (p <0.01). Renal ultrasound showed postoperative improvement of hydronephrosis in 85% and stable disease in 15% of patients following robot-assisted laparoscopic pyeloplasty, and improvement in 89.5% and stable disease in 10.5% after standard laparoscopic pyeloplasty. Symptoms resolved in 100% of patients (38 of 38) after robot-assisted laparoscopic pyeloplasty and 87.5% of patients (7 of 8) after standard laparoscopic pyeloplasty. Robot-assisted laparoscopic pyeloplasty and standard laparoscopic pyeloplasty are effective techniques to correct ureteropelvic junction obstruction, with similar outcomes. Robot-assisted laparoscopic pyeloplasty had a shorter operative time, and its success and complication rates are comparable to standard laparoscopic pyeloplasty.

Letter to the editor Distal blind-ending branch of a bifid ureter

Ureteral duplication is a common congenital anomaly of the urinary system observed in 0.8% of autopsy series [1]. However, bifid ureter with a blind branch is a rare condition. It is three times more prevalent in women than men and is observed twice as often on the right side as on the left side [2]. It does not generally give any clinical symptoms. However, in the literature, symptomatic cases with haematuria, flank pain, urinary infection, stone, vesicoureteral reflux and abdominal mass have been reported [3, 4]. We report a case on which ureteroscopy was performed to the right ureteral duplication with a blind-ending branch and left distal-end ureteral stone. A 40-year-old woman was admitted to our clinic with acute left renal colic, dysuria and frequency micturition. She had no previous history of urinary tract symptoms. Laboratory tests showed normal renal function. Urine analysis and culture showed haematuria without infection. In the direct urinary system graphy (DUSG) and ultrasonography (US) a left distal ureteral stone was detected; hence excretory urography (EU) was also performed on the patient. The EU showed a distal ureteral stone on the left side and two radio-opaque shadows in the region of the distal right ureter (Figures 1, ​,2).2). Surgery for the ureter stone and diagnostic ureteroscopy (DU) on the ureter with anomaly were planned to be performed in the same session. Ureteroscopic stone removal was performed on the left sided distal ureteral stone. In same session, DU was performed and distal blind-ending branch of bifid ureter 7 cm long was confirmed at the position 5 cm from the beginning of the ureterovesical junction (Figure 3). Figure 1 A schematic drawing of the blind-ending ureter Figure 2 Right duplicated system with bifid blind-ending ureter on excretory urography Figure 3 Normal and blind-ending ureter lumen orifice on diagnostic ureteroscopy No pathology was determined in the lumen of the blind-ending branch. The images were recorded on DU. The patient was discharged from the hospital the day following the operation. Since no complication related to ureter anomaly developed in the post-operative follow-up, blind-ending ureter was not intervened. Blind-ending bifid ureter is a rare congenital anomaly of the ureter which has three sub-types according to the localization. These are proximal, distal, and middle according to their frequencies [2]. Our case was a distal blind-ending ureter, which is less frequent than the proximal and more frequent than the middle blind-ending bifid ureter. Many blind-ending ureters are clinically insignificant and do not give any symptoms because of this. Patients who develop symptoms generally have complaints about abdominal pain, dysuria, frequency micturition, and haematuria. These complaints might depend on stone formation, vesicoureteric reflux or ureteral tumour [3–6]. Our patient did not have any symptoms or complications related to blind-ending bifid ureter. It was detected incidentally during the EU performed because of her complaints regarding the other ureter with stone. Conventional approaches such as EU and retrograde ureterography in diagnosis of ureteral anomalies can be sufficient [2]. Our patient was easily diagnosed since she had a ureteroureteral reflux (yo-yo ureteric peristalsis) between the normal ureter and blind-ending branch detected in EU. Voiding cystouretrography may help diagnosis in patients with vesicoureteric reflux [5]. Multidetector computed tomography (CT) imaging urography [5, 7] and magnetic resonance urography can be useful for diagnosis as alternative new advanced imaging methods [8]. However, these methods, being expensive, and multidetector CT having ionizing radiation, are disadvantageous. Another method for diagnosis of blind-ending bifid ureter may be ureteroscopy. This method is expensive and invasive but could be used in patients with planned surgery or in the presence of haematuria for the confirmation of diagnosis and evaluation of ureter lumen. We applied ureteroscopy in order to exclude other ureteral pathologies, and confirm the diagnosis. We recommend that the use of ureteroscopy is beneficial for such patients. Treatment of symptomatic patients must be planned according to the complication. In our patient, as there was no complication following the treatment of the stone in the normal ureter, no surgery was performed on the ureter with the anomaly and the patient was placed in follow-up. In conclusion, blind-ending bifid ureter is a rare entity, and unexpected complications during the surgery can be prevented if its probability is kept in mind, and it is visualized by diagnostic imaging methods and DU.

Surgeon-controlled robotic ureteral surgery

Surgeon-controlled, robotic-assisted, ureteral reconstructive and ablative surgery is being performed routinely for both benign and malignant pathology at centers possessing this technology in their armamentarium. The aim of this review is to detail the options for surgeon-controlled robotic management of ureteral pathology and evaluate the developments in the last 2 years. Surgeon-controlled robotic management of ureteric pathology involving all parts of the ureter with varying cause has been reported. Proximally, ureteral strictures and symptomatic retrocaval ureters have been repaired with long-term follow-up demonstrating resolution of obstruction. Ureterolysis and other mid-ureteral pathology have been treated with durable function results. Transitional cell carcinoma of the renal pelvis or distal ureter has been extirpated with successful oncologic outcomes. Reimplantation of refluxing ureters in children has been demonstrated to provide similar results of open surgery. Surgeon-controlled, robotic-assisted ureteral surgery is well tolerated, feasible, and effective for ablative and reconstructive indications with minimal complications. Knowledge of anatomy, pathology, experience of surgical team, and appropriate preoperative patient selection augmented with proper port placement to provide excellent exposure is critical to provide optimal outcomes.