Ureteral Reflux Research Articles

Long-term complications and outcomes of augmentation cystoplasty in children with neurogenic bladder

Augmentation cystoplasty (AC) is an effective surgical procedure for patients with neurogenic bladder whenever conservative treatments have failed. The present study aimed to determine the risks of metabolic complications, malignancy, long-term outcomes and histopathologic changes of native bladder and the augmented intestine after AC in children with neurogenic bladder. Pediatric patients < 18 years who underwent AC between 2000 and 2020 were enrolled. Early postoperative complications, long-term outcomes and histopathologic changes in mucosal biopsies of native bladder and the augmented intestine after AC were reviewed. Twenty-two patients with a mean age of 7.6 ± 4.4 years were included. The ileum was used in 19 patients and the sigmoid colon in 3 patients. The length of hospital stay was 14.8 ± 6.8 days. Post-operatively, the urinary continence rate improved from 22.7 to 81.8% (p < 0.001). Hydronephrosis resolved in 17 of 19 patients. Vesicoureteral reflux resolved in 16 (64.0%) of the refluxing ureter units and was downgraded in 7 (28.0%). Grades of hydronephrosis and reflux significantly improved following AC (p < 0.001). The estimated glomerular filtration rate also significantly increased (p = 0.012). Formation of urinary tract stones was the most frequent late complication (in 8 patients, 36.4%). Life-threatening spontaneous bladder perforation occurred in 1 patient. After a mean follow-up of 13.4 ± 5.9 years, there were no cases of mortality, new-onset symptomatic metabolic acidosis, or changes in serum electrolytes. Of the 17 patients who were followed for > 10 years, no cases of malignancy or metaplastic changes were identified in the native bladder or augmented bowel epithelium. AC is a safe and effective procedure with low surgical and metabolic complication rates. In addition, AC provides a satisfactory continence rate and long-term protection of renal function, increases functional capacity, and regresses reflux and hydronephrosis. Individualized surveillance is recommended for the early identification of urolithiasis and metabolic disturbances.

Xanthogranulomatous cystitis and bilateral ureteral reflux due to bladder neck obstruction: a case report

Xanthogranulomatous cystitis (XC) is a rare benign disease of chronic granulomatous inflammation. We report a 23-year-old woman with xanthogranulomatous cystitis. She was referred to our hospital with the chief complaint of a 1-year history of frequent, urgent dysuria with recurrent fever. An imaging examination showed bilateral ureteral reflux and a normal bladder. Urodynamic findings suggested bladder outlet obstruction and increased post-void residual urine. Finally, the patient underwent endoscopy, and bladder neck obstruction was confirmed. Additionally, we found multiple granulomatous masses in the bladder. Therefore, we performed transurethral resection of the tumor and bladder neck. A histopathological examination of resected tumor tissue showed xanthogranulomatous cystitis, and the patient received anti-infective therapy. Follow-up cystourethroscopic results and urination symptoms returned to normal, and the bilateral ureteral reflux was gradually reduced.

Lower urinary tract dysfunction in cases of anorectal malformations

Association of genitourinary anomalies in patients with ano-rectal malformations (ARM) is well known and its incidence is reported to be 30 -50%. Many of these anomalies either have less number of functioning renal units or have conditions with risk of continuous damage to renal units, increasing the risk of developing End stage renal disease (ESRD) in adolescence or adulthood. Although frequently described as associated malformations but few of these entities like Vesico ureteric reflux (VUR) could be the result of lower urinary tract dysfunctions.: To study incidence and spectrum of Lower urinary tract dysfunction in toilet trained patients of ARM. To find whether LUTD is the cause of worsening of VUR/HUN/ renal functions in patients with ARM. 2 years (October 2018 to 30 September 2020): Department of Paediatric surgery, Chacha Nehru Bal Chikitsalaya, Geeta Colony Delhi Prospective observational study. : Forty-two patients of ARM, meeting all inclusion criteria were enrolled in the study. All the following criteria were checked for enrolment of patient in the study. 1. Patients of all categories of anorectal malformations who were toilet trained; 2. Age more than 4 years; 3. Completed set of investigations planned for diagnosis of LUTD. 4. Consented to participate in the study and for follow up as and when required.Central cause of neurological deficits.A total of 125 patients who underwent PSARP during our study period. However only 42 patients met the inclusion criteria and got their work up completed for urological problems. 1.LUTD and renal failure can be seen even in absence of spinal malformations in patients with ARM; 2. Severity of LUTD in absence of neurological involvement changes with time; 3. Thorough history and clinical evaluation may provide important clues in suspecting presence of occult LUTD.

Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux

Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury. This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR. Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated. Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143min for unilateral VUR and 194min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases. Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view. Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

Urological Management of the Spinal Cord-Injured Patient: Suggestions for Improving Intermittent Catheterization and Reflex Voiding

Spinal cord injury can either be complete with no neural communication across the injury level or incomplete with limited communication. Similarly, motor neuron injuries above the sacral spinal cord are classified as upper motor neuron injuries, while those inside the sacral cord are classified as lower motor neuron injuries. Specifically, we provide recommendations regarding the urological management of complete upper motor neuron spinal cord injuries; however, we also make limited comments related to other injuries. The individual with a complete upper motor neuron injury may encounter five lower urinary tract conditions: first, neurogenic detrusor overactivity causing urinary incontinence; second, neurogenic detrusor underactivity resulting in high post-void residual volumes; third, detrusor sphincter dyssynergia, which is contraction of striated and/or smooth muscle urethral sphincters during detrusor contractions; fourth, urinary tract infection; and fifth, autonomic dysreflexia during detrusor contractions, which produces high blood pressure as well as smooth muscle detrusor sphincter dyssynergia. Intermittent catheterization is the recommended urinary management method because it addresses the five lower urinary tract conditions and has good long-term outcomes. This method uses periodic catheterizations to drain the bladder, but also needs bladder inhibitory interventions to prevent urinary incontinence between catheterizations. Primary limitations associated with this management method include difficulties with the multiple catheterizations, side effects of bladder inhibitory medications, and urinary tract infections. Three suggestions to address these concerns include the use of low-friction catheters, wireless, genital-nerve neuromodulation for bladder inhibition, and consideration of urine egress into the urethra as a risk factor for UTI as well as egress treatment. The second management method is reflex voiding. This program uses external condoms for urine collection in males and diapers for females. Suprapubic tapping is used to promote bladder contractions. This method is not recommended because it has high rates of medical complications. In particular, it is associated with high detrusor pressure, which can lead to ureteral reflux and kidney pathology. Botulinum toxin injection into the urethral striated sphincter can manage detrusor sphincter dyssynergia, reduce voiding pressures, and risks to the kidney. We suggest a modified method for botulinum toxin injections as well as five additional methods to improve reflex voiding outcomes. Finally, the use of intermittent catheterization and reflex voiding for individuals with incomplete spinal injuries, lower motor neuron injuries and multiple scleroses are briefly discussed.

345.2: Pregnancies Fathered by Transplant Recipients

The purpose of this study was to analyze 1408 pregnancy outcomes fathered by 875 male solid organ transplant recipients including exposure to mycophenolic acid products (MPA) and sirolimus. Data were collected by the Transplant Pregnancy Registry International (TPRI) via telephone interviews, online questionnaires, and review of medical records. Overall pregnancy outcomes fathered by transplant recipients are similar to the general US population (Table). TPRI Fathered Pregnancies Of the total fathered pregnancy experience, there were 333 outcomes with exposure to MPA. Outcomes included 297 (89%) live births, 33 (9.9%) miscarriages, 2 stillbirths and 1 ectopic pregnancy. Among the live births there were 11 birth defects reported (3.7%) and included: undescended testicle (n=2), tongue tied, pyloric stenosis, club foot, ureteral reflux, ventricular septal defect, Klinefelter’s syndrome, Prader-Willi syndrome, Down’s syndrome, and diaphragmatic hernia (neonatal death). Although male fertility has been reported to be decreased in males maintained on sirolimus, there are 29 fathered pregnancies resulting in 28 livebirths with 1 birth defect (ureteral stricture) and 1 miscarriage with exposure to sirolimus. Conclusions: The outcomes of pregnancies fathered by male transplant recipients are comparable to the general population and there is no evidence that male recipients need to avoid MPA when considering fathering a pregnancy. Data regarding sirolimus remains limited, however, to date increased risks for pregnancies fathered while taking sirolimus have not appeared. All transplant centers should encourage their recipients to participate in the TPRI. - Organ(s) Recipients Pregnancies/Outcomes* MPA exposure Live births (%) Mean gestational age (weeks) Mean birthweight (g) Birth Defects (%) Kidney 632 997/ 1019 21% 92% 39 ± 2.3 3357 ± 596 3.5% Heart 121 181/ 188 23% 89% 38.7 ± 2.4 3351 ± 659 3.6% Liver 87 148/ 155 22% 87% 39 ± 1.9 3318 ± 606 3.8% Kidney-Pancreas 35 44/ 46 40% 91% 38.7 ± 2.4 3321 ± 589 2.4% General Population 39 3389 4-6% *includes twins, triplets

Outcomes of seromuscular bladder augmentation compared with standard bladder augmentation in the treatment of children with neurogenic bladder.

BACKGROUNDIntestinal seromuscular bladder augmentation (SMBA) surgery has produced no mucosal-related complications, but its outcomes need to be studied.AIMTo evaluate the safety and effectiveness of SMBA in the treatment of children with neurogenic bladder.METHODSA retrospective analysis of the clinical data of children with SMBA was performed from March 2008 to February 2018, and the data were compared with those of children receiving standard cystoplasty (SC).RESULTSIn a cohort of 67 children who underwent bladder augmentation, the 46 children in the SC group had an average age of 10.6 years and a follow-up time of 36 mo, and the 21 children in the SMBA group had an average age of 7.6 years and a follow-up time of 29.7 mo. The preoperative and postoperative bladder volumes in the SMBA group were 151.7 mL and 200.4 mL, respectively, and those in the SC group were 173.9 mL and 387.0 mL, respectively. No significant difference in preoperative urinary dynamic parameters was found between the two groups, but the difference after operation was statistically significant. The main complications after SMBA were residual ureteral reflux and failed bladder augmentation, with incidences of 33.3% and 28.6%, respectively. In all 6 patients with failed augmentation in the SMBA group, ileum seromuscular patches were used for augmentation, and SC was chosen for reaugmentation. During reoperation, patch contracture and fibrosis were observed.CONCLUSIONThe improvement of urinary dynamic parameters in the SMBA group was significantly lower than that in the SC group. Children with SMBA had a higher probability of patch contracture and reaugmentation, which might be related to impaired blood supply and urine stimulation, and the sigmoid colon patch should be the priority.

Laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures: our experience.

This study was designed to evaluate the feasibility of laparoscopic ureteral reimplantation with a Boari flap for long-segment ureteric avulsion or ureteric strictures of the middle and lower ureters. By observing its curative effect and prognosis, we can provide a safer and reliable treatment option for patients with middle and lower ureteral injury. In this study, of the eight cases under study, five were diagnosed with long-segment ureteric strictures, one had long-segment ureteric avulsion, one was diagnosed with ureteral rupture caused by surgical injury of appendicitis, and the remaining one underwent ureterostomy after ureteralinjury. The location of ureteral injury was in the middle lower segment. All eight patients underwent laparoscopic ureteral reimplantation with a Boari flap from January 2018 to October 2021. In this study, two patients were treated with a Boari bladder flap with psoas hitching. All procedures were performed by the same surgeon with over 20years of experience in urological surgery. The mean length of ureteric avulsion or ureteric strictures was 7.94cm (range, 4-15cm). Laparoscopic ureteral reimplantation with a Boari flap was performed successfully between 120 and 240min. The mean duration of postoperative hospital stay was 6days, and no major complications related to the procedure in the perioperative period occurred. Postoperative follow-up showed no obvious hydronephrosis on computed tomography urography or urinary ultrasound in all eight patients. Postoperative reexamination did not reveal any significant hydronephrosis, urinary tract infection, or ureteral reflux, and none of the postoperative renal functions were abnormal. Laparoscopic ureteral reimplantation with a Boari flap is safe and feasible for experienced physicians. In our case, the length/width ratio of bladder flap is more than 4:1, with good blood supply and no obvious complications, it provides a longer alternative length.

V08-07 ROBOTIC PYELOPLASTY OF LOWER POLE MOIETY IN A 2 MONTH OLD INFANT WITH CUTANEOUS PYELOURETERAL (CPU) STENT

You have accessJournal of UrologyCME1 May 2022V08-07 ROBOTIC PYELOPLASTY OF LOWER POLE MOIETY IN A 2 MONTH OLD INFANT WITH CUTANEOUS PYELOURETERAL (CPU) STENTis corrected byV08-07 Robotic Pyeloplasty of Lower Pole Moiety in a 2 Month Old Infant With Cutaneous Pyeloureteral (CPU) Stent. Erratum Amrita Mohanty, Clark Judge, Anastasia Gliatis, Tony Da Lomba, and Mohan Gundeti Amrita MohantyAmrita Mohanty More articles by this author , Clark JudgeClark Judge More articles by this author , Anastasia GliatisAnastasia Gliatis More articles by this author , Tony Da LombaTony Da Lomba More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002606.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted laparoscopic pyeloplasty has been demonstrated to be safe and effective in infants. Here we demonstrate the steps to a left robotic pyeloplasty of a ureteropelvic junction obstruction in the lower pole moiety in a 2 month old with a duplicated left collecting system using a CPU stent. METHODS: Prenatal detection of left hydronephrosis and postnatal imaging confirmed grade 4 left hydronephrosis. Renal scan demonstrated significant obstruction of the left kidney, preserved renal function on the left (45%), and a possible duplex system on the left. Voiding cystourethrogram showed no ureteral reflux. The patient had not had any UTIs and was on antibiotic prophylaxis. After discussion with the patient’s parents, they elected to undergo a robotic left pyeloplasty to protect the patient’s renal function. RESULTS: The patient was found to have a duplicated system on the left with a high grade stenosis of the lower pole ureteropelvic junction and a dilated lower pole renal pelvis. The procedure was able to be completed in the standard fashion after the two ureters were dissected apart. The patient recovered well and was discharged on post op day 1. CPU stent was removed on post op day 12. He did suffer a superficial infection of the umbilical surgical site that resolved with antibiotics. At 6 weeks post-op, the patient was doing well and renal ultrasound showed a decompressed, but still hydronephrotic, left kidney. CONCLUSIONS: This video demonstrates that a robotic-assisted laparoscopic pyeloplasty with the use of a CPU stent can safely and effectively be performed in infants, even with duplicated systems. The CPU stent allows for stent removal in the office, avoiding a second round of anesthesia for the patient. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyMay 4, 2022, 12:00:00 AMV08-07 Robotic Pyeloplasty of Lower Pole Moiety in a 2 Month Old Infant With Cutaneous Pyeloureteral (CPU) Stent. Erratum Volume 207Issue Supplement 5May 2022Page: e715 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amrita Mohanty More articles by this author Clark Judge More articles by this author Anastasia Gliatis More articles by this author Tony Da Lomba More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abstract 157: Early onset VUR: A rare feature of Wolfram syndrome

Wolfram syndrome (WS), an autosomal recessive disorder is a form of monogenic diabetes that typically presents with insulin dependent diabetes mellitus in childhood and optic atrophy by the age of 16. Most with WS eventually develop diabetes insipidus and deafness, hence the acronym, DIDMOAD (Diabetes Insipidus (DI), Diabetes Mellitus (DM), Optic Atrophy (OA), and Deafness). Other Urological disorders (UD) & Neurological disorders (ND) usually develop at the beginning of the second decade (5% probability at 12–13 years for UD and 14–15 years for ND) and less than 1% have UD in the first decade. We describe one such a rare case of WS with early-onset urological disorder. A 10 year girl was diagnosed with type 1 diabetes at the age of 4 years and managed with basal bolus Insulin therapy. At the age of 6 years she developed urinary retention. Her sonogram & urinary flow studies revealed bilateral hydrouretreonephrosis with reflux uropathy. She was diagnosed with Vesico ureteric reflux (VUR) with neurogenic bladder dysfunction, in which outflow obstruction is induced by detrusor/sphincter dyssynergia. Due to frequent bedwetting a foley's catherter was inserted and remained insitu until she presented to us. For an year, she had polydipsia & polyuria (intake/output of 5-6L/day) despite fairly controlled blood glucose level. Water deprivation test confirmed the diagnosis of Diabetes Insipidus (DI). She had blurring of vision for around 6 months and ophthalmological evaluation revealed optic atrophy with visual acuity of 6/60 in both eyes. She has mild senorineuronal hearing loss. Our rare case with an early-onset urological disorder satisfies the EURO-WABB criteria (2 major+1 minor) for diagnosis of Wolfram (DIDMOAD) Syndrome. The genetic confirmation results are awaited. She is currently being managed with insulin and desmopressin.

On‐table urodynamic with ureteric occlusion: A resource for measuring bladder capacity and compliance in the management of patients with gross vesico‐ureteric reflux

To describe a technique for on-table urodynamic with ureteric occlusion (OUUO) and present a case series comparing bladder capacity and pressure measurements performed with and without ureteric occlusion in patients with gross vesico-ureteric reflux (grade ≥ IV VUR) to highlight the clinical utility. We performed OUUO in seven patients who were being considered for surgical management of VUR and/or nephro-ureterectomy. We occluded the refluxing ureters using hysterosalpingogram catheters (HSG, single lumen 5.5 Fr catheter with 1.5 ml balloon), guidewires, and rigid cystoscope. A 6 Fr dual-lumen urodynamic (UD) catheter is then inserted into the bladder to perform OUUO. Bladder capacity and Compliance (C = ∆bladder volume/∆detrusor pressure) are recorded and compared with values obtained at standard UD (without ureteric occlusion). The age range of the seven patients was 2.0-15.5 years. The etiology for the gross VUR were posterior urethral valve (PUV) and neuropathic. The bladder capacity and compliance finding between UD and OUUO findings were comparable in five patients. However, there was a clinically significant difference in bladder capacity (20%-50% decrease) and compliance (50%-90%) between UD and OUUO findings in two out of seven patients. In the presence of gross VUR, OUUO allows for a potentially more accurate assessment of bladder capacity and compliance. OUUO should be considered when planning ureteric opening bulking/reimplantation and nephro-ureterectomy.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

MP53-09 INDIA INK TATTOOING OF URETEROENTERIC ANASTOMOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP53)1 Sep 2021MP53-09 INDIA INK TATTOOING OF URETEROENTERIC ANASTOMOSES Mei Tuong, and Tracey Krupski Mei TuongMei Tuong More articles by this author , and Tracey KrupskiTracey Krupski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002083.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Upper tract access is necessary to treat diseases in the ureter or kidney after urinary diversion. Access through the insensate conduit is more cost-effective versus percutaneous kidney access. However, endoscopic ureteroenteric anastomoses (UEA) identification can be difficult. We injected India Ink (ink) into bowel mucosa near UEA during ileal conduit diversion (IC) to determine the safety and feasibility of ink tattooing and ability to facilitate retrograde upper tract access. METHODS: After IRB approval, patients undergoing IC were prospectively randomized to receive ink or normal saline (NS) injections, a control group to assess safety of ink. Injections were placed 1 cm from UEA in a triangular configuration with a 19-gauge needle. Follow-up minimized cost and radiation exposure to assess patency and location of UEA. 1-month loopogram assessed for ureteral reflux (UR). If there was any absent UR, looposcopy was performed to assess for occult UEA stricture (UEAS). Ability to visualize UEA and/or ink tattooing was recorded at time of looposcopy. RESULTS: 42 renal units (21 patients) undergoing IC were randomized to ink (20 renal units) or NS (22 renal units). Overall median age was 65 (IQR 60, 73) years with ink patients being older (72 vs 61 years old, p=0.04). Ink patients also had a higher Charlson Comorbidity Index (5 vs 2, p=0.01). Loopogram and looposcopy protocol data are shown in Figure 1. 20 renal units had no UR on loopogram (12/16 ink vs 8/20 NS). Of patients who returned for looposcopy, 14 non-UR renal units were assessed (6/12 ink vs 8/8 NS). Visualization of UEA was achieved in 6 (100%) and 4 (50%) in ink versus NS patients, respectively (p=0.26). Follow up of the cohort revealed a higher than expected UEAS rate in the ink group (N=3, 30%) compared to NS (N=1, 9%). The ink vs NS cohorts underwent 6 vs 1 surgeries respectively for UEAS (p=0.28). 2 ink and 1 NS patients were managed with either endoscopic dilation, percutaneous nephrostomy tube, or ureteral stent. 1 ink patient required open reimplantation of UEA. CONCLUSIONS: Our pilot study demonstrates ink is well-visualized following injection near UEA during IC. However, the ink cohort had more UEAS than our prior rates of UEAS (6%) and in the literature. While this study sample is small, the higher development of UEAS after ink leads to question the utility and safety of ink injection following IC. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e942-e942 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mei Tuong More articles by this author Tracey Krupski More articles by this author Expand All Advertisement Loading ...

V13-01 EXTENDED URETERAL MEATOTOMY FOR OUTPATIENT CHEMOTHERAPY ADMINISTRATION AND URETEROSCOPY IN PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyBladder & Upper Tract Urothelial Oncology (V13)1 Sep 2021V13-01 EXTENDED URETERAL MEATOTOMY FOR OUTPATIENT CHEMOTHERAPY ADMINISTRATION AND URETEROSCOPY IN PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA Nikhil Gopal, Sameh Naim, Bertie Zhang, John Phillips, and Majid Eshghi Nikhil GopalNikhil Gopal More articles by this author , Sameh NaimSameh Naim More articles by this author , Bertie ZhangBertie Zhang More articles by this author , John PhillipsJohn Phillips More articles by this author , and Majid EshghiMajid Eshghi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002100.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with ureteral tumors managed endoscopically often benefit from adjuvant immuno-chemotherapy and require interval upper tract surveillance with ureteroscopy. However, both often require general anesthesia, which can be problematic for a predominantly elderly population with multiple co-morbidities. Here we describe an endoscopic technique of ureteral meatotomy to not only predictably allow for reflux of intravesical agents through the ureter, but also to allow upper tract endoscopy to be performed in the office setting. METHODS: From 2015-2021, we performed ureteral meatotomy on 10 patients. All patients who underwent this procedure had upper tract urothelial tumors deemed suitable for primary endoscopic management, based on patient’s clinical characteristics; tumor number; size; location; and/or biopsy grade.Under general anesthesia, a 10 F dual lumen ureteral catheter or 6-12 F Nottingham dilator was inserted into the distal ureter in order to allow for alignment of the ureter towards the bladder neck and to ensure the orifice is incised in the correct direction. Using either a Holmium laser or Collin’s knife, a full-thickness 2 cm incision was made on the distal intramural ureter at the 12 o’clock position, until the anterior portion of the catheter was visualized. Intraoperative cystogram was used to confirm ureteral reflux. A double J stent was then left in place for 3 weeks for mucosal healing and reshaping of the distal ureteral segment. Postoperatively, patients underwent 6 cycles of mitomycin, either via indwelling Foley catheter or nephrostomy tube. Lower and upper urinary tract surveillance was performed using flexible cystoscope and/or ureteroscope in the office every 3-6 months for the first two years and annually thereafter. RESULTS: 10 patients with average age of 77 years, 40% of whom were male, underwent ureteral meatotomy between 2015 and 2021. 90% of tumors were either in the distal ureter or UPJ/renal pelvis. Average tumor size was 1.6 cm. 70% of tumors were low grade on biopsy. 3 patients had concomitant bladder cancer. There were no complications associated with chemotherapy instillation. Of the patients who had only upper tract disease, none developed a new recurrence in the bladder. CONCLUSIONS: We describe a novel anterior intramural ureteral incision technique in patients with ureteral tumors managed endoscopically that reliably allows for both chemotherapy administration and upper tract surveillance in an office setting. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1078-e1078 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikhil Gopal More articles by this author Sameh Naim More articles by this author Bertie Zhang More articles by this author John Phillips More articles by this author Majid Eshghi More articles by this author Expand All Advertisement Loading ...

The impact of our acquired experience on endoscopic injection treatment outcomes of vesicoureteral reflux during the first ten years of practice

Introduction: Endoscopic injection treatment (EIT) for vesicoureteral reflux (VUR) correction is widely accepted as an optimal method for more than thirty years. However, it is still in its infancy in many pediatric surgical centers. It presents variable cure rates, with many factors affecting its successfulness. Objectives: We aimed to identify how accumulated endoscopic experience affected the VUR resolution success rates, in association with a variety of characteristics, since the beginning of practicing the technique. We attempt to improve patient selection. Patients and Methods: The outcomes of 53 children, corresponding to 78 refluxing ureteral units (RUUs), treated with endoscopic injection during the first years of practice (2010-2016), and 26 children with 42 RUUs during the latest years (2017-2020), were compared. Characteristics such as age, gender, VUR grades, preoperative voiding cystogram and dimercaptosuccinic acid scintigraphy, side, laterality were analyzed in relation with outcome of the groups of the study population. Outcomes presenting statistically significant differences were considered related to experience. Results: Refluxing ureters of the second group presented significant improved endoscopic treatment success rates and also significant reduced need for open surgery. The second group of experienced performance presented significant improved success rates in younger children, in girls, in children with bilateral VUR or duplex ureteral system, and when reflux presented at the filling phase of voiding cystourethrogram. Furthermore, the second group of experienced performance presented significant improved success rates in ureteral units of a duplex system or with grade III and high grades IV-V VUR. Conclusion: Our initial experience with EIT has been promising. Boys, and children with bilateral VUR or duplex ureteral system should be treated by more experienced endoscopic surgeons. Furthermore, high grade VUR is a predisposing factor for endoscopic treatment failure, performing by less experienced surgeons. Pediatric surgeons must upgrade their learning curve, initiating their experience, and developing their surgical skills with more simple cases before expanding their practice to more complicated.

The utility of native ureter in the management of ureteral complications in children after renal transplantation.

Ureteral complications after renal transplantation in children are a major source of morbidity. Management is complex and variable. With IRB approval, health records were retrospectively reviewed of patients who: were <18years, underwent kidney transplant between 1997 and 2017, had at least 2years of follow-up, and underwent interventions due to post-transplant ureteral complications. Of 136 patients, seventeen (13%) required ureteral intervention due to stricture (n=3), reflux (n=12), or both (n=2). Transplant occurred at median 10.5years (3.1-14.7). Reconstruction occurred at median 10months (7-15) after transplant. Pre-existing bladder pathology was present in 6 (35%) patients. Four of five patients with strictures had at least one endoscopic balloon dilation. Ultimate management included reimplantation, ureteroureterostomy of native to transplant ureter, pyeloureterostomy to native ureter, multiple endoscopic interventions followed by a Boari flap, or multiple failed endoscopic interventions. Fourteen patients with VUR underwent reimplantation (n=5), ureteroureterostomyof native to transplant ureter (n=4), pyeloureterostomyto native ureter (n=4), and one underwent endoscopic injection with Deflux of the transplant ureter. Only one patient had a non-functioning graft due to ureteral complication. All patients were alive at follow-up (median 17years [12-19]). Transplant ureteral reflux and stricture are significant complications following pediatric renal transplantation and may require surgical management. In our population, reflux or stricture requiring ureteral reconstruction occurred in 10% and 4%, respectively. Endoscopic interventions were rarely successful. Native ureters were used for ureteral reconstruction in more than two thirds of patients should be considered in management of ureteral complications.

POS-189 Urinary tract infection in renal transplant recipients:Experience of a single departement

Urinary tract infection (UI), is the most common cause of infectious complications in kidney transplant recipients.These infections remain suspect due to their impact on graft survival and therefore on the morbidity and mortality of this population .These can occur at any time but with the highest incidence in the first 3–6months after transplantationour aims were as follow: 1. Assess the prevalence of UI in kidney transplant recipients. 2. Identify the risk factors for UI in kidney post transplantation.3. Study the microbiological profile and therapeutic attitudes of these UIs This is a descriptive and analytical retrospective study, carried out between January 2017 and November 2019 at the renal transplant unit in the nephrology department of Fattouma Bourguiba Hospital in Monastir. we included all kidney transplant patients hospitalized during this period During this period 360 patients were hospitalized, IU was diagnosed in 32 patients. The average age of our population was 35.5 ± 9.6 years with a sex ratio of 1. The prevalence of IU in kidney transplant recipients was estimated at 8.8%. The graft acute pyelonephritis was the most frequent presentation. The most incriminated germs were the bacillus gram negative (BGN) represented mainly by Klebsielle pneumonae (47.7%). The most prescribed antibiotics were carbapenemes in 34% of cases followed by third generation cephalosporin (C3G) mainly cefotaxime (21.5%). The only UI risk factor found in our study with a statistically significant p was ureteric vesic reflux complicating a kidney transplant. View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Several other risk factors have been identified in the literature not objectived in our study, their recognition is important to identify kidney transplant recipients who are more likely to develop urinary tract infections and to minimize the risk with personalized care. for example, adequate screening and prophylaxis.

Kidney damage associated with vesico ureteric reflux.

The aim of this review is to highlight the most recent developments in the understanding of kidney damage associated with vesico ureteral reflux. The severe damage, with major adverse long-term sequelae, was thought to be, for the most part, the result of pyelonephritis, predisposed to by vesico ureteral reflux. It is now recognized that there are two distinct forms of kidney damage (congenital and acquired), in association with reflux. We examined the most recent research regarding these two conditions. The most recent articles focus on an understanding and the possible interventions for the congenital and acquired abnormalities of the kidney, associated with reflux. Of particular interest in congenital disorders, is the importance of urothelium and gene mutations in normal and aberrant development of the urinary tract. As regards the predisposition to urinary tract infections and kidney scarring, the importance of uromodulin in the defence mechanism preventing infection, and the role of interventions aimed at reducing scarring, such as vitamin A and steroids during the acute phase of the infection, are discussed. A recent article of particular value demonstrated the absence of long-term adverse outcomes during pregnancy, in women investigated for urinary tract infections in childhood.

Peadiatric transvesicoscopic dismembered ureteric reimplantation for ectopic upper ureter in duplication anomalies

Ectopic upper pole ureters in duplex kidneys can be managed surgically by ipsilateral distal ureteroureterostomy or reimplantation of both ipsilateral ureters when upper pole shows reasonable function. This study aimed to evaluate the clinical outcomes of transvesicoscopic dismembered upper ureteric reimplantation for patients with ectopic upper pole ureters in duplication anomalies. Between July 2015 and January 2019, laparoscopic transvesicoscopic ureteral reimplantation was performed in 20 patients with ectopic upper pole ureters. An incision was made in the bladder wall at 1.0cm proximal to the lower ureteral orifice of affected side. The upper pole ureter was recognized, and the terminal portion of the upper ureter was ligated and cut. Then the proximal portion of the upper ureter was mobilized, a transverse submucosal tunnel was created and upper ureteric reimplantation was performed with 6/0 absorbable sutures. Patients were followed up with renal ultrasonography and voiding cystourethrogram for clinical outcomes and hydronephrosis trends. Median (range) age at surgery was 22.5 (10-53) months. All of the 20 operations were successful, and none required conversion to an extravesical approach or open surgery. Four patients presented with worsening upper pole hydroureteronephrosis but recovered three to six months postoperatively. Resolution of symptoms and improving hydroureteronephrosis were achieved in all patients and VUR of the upper and lower ureters was not detected at postoperative follow-up. To our knowledge, dismembered reimplantation of upper pole ureters has been reported only in a small series through extravesical technique. In our study, we performed intravesicoscopic upper ureter Cohen reimplantation for duplex system ureteral ectopia. Compared with the extravesical approach, the transvesicoscopic approach leave most of the pelvic structures intact and the creation of a submucosal tunnel for prevention of ureteral reflux is more reliable; in addition, this approach avoids any manipulation of the lower pole ureter compared to ipsilateral ureteroureterostomy. But this method does not seem applicable to children under 6 months of age because of the small bladder capacity. The laparoscopic intravesical technique of dismembered ureteral reimplantation was safe and feasible in our cases and may be an alternative surgical treatment for ectopic upper pole ureters in duplication anomalies.

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.