Ureteral Resection Research Articles

Pitfalls of frozen section diagnosis in ureter margin evaluation of plasmacytoid urothelial carcinoma of urinary bladder.

Plasmacytoid urothelial carcinoma (PUC) is a rare and aggressive subtype that often presents at advanced stages with poor prognosis. This study investigated tumor invasion to better understand tumor behavior and potentially to improve management strategies by comparing the clinicopathologic characteristics of PUC with positive ureter resection margin (+ URM) with PUC with negative URMs (-URM). This retrospective analysis used pathology reports from 2017 to 2023 for cases diagnosed with PUC during radical cystectomy (RC). All applicable H&E slides of RC specimens were reviewed. Cases with a plasmacytoid component greater than 25% in the RC specimens were analyzed. Frozen section analyses (FSAs) and permanent section analyses (PSAs) of ureter resection margins were performed. Fifteen patients with a plasmacytoid component greater than 25% in their RC specimens were identified. Compared with -URM PUC cases, +URM PUC cases were located more frequently at the trigone or bladder neck, and all + URM cases exhibited ureter orifice involvement. Among 6 PSA-positive cases, three (50%) cases showed discrepancies with FSA. Three + URM cases exhibited PUC tumor cells along the submucosa and muscularis propria layer, and the 3 remaining cases showed PUC tumor cells along the adventitia. We observed a consistent adventitia invasion in all the discordant cases, with sectioning errors and misinterpretation identified as the primary causal factors. To the best of our knowledge, this is the first study to demonstrate two separate patterns of tumor infiltration along the ureter and to discuss the significance of comparing FSA with PSA in PUC. The significance of comprehensive management strategies for PUC patients, including a thorough evaluation of ureteral margins and accurate interpretation of periureteral fat tissue, is highlighted. Large, well-designed studies are needed to strengthen the evidence and to establish optimal management strategies for patients with PUC.

Intraoperative ICG-fluorescence imaging of ureteral defect: case report and literature review

Iatrogenic ureteral injury is the most frequent trauma during pelvic surgery. Due to the peculiarities of this topographic region, assessment of ureteral wall perfusion is critical for prevention of ischemic complications.In modern surgical practice, assessing local ureteral perfusion is often based on the surgeon’s subjective opinion. Intraoperative angiography with indocyanine green (indocyanine green, ICG) has been shown to be an adequate reflection of tissue perfusion and potentially influence the outcome of surgery.Currently, there are insufficient data regarding the use of ICG in iatrogenic ureteral injury. In this article, we describe a successful ICG fluorescence-guided middle third ureteroplasty in a 92-year-old patient with uterine cancer who underwent a simple hysterectomy. We also review the literature on this topic. The literature search for the review was performed using the PubMed database.Based on currently available data, the use of ICG for defect detection and control during ureteral resection is feasible and safe. However, the significance of this procedure should be evaluated in further studies.

Comparison of surgical effectiveness: kidney sparing surgery for upper tract urothelial carcinoma.

This review provides an overview of the recent publications on kidney-sparing-surgery (KSS) for upper tract urothelial carcinoma (UTUC), an alternative to radical nephroureterectomy (RNU) for an increasing number of indications. Recent studies highlight comparable survival outcomes between KSS [ureterorenoscopy with tumour ablation (URS) or segmental ureteral resection (SUR)] and RNU, even in high-risk UTUC patients. KSS has shown to preserve renal function without significantly compromising oncologic control in appropriately selected patients. Included literature also researched surgical complications, surveillance strategies, such as second-look ureteroscopy, and comparative cost analyses. Over the past two and a half years, studies have emphasized the growing usage of URS and SUR in treating selected UTUC patients. Recent literature has remarkably included relatively large numbers of typically high-risk patients with features such as high-grade tumours, stage >Ta, multifocality, and hydronephrosis with acceptable results. Further research should expand on the different indications for KSS, its postoperative surveillance and comparative economic analyses.

Organ-preserving treatment for urothelial carcinoma of the upper urinary tract

Urothelial carcinoma of the upper urinary tract is rare but the incidence is currently increasing in western countries. Radical nephroureterectomy has long been the standard treatment; however, it can lead to chronic kidney failure and also the necessity for dialysis. Therefore, organ-preserving treatment is now recommended for selected patients with low-risk tumors. The choice of treatment depends on the tumor characteristics, comorbidities and individual risk factors. Surgical options for organ preservation include ureterorenoscopy (URS), percutaneous treatment and partial ureteral resection. The URS is the most frequently used method for organ preservation. Photodynamic diagnostics (PDD) and narrow band imaging (NBI) can potentially also be used for tumor detection in the upper urinary tract. Conservative options such as topical treatment with mitomycinC or Bacillus Calmette-Guérin (BCG) and systemic treatment options are also possible.

A new technique for ureteral resection to prevent urine dissemination and cancer seeding.

We describe a case in which robot-assisted radical ureterectomy was performed for residual ureteral recurrence in a postoperative patient with renal pelvis cancer. A 75-year-old woman underwent laparoscopic radical nephroureterectomy for left renal pelvic cancer at another hospital. During follow-up, a papillary tumor was found in the bladder on cystoscopy, and a continuous tumor was found in the residual ureter on computed tomography. Robot-assisted radical ureterectomy was performed in combination with transurethral resection of bladder tumors. To avoid urine spillage, bladder cuff excision was performed using a mechanical suture device while monitoring the interior of the bladder. We developed a new technique for remnant ureteral resection using cystoscopy and a vascular stapler to prevent urine dissemination and cancer seeding.

High Rates of Discordant Ureteral Perfusion During Open Ureteral Reconstruction With Indocyanine Green: Does Near-Infrared Fluorescence Imaging Change Management or Stricture Outcomes?

OBJECTIVETo determine the role of near-infrared fluorescence imaging (NIFI) combined with indocyanine green (ICG) to assess ureteral tissue perfusion in a benign genitourinary reconstruction cohort with a high prevalence of prior abdominopelvic radiation and surgery. MATERIALS AND METHODSA prospective, single-surgeon series, between June 2018 and April 2022, of patients who underwent open genitourinary reconstructive surgeries in which NIFI/ICG was utilized to intraoperatively assess ureteral tissue perfusion prior to ureteral anastomosis. Primary outcome was ureteroanastomotic stricture (UAS). Secondary outcomes included impact of NIFI/ICG on surgical decision-making and ureter resection length. RESULTS39 patients, median age 66, underwent 40 multimodality reconstructive surgeries during which NIFI/ICG was utilized in the open setting. Radiation-induced etiology was present in 32 of 40 (80%) patients. UAS occurred in 1 of 57 (1.8%) anastomoses with median follow-up 23.4 months. Use of NIFI/ICG changed intraoperative decision-making in 63% of cases. Change in intraoperative decision-making was more common in patients with prior abdominopelvic radiation (66%) compared to non-radiated patients (13%), p=0.007. Discordance between subjective (white-light) and objective (NIFI/ICG) ureteral perfusion (white-light) occurred in 61% of ureters. Mean length of resected ureter was higher following objective assessment with NIFI/ICG (3.6 cm) versus subjective assessment (white light) conditions (1.8 cm), p=0.001. CONCLUSIONSUse of NIFI/ICG was associated with low rates of UAS at 2 years follow-up in a cohort with high prevalence of prior radiation. NIFI/ICG was associated with longer lengths of ureter resection and ureteral perfusion assessment discordance compared to subjective surgeon assessment under white-light conditions.

Two cases of pararenal artery aortic aneurysm treatment after pancreaticoduodenectomy and abdominal aortic aneurysm stent grafting

BackgroundAcute pancreatitis caused by surgical procedures may occur less frequently in surgeries for aortic aneurysm involving the abdominal branch. However, in such cases, the associated mortality rate increases significantly. There have been few reports on abdominal aortic aneurysm surgery after pancreatoduodenectomy; as such the incidence of postoperative pancreatitis remains unclear.Case presentationTwo cases of pararenal artery aortic aneurysm after pancreaticoduodenectomy and endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm are reported. In the first case, a 74-year-old man was diagnosed with abdominal aortic aneurysm and duodenal cancer 6 years earlier and underwent pancreaticoduodenectomy after EVAR. Subsequently, the abdominal aorta expanded to 58 mm at the level of the renal artery proximal to the EVAR site. Graft replacement was performed through a left thoraco-retroperitoneal incision. However, the patient died from acute pancreatitis, believed to be caused by intraoperative manipulation. Given this initial experience, in the second case, a 77-year-old man had undergone a pancreaticoduodenectomy for a gastrointestinal stromal tumor 17 years earlier and EVAR for an abdominal aortic aneurysm 10 years earlier. The abdominal aorta had expanded to 50 mm immediately below the right renal artery on the proximal side of the EVAR. Subsequently, hematuria was noted, and he was diagnosed with right ureteral cancer. Autologous transplantation of the left kidney and EVAR was performed avoiding manipulation of the area around the pancreas and achieved good results. Combined right renal and ureteral resections were performed 20 days after EVAR.ConclusionsWhile performing aortic surgery after pancreaticoduodenectomy, surgeons should avoid manipulating tissues around the pancreas.

Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion

To identify the impact of length of distal ureteral resection on the risk of benign uretero-enteric anastomotic stricture (UEAS) formation following cystectomy and urinary diversion. A database of patients who underwent cystectomy and urinary diversion from 2015 to 2022 was analyzed. Distal ureteral resections were sent for final pathology. The length of resected ureter was collected from pathology reports. Benign UEAS were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. The relationship between stricture formation and clinical parameters were assessed using T-tests, Chi-square tests, and multivariable analysis. A total of 366 patients underwent cystectomy and urinary diversion. Of the cohort, 35 (9.5%) patients developed UEAS. Median time to stricture formation was 12.5 months (IQR 4-30). Of the 711 uretero-enteric anastomoses, 40 (5.6%) ultimately formed a UEAS. Median distal ureteral resection was significantly longer among ureteral anastomoses which did not form a UEAS (2.3 cm vs. 1.65 cm, p=0.028). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated that longer distal ureteral resections were inversely associated with odds of UEAS formation (OR 0.73, 95% CI 0.58-0.92). Multivariable Cox regression analysis similarly showed that length of distal ureteral resection was inversely associated with time to stricture formation (HR 0.78, 95% CI 0.62-0.98). The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients.

Abstract P3013: Rare Case Of Catheter-related Right Atrial Thrombosis In A Pediatric Multi-visceral Transplant Patient

Introduction: There has been a recent increase in the use of intraoperative transesophageal echocardiography (TEE) in liver transplant surgeries to identify intracardiac thrombi and pulmonary embolism (PE). These are rare but serious complications of transplant surgery that carry a high mortality risk. However, there is a lack of literature supporting the use of TEE during liver transplants, especially in pediatric cases. Case Presentation: We present a rare case of intraoperative catheter-related right atrial thrombus (CRAT) in a nine-year-old multi-visceral transplant (MVT) patient. This patient’s medical history was notable for preterm birth and gastroschisis complicated by neonatal necrotizing enterocolitis resulting in short-gut syndrome. He had a significant surgical history, including intestinal resection, Hartmann Procedure, and cholecystectomy, after which he developed non-cholestatic liver disease. He was admitted for MVT for intestinal failure associated with ESLD. The procedure was complicated by massive hemorrhage during the dissection phase, significant coagulopathy after engrafting the donor liver, profound hemodynamic instability requiring inotropic drug support, and multiple instances of intraoperative CPR. Intraoperative TEE identified right atrial thrombi around the central venous line. The patient developed RV dysfunction and PEA secondary to PE on two occasions and received a total of 4 mg tissue plasminogen activator (tPA). In both cases, ROSC was achieved after thrombolysis. Due to profound coagulopathy and massive blood loss (70 liters), the completion of the surgery was postponed, and the patient left the operating room with an open abdomen. The patient’s postoperative course was complicated by hemodiafiltration, ureteral resection with reimplantation to bladder, pyloroplasty, appendectomy, small bowel resection, end colostomy and double-barrel ileostomy. The patient eventually developed a subarachnoid hemorrhage on POD3 and expired. Conclusion: This case highlights the importance of utilizing intraoperative TEE in pediatric liver transplant surgeries to diagnose intracardiac thrombi and PE.

MP65-17 LENGTH OF URETER RESECTED AT TIME OF URINARY DIVERSION IS ASSOCIATED WITH URETERAL STRICTURE RATE

You have accessJournal of UrologyCME1 Apr 2023MP65-17 LENGTH OF URETER RESECTED AT TIME OF URINARY DIVERSION IS ASSOCIATED WITH URETERAL STRICTURE RATE Arighno Das, Tudor Borza, Daniel Shapiro, E. Jason Abel, David Jarrard, and Kyle Richards Arighno DasArighno Das More articles by this author , Tudor BorzaTudor Borza More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , E. Jason AbelE. Jason Abel More articles by this author , David JarrardDavid Jarrard More articles by this author , and Kyle RichardsKyle Richards More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Benign ureterointestinal anastomotic (UIA) strictures are a morbid complication following cystectomy with urinary diversion. Data from renal transplantation literature suggests that shorter ureters may result in fewer anastomotic strictures due to improved vascularization of the re-implanted segment. We evaluated whether length of distal ureteral resection may impact rates of UIA strictures in cystectomy patients. METHODS: A database of patients who underwent cystectomy with urinary diversion from 2015 to 2022 was analyzed. All cases were performed by a single surgeon to control for variations in surgical technique. Distal ureteral resections were routinely sent for final pathology. Length of this resection was collected from pathology reports. Benign UIA strictures were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. Relationship between stricture formation and clinical parameters were assessed using T-tests, Chi-squared tests, and multivariable analysis. RESULTS: A total of 362 patients underwent cystectomy with urinary diversion from 2015 to 2022. Of the cohort, 35 (9.6%) patients developed UIA strictures. Median time to stricture formation was 12.5 months (IQR 4-30). Of the 724 ureteral anastomoses among the 362 patients, 40 anastomoses developed benign strictures (6%). Median distal ureteral length resected was significantly longer among anastomosis that did not form a stricture (2.2 cm vs 1.65 cm, p=0.044, Table). Strictures more commonly formed on the left side, although this did not reach significance (65% vs 35%, p=0.051). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated longer distal ureteral resections were associated with a significantly lower risk of ipsilateral stricture formation (OR 0.74, 95% CI 0.58-0.94). CONCLUSIONS: The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients, consistent with renal transplantation data. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e898 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arighno Das More articles by this author Tudor Borza More articles by this author Daniel Shapiro More articles by this author E. Jason Abel More articles by this author David Jarrard More articles by this author Kyle Richards More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-02 THREE-DIMENSIONAL AUGMENTED REALITY ROBOT-ASSISTED SEGMENTAL URETERECTOMY WITH BUCCAL MUCOSA GRAFT FOR THE REPAIR OF UPPER COMPLEX URETERAL STRICTURES

You have accessJournal of UrologyCME1 Apr 2023V01-02 THREE-DIMENSIONAL AUGMENTED REALITY ROBOT-ASSISTED SEGMENTAL URETERECTOMY WITH BUCCAL MUCOSA GRAFT FOR THE REPAIR OF UPPER COMPLEX URETERAL STRICTURES Alberto Piana, Daniele Amparore, Giovanni Busacca, Paolo Alessio, Enrico Checcucci, Federico Piramide, Sabrina De Cillis, Gabriele Volpi, Paolo Verri, Michele Sica, Mariano Burgio, Andrea Bellin, Matteo Manfredi, Cristian Fiori, and Francesco Porpiglia Alberto PianaAlberto Piana More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Giovanni BusaccaGiovanni Busacca More articles by this author , Paolo AlessioPaolo Alessio More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Federico PiramideFederico Piramide More articles by this author , Sabrina De CillisSabrina De Cillis More articles by this author , Gabriele VolpiGabriele Volpi More articles by this author , Paolo VerriPaolo Verri More articles by this author , Michele SicaMichele Sica More articles by this author , Mariano BurgioMariano Burgio More articles by this author , Andrea BellinAndrea Bellin More articles by this author , Matteo ManfrediMatteo Manfredi More articles by this author , Cristian FioriCristian Fiori More articles by this author , and Francesco PorpigliaFrancesco Porpiglia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stenosis constitutes a very complex surgical scenario with a high rate of post-operative failure. For 2-3 cm upper stenosis, a robotic-assisted segmental ureteral resection with subsequent uretero-ureteral anastomosis using a buccal mucosa graft is a fesible option. For the intraoperative identification of the stenosis, a concomitant ureteroscopy is usually performed. However, the addition of the endoscopy increases the intraoperative complexity and costs of the surgery. In order to increase the precision in locating the stricture during the surgical dissection of the ureter, we tested 3D augmented reality (AR) surgical navigation during the intervention. METHODS: AR intraoperative navigation is performed using a dedicated ICON rack connected to the DaVinci® surgical console. A 3D mouse is used by an assistant to manually overlap the 3D virtual model on the operative field. The surgeon can visualize the superimposed images in real time via Tile Pro technology. Three cases of different level ureteral strictures caused by stones embedded into the ureteral wall and located above the iliac vessels cross are shown in the video. AR is used to superimpose the 3D virtual model of the ureter together with its stone over the operative field, leading to a precise location and resection of the stricture. In the reconstructive phase, the mucosal graft is put into the abdominal cavity once the posterior plate of the anastomosis is realized with a termino-terminal suture, minimizing the tension on the defect repair. RESULTS: In all the three cases, AR allowed a proper identification of the endoluminal stricture. All the surgeries were successful without significative intra and post-operative complications. Postoperative examinations confirmed the success of the procedures. CONCLUSIONS: AR intraoperative guidance showed to be a useful and precise technological tool able to correctly identify the ureteral stricture even when not visible on the ureteral wall surface, leading to maximize the preservation of ureteral peri-strictural healthy tissue. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e79 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Piana More articles by this author Daniele Amparore More articles by this author Giovanni Busacca More articles by this author Paolo Alessio More articles by this author Enrico Checcucci More articles by this author Federico Piramide More articles by this author Sabrina De Cillis More articles by this author Gabriele Volpi More articles by this author Paolo Verri More articles by this author Michele Sica More articles by this author Mariano Burgio More articles by this author Andrea Bellin More articles by this author Matteo Manfredi More articles by this author Cristian Fiori More articles by this author Francesco Porpiglia More articles by this author Expand All Advertisement PDF downloadLoading ...

8400 Distal Ureteral Resection with Ureteroneocystotomy; A Case of Robotic Assisted Laparoscopic Management of Ureteral Endometriosis

<h3>Study Objective</h3> Video presentation showing distal ureterectomy and reimplantation. <h3>Design</h3> Case presentation with showing procedural techniques in detail. <h3>Setting</h3> Tertiary academic teaching hospital. <h3>Patients or Participants</h3> 39-y.o. G6P3033 with past medical history of upper extremity deep venous thrombosis and surgical history of tubal ligation as well as endometrial ablation for menorrhagia, presented to the emergency room with right lower quadrant pain and was found to have right hydronephrosis and a 1.6 cm right ureterovesical junction mass on CT scan. She underwent a cystoscopy and right ureteric balloon dilation with stent placement with no evidence of bladder endometriosis. MRI showed a 1.6cm nodule at a low-intensity signal in T2-weighted sequences, suspicious for ureteral endometriosis. <h3>Interventions</h3> She underwent diagnostic laparoscopy with total hysterectomy and bilateral salpingectomy, robotic assisted distal ureterectomy with ureteroneocytotomy and stent placement. Her anticoagulation was held 48h prior to the surgery and re-initiated the day after her surgery. <h3>Measurements and Main Results</h3> The stent was discounted at 8 weeks post-operative. At 12 weeks post-operative she had an ultrasound done with normal fin dings and resolved hydronephrosis. <h3>Conclusion</h3> Preoperative planning and multidisciplinary team approach to management of severe endometriosis affecting the ureter is of paramount importance. While medical management is often the first-line therapy for endometriosis, urinary tract involvement often represents advanced stage of the disease, thereby timely diagnosis and appropriate surgical intervention is required to avoid permanent kidney injury.

Laparoscopic ureteroneocystostomy and round ligament bladder hitching for ureteral stenosis in parametrial deep endometriosis: Our tips for a tension-free anastomosis.

To investigate the feasibility and the efficacy of laparoscopic ureteroneocystostomy with round ligament bladder hitching. This is a monocentric retrospective study. Enrolled patients affected by deep endometriosis underwent laparoscopic nerve-sparing parametrectomy and monolateral ureteroneocystostomy with bladder suspension to the round ligament. Perioperative and postoperative outcomes were collected, as well as urinary and pain symptoms before and after surgery. Laparoscopic ureteroneocystostomy with round ligament bladder hitching was performed in nine women. The most frequent postoperative complication was post-voiding urinary retention (22.2%). No ureteral fistula or stenosis of the anastomosis was reported. In selected cases of ureteral resection and reimplantation, performing a round ligament bladder hitching allowed us to overcome the ureteral gap. This is a safe and feasible procedure to ensure stability of the anastomosis and avoid the possible disadvantages of the "standard" psoas hitch procedure.

Survival and Long-term Effects of Kidney-sparing Surgery Versus Radical Nephroureterectomy on Kidney Function in Patients with Upper Urinary Tract Urothelial Carcinoma

BackgroundCurrent European Association of Urology (EAU) guidelines discriminate between high- and low-risk upper urinary tract urothelial carcinoma (UTUC) to determine treatment by means of radical nephroureterectomy (RNU) or kidney-sparing surgery (KSS). ObjectiveTo compare long-term oncological outcomes and renal function for patients with UTUC treated by RNU versus KSS. Design, setting, and participantsA retrospective cohort study, including 186 renal units with nonmetastatic UTUC treated in a tertiary referral centre between 2010 and 2021, was conducted. InterventionRNU, ureterorenoscopy, percutaneous tumour resection, and segmental ureteral resection. Outcome measurements and statistical analysisRecurrence-free survival, metastasis-free survival (MFS), overall survival (OS), cancer-specific survival (CSS), and renal function were analysed by means of the log-rank test and the independent-sample t test. Results and limitationsOS was 71.1% for the RNU group and 81.9% for the KSS group. In a cohort matched for propensity weight based on EAU risk stratification progression-free survival (PFS; RNU 96.0%; KSS 86.0%), MFS (RNU 72.0%; KSS 84.0%), CSS (RNU 84.0%; KSS 86.0%), and OS (RNU 76.0%; KSS 76.0%) were all similar between both groups. No significant differences in renal function were seen at 2 and 5 yr after the intervention. Although this series represents the largest cohort of (high-risk) UTUC patients treated by means of KSS to date, it is not suitable for performing a multivariate analysis. ConclusionsPFS, MFS, CSS, and OS were all comparable when analysing the RNU and KSS groups. Similar results for groups with evenly distributed risk factors and a large percentage of high-risk disease suggest that current risk stratification might not be accurate in discriminating low-risk from high-risk disease. Patient summaryIn this report, we looked at outcomes for upper urinary tract urothelial carcinoma in a specialised hospital. We conclude that kidney-sparing surgery and radical nephroureterectomy have comparable outcomes and that risk factors for worse outcome might not be identified correctly.

MP46-04 10-YEAR EXPERIENCE WITH MIDLINE EXTRAPERITONEAL RETROPERITONEAL LYMPH NODE DISSECTION

You have accessJournal of UrologyCME1 May 2022MP46-04 10-YEAR EXPERIENCE WITH MIDLINE EXTRAPERITONEAL RETROPERITONEAL LYMPH NODE DISSECTION Muhannad Alsyouf, Sanam Ladi Seyedian, Arman Ashrafi, Hamed Ahmadi, Madeleine Burg, Alireza Ghoreifi, Antoin Douglawi, Sumeet Bhanvadia, Anne Schuckman, Hooman Djaladat, and Siamak Daneshmand Muhannad AlsyoufMuhannad Alsyouf More articles by this author , Sanam Ladi SeyedianSanam Ladi Seyedian More articles by this author , Arman AshrafiArman Ashrafi More articles by this author , Hamed AhmadiHamed Ahmadi More articles by this author , Madeleine BurgMadeleine Burg More articles by this author , Alireza GhoreifiAlireza Ghoreifi More articles by this author , Antoin DouglawiAntoin Douglawi More articles by this author , Sumeet BhanvadiaSumeet Bhanvadia More articles by this author , Anne SchuckmanAnne Schuckman More articles by this author , Hooman DjaladatHooman Djaladat More articles by this author , and Siamak DaneshmandSiamak Daneshmand More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002612.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has demonstrated significantly decreased morbidity compared to a transperitoneal approach. We aimed to review our 10-year experience in patients with germ cell tumors (GCT) who underwent EP-RPLND at USC. METHODS: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. All patients were considered for EP-RPLND except for men undergoing aortic resection, extensive retrocrural dissection, or intraperitoneal resection. Perioperative and long-term outcomes were analyzed including recurrence rates and patterns. Ileus was defined as nausea/vomiting requiring nasogastric decompression. Mann-Whitney U and Chi-square tests were used for univariate analysis, with p<0.05 considered significant. RESULTS: Overall, 172 patients underwent EP-RPLND, of which 73% were performed in the post-chemotherapy (PC) setting. Median size of radiologic retroperitoneal disease was 3.2 cm (IQR 2 – 5.4), of which 12 cases were >10 cm. Median number of lymph nodes resected was 29 (IQR 17–39). There were no cases of postoperative ileus, and median hospital stay was 2 (IQR 1-3) days (Table 1). In the PC group, 23% underwent adjunct procedures including: vascular reconstruction (10), cavectomy (9), nephrectomy (8), ureteral resection (3), retrocrural dissection (2), suprahilar dissection (1), neck dissection (2), iliac vessel resection (2), & bone biopsy (1). Twenty three patients experienced 24 (13.5%) 90-d complications. In patients who underwent nerve-sparing, 86.9% maintained antegrade ejaculatory function. Out of 18 patients who experienced disease recurrence at a median of 4.4 mo, 4 were in-field recurrences (Table 2). CONCLUSIONS: Midline extraperitoneal approach for RPLND in GCT is safe, associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and post-chemotherapy settings, even when adjunct procedures are necessitated. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e773 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhannad Alsyouf More articles by this author Sanam Ladi Seyedian More articles by this author Arman Ashrafi More articles by this author Hamed Ahmadi More articles by this author Madeleine Burg More articles by this author Alireza Ghoreifi More articles by this author Antoin Douglawi More articles by this author Sumeet Bhanvadia More articles by this author Anne Schuckman More articles by this author Hooman Djaladat More articles by this author Siamak Daneshmand More articles by this author Expand All Advertisement PDF DownloadLoading ...

Granulation tissue-type hemangioma of ureter: a highly misdiagnosed disease (a rare case report and literature review)

BackgroundUreteral granulation tissue hemangiomas are rare benign vascular lesions, and they may be clinically asymptomatic or present with massive or recurrent hematuria. Sometimes hemangiomas are difficult to distinguish from malignant ureteral tumors, and most ureteral hemangiomas are confirmed by postoperative pathological examination. This article aims to present a case of granulation tissue-type hemangioma of the ureter and briefly review the current literature on this condition.Case presentationA 30-year-old male patient presented with complaints of painless macroscopic hematuria for 2 months. Computerized tomography of the urinary system showed that the upper 1/3 of the right ureter was occupied, and then the possibility of tumor lesions was considered. The urine cytology showed occasional nuclear abnormalities and many light-stained crystals in urine. Because of suspicious radiological and cytological findings, the patient underwent the right ureteroscopy and the laparoscopic right ureteral mass resection. The postoperative pathological report showed that it was a mesenchymal tumor. The morphological and immunohistochemical staining was consistent with that of hemangioma, tending to granulation tissue hemangioma. After surgery, the patient was in a good state and recovered well at the last follow-up.ConclusionsUreteral granulation tissue hemangiomas are an easily misdiagnosed disease. Intermittent painless hematuria is an important characteristic of this disease. Therefore, we suggest that unnecessary radical surgery can be avoided when clinicians consider the possibility of benign ureteral tumors during the evaluation.

Circumcaval ureter in two ferrets

Circumcaval ureter is an anomaly in the development of the caudal vena cava, rarely reported in ferrets. Inclusion criteria for ferrets were circumcaval ureter confirmed on surgery or post-mortem examination. Data collection of ferrets with circumcaval ureters presented between January 2014 and January 2021 included signalment, medical history, clinical signs, laboratory diagnostics, diagnostic imaging results, treatments, and clinical outcomes. Two ferrets met the inclusion criteria. One presented following diarrhea, and one was found on routine examination that revealed a right nephromegaly. Abdominal ultrasound revealed severe unilateral hydronephrosis associated with hydroureter in both ferrets. No obvious cause of obstruction was identified. Biochemical results were unremarkable in both patients. Hydronephrosis was investigated through CT scans, revealing Type 1 circumcaval ureter in both ferrets. Section and relocation of the right ureter by uretero-vesical anastomosis was performed in one ferret. This ferret died 48 hours later following a nephrectomy performed due to persistent hydronephrosis. The second cas underwent right nephrectomy andd ureter resection due to severe hydronephrosis and stenosis of the circuncaval segment. This ferret has remained healthy on followup with no abnormalities found in biochemistries or ultrasound examination. Findings suggest that circumcaval ureter should be suspected in ferrets with unilateral hydronephrosis and associated hydroureter without any identified cause of obstruction on abdominal ultrasonography. It should be confirmed with CT scan and/or urography and treated surgically.

Upper Tract Urinary Cancer Recurrence after Radical Cystectomy: Risk Assessment of Intraoperative Frozen Section

Introduction: Upper tract urinary cancer recurrence (UTUCR) after radical cystectomy (RC) is outcome-limiting. Surgical recommendations on intraoperative performance of frozen section analysis (FSA) and management of positive ureteral margin (PUM) are lacking. Methods: 634 RC cases were identified (2010–2018). In patients with PUM, sequential ureteral resections up to a negative margin were performed. We investigated the accuracy of FSA, significance of PUM, and identified risk factors (RFs) to stratify patients for UTUCR. Results: FSA was performed in 355 patients, including a total of 693 ureters. FSA sensitivity was 0.93 and specificity 0.99. PUM conversion was possible in 52 (91.2%) cases. UTUCR occurred in 17 (4.8%) patients. Identified UTUCR RFs are non-muscle invasive bladder carcinoma (NMIBC) (OR 3.8, 95% confidence intervals [CI] 1.4–10.2, p = 0.008), multifocal bladder cancer in cystectomy specimen (OR 4.7, CI 1.1–20.8, p = 0.042), and recurrent NMIBC (OR 4.1, CI 1.5–10.9, p = 0.006). Risk-group stratification showed a six-fold increase in UTUCR risk (low-to high-risk). Conclusion: FSA is a sensitive and specific method to identify PUM. UTUCR occurs significantly more often in patients with recurrent, multifocal NMIBC at the time of RC. Patients can be risk stratified for UTUCR. In case of NMIBC-PUM, surgeons can safely opt for a kidney preserving strategy.

Nomogram for Predicting a Complex Ureteral Procedure in Pelvic Endometriosis Surgery

To develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2). Retrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated. Tertiary referral hospital and expert center in endometriosis. A total of 920 patients with DE. Ureteral procedure during surgery for DE. In total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p=.036), a previous surgery for endometriosis (p <.01), and ureteral dilatation on magnetic resonance imaging (p <.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60-0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n=15). Age, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance.

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

To assess whether deep endometriosis surgery affects the bladder function. Prospective multicenter observational study (Canadian Task Force classification II-2). Academic research centers. Thirty-two patients with diagnosis of deep endometriosis requiring surgery. Women were evaluated with urodynamic studies, International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form, and International Consultation on Incontinence Questionnaire Overactive Bladder Module questionnaires before and 3 months after surgery. The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 mL; p <.001) and the bladder capacity (358 vs 409 mL; p=.011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 mL/s; p=.026). The International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (2.5 vs 0; p=.0005) and International Consultation on Incontinence Questionnaire Overactive Bladder Module (4.3 vs 1.2; p <.001) questionnaires showed a significant postoperative improvement too. Our data show that in a selected population of patients with deep infiltrating endometriosis (not requiring bowel or ureteral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with deep infiltrating endometriosis become aware of bladder filling later, have a higher bladder capacity, and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.