Ureteral Stent Insertion Research Articles

P0035 Palliative chemotherapy compared with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for patients with colorectal peritoneal carcinomatosis

Background Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) prolong survival in selected patients with colorectal peritoneal carcinomatosis. However, this modality of treatment is not standard therapy, and many patients are offered palliative chemotherapy (PC) instead. We hypothesise that PC is suboptimal as complications from the peritoneal disease often disrupts or prevents the PC. We compared overall survival between patients treated with PC and patients undergoing CRS and HIPEC, and we analysed morbidity in those receiving PC. Methods We performed a retrospective review of a prospectively maintained database at the National Cancer Centre Singapore from January 2008, to December 2013. 34 patients underwent CRS and HIPEC, 21 patients were treated with PC. Secondary outcomes were frequency of disruption of chemotherapy, need for surgery or invasive interventions, and duration of hospitalisation for complications of peritoneal disease. Findings Median overall survival for patients receiving PC was 1.7 years (95% confidence interval (CI) 0.7–2.1), but that of CRS and HIPEC was not reached. This was in spite of a longer median follow-up time for patients undergoing CRS and HIPEC of 2.2 years (0.2–7.2) compared with 1.1 years (0.0–3.8) with PC. The hazard of death for a patient treated with PC was 5.5 times that of a patient who underwent CRS and HIPEC (p < 0.05). Of the PC group, 71.4% had chemotherapy disruptions; 60.0% due to complications of peritoneal disease. 14.3% of patients required emergency surgery with stoma creation for intestinal obstruction, and 23.8% of patients required abdominal cope loop and ureteric stent insertion. Median total duration of unforeseen hospitalisation post-CRS and HIPEC was 11 days (0–149), compared with 21 days (0–85) in the PC group. Interpretation CRS and HIPEC prolonged survival compared with PC in selected patients with CLR peritoneal carcinomatosis. Patients treated with PC have significant morbidity from disease progression, which disrupts planned chemotherapy and results in significantly longer hospitalisation compared with CRS and HIPEC. Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) prolong survival in selected patients with colorectal peritoneal carcinomatosis. However, this modality of treatment is not standard therapy, and many patients are offered palliative chemotherapy (PC) instead. We hypothesise that PC is suboptimal as complications from the peritoneal disease often disrupts or prevents the PC. We compared overall survival between patients treated with PC and patients undergoing CRS and HIPEC, and we analysed morbidity in those receiving PC. We performed a retrospective review of a prospectively maintained database at the National Cancer Centre Singapore from January 2008, to December 2013. 34 patients underwent CRS and HIPEC, 21 patients were treated with PC. Secondary outcomes were frequency of disruption of chemotherapy, need for surgery or invasive interventions, and duration of hospitalisation for complications of peritoneal disease. Median overall survival for patients receiving PC was 1.7 years (95% confidence interval (CI) 0.7–2.1), but that of CRS and HIPEC was not reached. This was in spite of a longer median follow-up time for patients undergoing CRS and HIPEC of 2.2 years (0.2–7.2) compared with 1.1 years (0.0–3.8) with PC. The hazard of death for a patient treated with PC was 5.5 times that of a patient who underwent CRS and HIPEC (p < 0.05). Of the PC group, 71.4% had chemotherapy disruptions; 60.0% due to complications of peritoneal disease. 14.3% of patients required emergency surgery with stoma creation for intestinal obstruction, and 23.8% of patients required abdominal cope loop and ureteric stent insertion. Median total duration of unforeseen hospitalisation post-CRS and HIPEC was 11 days (0–149), compared with 21 days (0–85) in the PC group. CRS and HIPEC prolonged survival compared with PC in selected patients with CLR peritoneal carcinomatosis. Patients treated with PC have significant morbidity from disease progression, which disrupts planned chemotherapy and results in significantly longer hospitalisation compared with CRS and HIPEC.

Extracorporeal shock wave lithotripsy in the primary treatment of encrusted ureteral stents.

Double pigtail (JJ) ureteral stents, are the most commonly used method of urinary diversion in the ureteral obstructions. Encrustations may occur as a result of prolonged exposure due to forgetting these stents in the body. Removing these materials might be an annoyance. Forty-four patients from three tertiary referral centres with forgotten JJ stents left in them between the years 2007 and 2014 were included in the study. Stents could not be removed by attempted cystoscopy. As an alternative approach, extracorporeal shock wave lithotripsy (ESWL) was the first choice since it is minimally invasive. The results of that treatment are presented along with the relevant demographic data. JJ stenting for urolithiasis was performed in 36 patients, after open surgery in five patients, and for oncological reasons in three patients. ESWL was applied to stents or to any suspicious region adjacent to the stent. In 29 of 44 patients, the stents were easily removed under cystoscopic procedures while in one patient the fragmented residual stent was spontaneously excreted. In eight patients, ureteroscopy was required; in five patients, percutaneous nephrolithotripsy was required; and in one patient, open surgery was required in order to remove stents. ESWL can be considered as a first-line treatment when a forgotten JJ stent is detected despite all precautions after any kind of urological intervention involving insertion of ureteral stents.

Retrograde ureteric stent insertion in the management of infected obstructed kidneys.

To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi. Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission. In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths. Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.

MP40-12 THE EFFECT OF RACE AND SKIN COLOR ON NEAR-INFRARED SPECTROSCOPY READINGS IN PEDIATRIC PATIENTS WITH UNILATERAL ACUTE SCROTUM

fluoroscopic settings were recorded. Dosimetry data was recorded after analysis of single point dosimeters. RESULTS: Seventy-one patients underwent 75 operative procedures including retrograde pyelogram, ureteral stent insertion ureteroscopy and percutaneous nephrolithotomy (PCNL) with dosimeter placement. Underlying diagnoses included nephrolithiasis, calyceal diverticulum, hematuria, hydronephrosis and ureteropelvic junction obstruction. Mean age was 10.8 years, and mean BMI was 21.4 (62nd percentile for age). Dosimetry data demonstrated overall cohort average dose of 210 mrad per procedure. When divided by procedure, patients received a mean dose of 2,887 mrad per PCNL, 315 mrad per ureteroscopy, 149 mrad per stent insertion and 160 mrad per retrograde pyelogram. Radiation dose was significantly higher in patients undergoing PCNL when compared with ureteroscopy, stent insertion and retrograde pyeologram. CONCLUSIONS: Pediatric radiation exposure during urologic procedures is not insignificant, approaching and exceeding the recommended limit of 500mrad/year for patients under 18 years of age. Further study characterizing pediatric urologic exposure across multiple institutions would provide context for our findings. Protocols to optimize fluoroscopic settings and minimize patient exposure continue to be refined, andshouldplayakey role inall pediatric radiationsafety initiatives.

MP40-11 PROSPECTIVE ASSESSMENT OF PEDIATRIC RADIATION EXPOSURE: THE PEDIATRIC UROLOGY RADIATION SAFETY EVALUATION (PURSE) STUDY

You have accessJournal of UrologyPediatrics: Testis & Varicoceles, Stones1 Apr 2015MP40-11 PROSPECTIVE ASSESSMENT OF PEDIATRIC RADIATION EXPOSURE: THE PEDIATRIC UROLOGY RADIATION SAFETY EVALUATION (PURSE) STUDY Anne Dudley, Moira Dwyer, Pankaj Dangle, Omaya Banihani, Heidi Stephany, Glenn Cannon, Francis Schneck, and Michael Ost Anne DudleyAnne Dudley More articles by this author , Moira DwyerMoira Dwyer More articles by this author , Pankaj DanglePankaj Dangle More articles by this author , Omaya BanihaniOmaya Banihani More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , Glenn CannonGlenn Cannon More articles by this author , Francis SchneckFrancis Schneck More articles by this author , and Michael OstMichael Ost More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1193AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pediatric urologic patients often undergo procedures guided by fluoroscopy. Pediatric tissues are exquisitely sensitive to ionizing radiation, and patients are at risk for detrimental long term effects throughout their lifetimes. We sought to prospectively monitor radiation exposure in our pediatric urologic patients using single point dosimeters during fluoroscopic guided operative procedures. METHODS Pediatric patients undergoing fluoroscopic guided urologic procedures from August 2013 through October 2014 were prospectively enrolled in the IRB approved study. After obtaining informed consent from the patient's guardian, single point dosimeters were affixed to the flank of the planned procedural side with a transparent adhesive dressing. Patient demographics, procedural variables, fluoroscopic settings were recorded. Dosimetry data was recorded after analysis of single point dosimeters. RESULTS Seventy-one patients underwent 75 operative procedures including retrograde pyelogram, ureteral stent insertion ureteroscopy and percutaneous nephrolithotomy (PCNL) with dosimeter placement. Underlying diagnoses included nephrolithiasis, calyceal diverticulum, hematuria, hydronephrosis and ureteropelvic junction obstruction. Mean age was 10.8 years, and mean BMI was 21.4 (62nd percentile for age). Dosimetry data demonstrated overall cohort average dose of 210 mrad per procedure. When divided by procedure, patients received a mean dose of 2,887 mrad per PCNL, 315 mrad per ureteroscopy, 149 mrad per stent insertion and 160 mrad per retrograde pyelogram. Radiation dose was significantly higher in patients undergoing PCNL when compared with ureteroscopy, stent insertion and retrograde pyeologram. CONCLUSIONS Pediatric radiation exposure during urologic procedures is not insignificant, approaching and exceeding the recommended limit of 500 mrad/year for patients under 18 years of age. Further study characterizing pediatric urologic exposure across multiple institutions would provide context for our findings. Protocols to optimize fluoroscopic settings and minimize patient exposure continue to be refined, and should play a key role in all pediatric radiation safety initiatives. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e466-e467 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anne Dudley More articles by this author Moira Dwyer More articles by this author Pankaj Dangle More articles by this author Omaya Banihani More articles by this author Heidi Stephany More articles by this author Glenn Cannon More articles by this author Francis Schneck More articles by this author Michael Ost More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A critical assessment of the effects of tamsulosin and solifenacin as monotherapies and as a combination therapy for the treatment of ureteral stent-related symptoms: a 2 × 2 factorial randomized trial.

To assess the efficacy of tamsulosin, solifenacin, and combination therapy of both agents for the treatment of ureteral stent-related symptoms (SRSs). An open-label, randomized controlled trial was conducted with 112 patients who underwent unilateral ureteral stent insertion following ureteroscopic stone surgery. Patients were randomized with a 2 × 2 factorial design to one of four groups, i.e., A (control), B (tamsulosin 0.2 mg once daily), C (solifenacin 5 mg once daily), and D (both active treatments). Patients were evaluated at week 2 by the ureteral stent symptom questionnaire (USSQ). The primary efficacy outcome was the urinary symptom score of the USSQ, and the secondary efficacy outcomes were the scores in the other five USSQ domains, the Euro-QOL score, and oral analgesic requirements during the 2 weeks. Efficacy outcomes were primarily analyzed for the per-protocol set population. The four groups were generally well balanced in terms of baseline characteristics. Eighty-one patients (72.3 %) completed the study protocol. Comparison of the six USSQ domain scores at week 2 showed no differences between the four groups. Similarly, comparison of the domain scores stratified by tamsulosin or solifenacin medication showed no differences for either medication. The other secondary outcomes were also similar in the group comparisons. Neither tamsulosin nor solifenacin medications provide beneficial effects for relieving various SRSs. In addition, the combination therapy did not have beneficial effects. Further studies are warranted to determine the benefit of medical therapy for the treatment of SRSs and to determine the optimal management strategy for SRSs.

Extracorporeal Ureteric Stenting for Pediatric Laparoscopic Pyeloplasty.

We aimed to evaluate a novel technique for ureteric stent insertion during dismembered pediatric laparoscopic pyeloplasty. Following identification and dissection of the ureteropelvic junction (UPJ) with the proximal part of ureter, the ureter is dismembered just proximal to the UPJ at the level of the renal pelvis, allowing use of the excess pelvic tissue for further manipulation of the ureter. Then the abdomen is desufflated and the ureter delivered to the skin level. The externalized ureter is then spatulated and the stent inserted in an antegrade fashion to the bladder. The first stitch for further laparoscopic anastomosis is applied to the lower part of the spatulated ureteric end and then following insufflations the ureter is returned to the abdomen. The laparoscopic anastomosis is completed in a routine fashion. Over the past 4 years, we have used this technique in 26 children (17 boys and 9 girls) with median age of 4 years (range, 2-18 years). Left pyeloplasty was performed in 16 and right pyeloplasty in the remaining 10 patients. The mean (range) time of insertion was 6 minutes (range, 4-7 minutes). All stents were correctly placed. In one patient, the stent dislodged to distal part of the ureter. No other intraoperative or postoperative complications related to our technique of stent insertion were observed. Our data show that extracorporeal antegrade ureteric stent insertion is an easy-to-learn and a safe and reliable technique for pediatric dismembered pyeloplasty. It obviates the problem of having the stent in the pelvis during dissection and the need for patient repositioning.

Ureteral Stent Failure in Pediatric Patients Under 10 Years: Occurrence and Risk Factors

To examine the occurrence of ureteral stent failure in pediatric patients aged <10 years and to determine risk factors for failure. We performed a retrospective cohort analysis of 100 patients who underwent ureteral stent insertion between January 2006 and December 2013. All patients were aged <10 years and were followed up until ureteral stent removal. Information regarding patient demographics, reason for stent insertion, duration of stent maintenance, stent diameter and length, and postoperative results was collected. Risk factors for stent failure were analyzed. Ureteral stenting was performed in 114 ureter units. The median age at stenting was 34.1 months (interquartile range [IQR], 8.1-71.2 months), and the median duration of stent maintenance was 35.0 days (IQR, 21.0-44.3 days). A 3-Fr stent was used in 39.5% of patients. Stent failure was observed in 11 ureter units (9.6%) at a median of 11.5 days (IQR, 7.8-24.5 days) after insertion, and the stent was subsequently removed. Use of a 3-Fr ureteral stent was the only risk factor for the development of stent failure; the failure rate was 20.0% with this stent diameter. Ureteral stenting was a useful procedure with a high success rate, even in patients aged <10 years. A 3-Fr ureteral stent was the only risk factor for stent failure; its substantial failure rate should be considered when deciding whether to insert a stent. Also, short-term re-evaluation after ureteral stent insertion is mandatory, especially with 3-Fr ureteral stents.

Where are the Stents? A Computerized Tracking System to Eliminate the Forgotten Ureteral Stent

IntroductionUreteral stent placement is the main treatment for ureteral obstruction in contemporary urological practice. Meticulous followup is required to confirm ureteral stent removal. Forgotten ureteral stents create significant patient and physician risk. We assessed the efficacy of an electronic spreadsheet tracking system at a VA medical center urology practice to monitor ureteral stent placement and retrieval. MethodsFrom January 2012 to February 2014 a computer based monitoring system was begun for all stents placed in our practice. An Excel® spreadsheet was used to track ureteral stent insertion and removal. The VA Computerized Patient Record System was used to confirm ureteral stent removal. The spreadsheet included an automatic calculator feature to alert technicians/surgeons when stents remained in place 180 days or longer. ResultsIn 335 patients a total of 379 stents were placed from January 2012 to February 2014. Of these 379 stents 369 were removed or exchanged in 180 days or less. Ten patients died with stents in place and were counted in the removal group for an overall 100% rate of stents accounted for/removed during the study period. ConclusionsAn electronic spreadsheet is an effective method to track ureteral stent placement and removal. Manual data entry, and frequent spreadsheet followup and monitoring contributed to a 100% retrieval rate in this study. Future efforts should focus on automated systems that generate reminders with less emphasis on human data entry and tracking.

Efficacy of Tadalafil on Lower Urinary Tract Symptoms of Patients with Ureteral Stents: A Study Protocol for a Randomized Controlled Trial

ABSTRACT Objectives: Ureteral stenting is a common intervention in endourological procedures. Despite the usefulness of stents, patients may experience various stent-related symptoms. These symptoms can have a significant impact on patients’ health related quality of life. There are several medical modalities for symptom improvement and Phosphodiesterase 5 Inhibitors are recent therapeutic option. This study is designed to evaluate the effects of Tadalafil on alleviation of stent associated symptoms measured by Ureteral Stents Symptom Questionnaire. Design: In this Randomized Controlled Trail patients were randomly assigned to an intervention or Placebo group by a computer based random block design. Patients received encoded drug packages from a central call system. Physicians, patients and statistical analyzers were not aware of the designated intervention. Setting and Conduct: Patients received treatment with Tadalafil or placebo for four weeks after ureteral stent insertion and completed a follow up session four weeks after the intervention.

Ureteral stent insertion for gynecologic interstitial high-dose-rate brachytherapy.

To determine the utility of ureteral stents in interstitial gynecological brachytherapy. We reviewed 289 patients with cervix cancer treated with high-dose-rate interstitial brachytherapy who did not have pretreatment hydronephrosis to determine the relative incidence of benign ureteral strictures after treatment. We also did comparative dosimetry analysis in five cases of high-dose-rate brachytherapy. Bilateral ureteral stents were placed during the procedure. Three dosimetry plans were created to determine the impact of modifying clinical target volume (CTV) and applying ureteral dose constraints. In Plan 1, the ureters were contoured and excluded from the CTV and 120% dose constraints were applied. In Plan 2, the ureters were contoured and excluded, but no dose constraints were applied to the ureter. In Plan 3, the CTV was created as if the location of the ureters was unknown and then ureteral dose was determined. There were 11 ureteral strictures observed in 255 nonstented cases and 0 ureteral strictures in 34 stented cases. Plan 1 reduced the ureter dose (D(0.1cc)) by a median 22% (7.0-53.8%) compared with Plan 2 and by a median of 30.9% (12.3-65%). compared with Plan 3. Placement of stents and ureteral dose constraints facilitates dosimetry and reduces the dose to ureters. Temporary ureteral stents prevent obstruction during interstitial gynecologic brachytherapy and allows the ureters to be addressed as an organ at risk.

Is Routine Postoperative Diuresis Renography Indicated in All Adult Patients After Pyeloplasty for Ureteropelvic Junction Obstruction?

To determine if routine follow-up diuresis renography is indicated in all adult patients after pyeloplasty for ureteropelvic junction obstruction (UPJO). A multicenter retrospective analysis was conducted in adults who underwent pyeloplasty for symptomatic UPJO between January 2002 and August 2012. Patients with unilateral UPJO demonstrated on diuresis renography, treated with pyeloplasty, and aged >18 years at time of surgery were included in the study. Patients with contralateral renal abnormalities, genitourinary anomalies, and those who declined renography during follow-up were excluded. All eligible patients underwent diuresis renography approximately 3 months postoperatively. Minimal follow-up was 12 months. Patients were divided into 2 groups: patients with persistent pain at 3 months after pyeloplasty and patients who became asymptomatic. Treatment failures in each cohort were identified. Comparisons were performed using the Fisher exact test. A total of 100 pyeloplasties were performed. Of them, 90 were eligible for the study. Mean age was 40 years. Mean follow-up was 21 months. Seventy-three patients (81.1%) became pain free after pyeloplasty. One patient (1.4%) had worsening of differential renal function despite unobstructed drainage on diuresis renogram. None of the patients in the asymptomatic cohort was identified to have unequivocal drainage obstruction on postoperative renogram. Seventeen patients (18.9%) remained symptomatic with pain at 3 months after pyeloplasty; 3 (17.6%) of those patients with loin pain after pyeloplasty were confirmed to have persistent obstructed drainage postoperatively on diuresis renogram (P <.001). All 3 patients required insertion of ureteric stents and/or revision surgery (P <.007). In our series, adult patients who became pain free after unilateral pyeloplasty for UPJO did not have persistent obstruction of renal drainage on renography. Routine diuresis renogram to assess drainage and differential renal function in patients who become pain free after pyeloplasty for UPJO may not be necessary. If objective evidence of postoperative outcome is required, then a single renogram at 3 months is recommended.

Comparison of efficacy and bladder irritation symptoms among three different ureteral stents: A double-blind, prospective, randomized controlled trial

Objective. Various ureteral stents have been developed to reduce ureteral stent-related discomfort. The aim of this prospective, randomized study was to compare the efficacy and morbidity of three different ureteral stents. Materials and methods. Between June 2012 and May 2013, patients who underwent ureteral stent insertion after ureteroscopic stone removal were randomized in a double-blind fashion to receive three different stents (group 1, Endo-Sof™ double-pigtail ureteral stent, Cook Medical; group 2, Enhanced Durometer loop stent, Bioteq; group 3, Polaris™ Ultra ureteral stent, Boston Scientific). Ninety patients who met the inclusion criteria were administered the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) preoperatively, after 2 weeks with the stent in situ and 4 weeks after its removal. The Visual Analogue Pain Scale (VAPS), presence of gross hematuria and ultrasound for hydronephrosis grade were checked at 2 weeks with the stent in situ and 4 weeks after its removal. Results. After stent insertion, the degree of hydronephrosis was not significantly different among the three groups. Patients in group 3 showed significantly less increase in the total IPSS and storage symptom subscores than did those in the other groups. Mean VAPS after ureteral stent insertion was significantly lower in group 3 than in the other groups. The presence of gross hematuria after ureteral stent insertion occurred more frequently in groups 1 and 2 than in group 3. Conclusions. The Polaris Ultra ureteral stent showed similar efficacy and favorable tolerability in regard to bladder irritation symptoms, stent-related pain and presence of gross hematuria compared with other stents.

Ante-grade ureteric stenting, retrospective experience in managing 89 patients: Indications, complications and outcome

Background: Over the past three decades there has been a remarkable increase in interventional uro-radiological procedures in the developed countries. Long-term drainage of the obstructed upper urinary tract may be achieved by percutaneous nephrostomy or ureteric stenting. Previously most ureteric stents were inserted by the retrograde approach at cystoscopy and these procedures have required the use of general or spinal anesthesia. With the development of a nephrostomy service in most hospitals throughout the world ante-grade ureteric stenting procedures are being carried out by trained interventional radiologists in the radiology department without the need for a general or spinal anesthesia. Aims/materials and methods : To review the records of all 89 patients who had insertion of ante-grade ureteric stents for ureteric obstruction between February 2010 and January 2013 in order to document the following: The causes of obstruction; The side (left, right or both sides) and site of the ureteric obstruction (upper, mid or lower ureter); The sex and ages of the patients; Success or failure of the procedure; Complications of procedure; The management of the complications. Results : Ante-grade ureteric stenting was successful in 105 out of 121 procedures (86.7%) which 89 patients underwent. Out of 105 successful ante-grade stenting procedures carried out, 103 were successful at first attempt, another two were successful at second attempt and one successful at a third attempt, making it a total of 105 successful procedures. There were minimal complications. Conclusion and recommendation: Ante-grade ureteric stenting is a safe procedure with minimal complications. Every radiology unit should have a trained interventional radiologist capable of performing ante-grade ureteric stenting.

PLD.46 Bladder injuries at caesarean section (c/s); 2 different presentations

Changing demographics of the obstetric population with older mothers, raised BMI, increased CS rates, along with the challenge of keeping training within the EWTD constraints makes it important to revisit...

Colonic perforation during percutaneous nephrolithotomy: An 18-year experience.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large, extracorporeal lithotripsy failure stones and those in the inferior calyx. Despite the development of new techniques and the increasing experience in recent decades, complications may still occur. Colonic perforation is one of the most dangerous and rare complications of PCNL, which may lead to peritonitis and sepsis. We present our 18-year experience on the diagnosis and management of colonic perforation during PCNL. We retrospectively reviewed the data of 5260 PCNL procedures performed between May1995 and August 2013. Preoperative and operative factors, such as age, sex, history of previous ipsilateral stone intervention, stone side, stone location, site of skin puncture and punctured calyx, were reviewed in patients with colonic injury. Colonic perforation was found in 11 patients (5 males and 6 females) and the mean age was 40.4 ± 22.2 years (range: 4 to 71). All injuries were retroperitoneal. The left side was affected in 5 patients and the right side was injured in 6 cases. Conservative management was the treatment planned for all patients. It included withdrawal of the nephrostomy tube outside the kidney to the colon as a percutaneous colostomy, insertion of a double-J ureteral stent, intravenous broad-spectrum antibiotics, bowel rest and total parenteral nutrition. Under this conservative management, complete healing of the colon was achieved in all patients. Early diagnosis and conservative management of colonic perforation can minimize patient morbidity and mortality and result in excellent healing of the fistulous tract without any serious complications.

Three‐dimensional sonographic virtual cystoscopy in a case of placenta percreta

The three forms of morbidly adherent placenta (MAP), accreta, increta and percreta, are an emerging obstetric challenge, at times resulting in life-threatening bleeding and/or need for peripartum hysterectomy. The increasing incidence of MAP appears to be linked directly to that of Cesarean delivery. Prenatal diagnosis of MAP by means of ultrasound and/or magnetic resonance imaging in high-risk populations is feasible and leads to improved maternal and neonatal outcomes through multidisciplinary planning of delivery1. Of particular importance is the differential diagnosis between placenta percreta and the less severe forms of MAP, i.e. placenta accreta and increta, and it has been shown that this is possible using ultrasound2-4. Preoperative knowledge about the degree of bladder invasion is key to safe and successful surgical management of MAP: in some cases, cystectomy with preoperative insertion of ureteral stents are required. Moreover, in some cases of severe placenta percreta, depending on the degree of bladder invasion, conservative treatment without hysterectomy is feasible. Conventional cystoscopy can identify lesions occupying the full thickness of the bladder wall but does not provide detail on vascularization of the adjacent placental basal layer (Figure 1), the extent of which is related directly to the degree of MAP. In our diagnostic work-up of patients with MAP, we have introduced three-dimensional high-definition flow (3D-HD-flow) ‘sonographic virtual cystoscopy’5 to analyze the vascular topography of the uterine–bladder interface (Figure 2). In this case of placenta percreta, we carried out a targeted 3D-HD-flow transvaginal examination (Voluson E8 Expert machine, GE Medical Systems, Zipf, Austria), with the bladder filled to 300 mL, which we consider optimal for evaluating the uterine–bladder interface. Following volume acquisition, we analyzed the image with glass-body rendering (Figure 2 and Videoclip S1) and were able to determine that the posterior bladder wall was contiguous with the abnormal site of placental insertion. In cases of placenta percreta, visualization of the vascularity within the basal layer of the placenta allows early ascertainment of the degree of myometrial infiltration and involvement of the bladder mucosa. This knowledge is important for scheduling the timing of delivery and the surgical approach. In the management of placenta percreta, we believe that sonographic virtual cystoscopy can complement information provided by conventional cystoscopy. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. The following supporting information may be found in the online version of this article: Videoclip S1 Rotation of a three-dimensional high-definition flow sonographic glass-body rendered volume, showing widespread vascularization of the uterine serosa–bladder interface with intact bladder mucosa in a case of early placenta percreta.

Retrograde Transileal Conduit Stent Placement for Obstructed Uropathy—Success of Primary and Exchange Stent Placement

PurposeTo assess the safety, success, and complications associated with retrograde ureteric stent insertion via the ileal conduit. Materials and MethodsThe study population comprised 35 consecutive patients (17 men and 18 women; mean age, 55 y; age range, 40–75 y) requiring primary (20 stents) and exchange (70 stents) retrograde ureteric stent insertion via the ileal conduit over a 3-year period. Patient demographic data, procedural and technical data, and clinical follow-up data were collected. ResultsTechnical success was 90% (18 of 20) for primary stent placement and 100% (70 of 70) for stent exchange. There were two immediate complications (< 24 h) of sepsis and ureteric injury and one early complication (> 25 h but < 30 d) of sepsis requiring observation and medical management. Difficult procedures (defined as a fluoroscopy screening time > 31 min) and technical failures were found to be associated with encrusted stents visualized on prior computed tomography (P = .012), increased length of ileal conduit (> 20 cm) (P = .023), and ileal conduit kink (< 90 degrees) (P = .032). Only the occurrence of encrusted stents visualized on prior computed tomography (P = .022) was associated with complications. ConclusionsRetrograde placement of ureteric stents via the ileal conduit is safe and effective. Retrograde stent placement should be considered the treatment option of choice for a first-time occurrence of obstructive uropathy at the ureteroileal anastomosis.

Salvage Laparoscopic Pyeloplasty in the Worst Case Scenario: After Failed Open Repair and Endoscopic Salvage

We present the video of a laparoscopic correction of a left ureteropelvic junction obstruction in a patient who has already undergone previous surgical open pyeloplasty and subsequent acucise for failure of the first surgery. At 8 years after the second surgery, the patient showed a recurrence of the obstruction of the left ureteropelvic junction. It was decided to perform the retroperitoneal laparoscopic correction of the obstruction. With the patient placed in a 90° flank position, 4 trocars are placed in the retroperitoneum space by the Hasson tecnique. After the creation of the retroperitoneum space, the Gerota's fascia is opened. The posterior layer of the Gerota's fascia appears very thickened at the level of the lower pole of the kidney and is very adherent with the surrounding structures, in particular the psoas muscle. Gerota's fascia is incised and removed from the previous surgery and the psoas muscle is identified. The distal lumbar ureter is tenaciously anchored to the psoas muscle. The lower pole of the kidney is freed from the adhesions of the previous surgery. The proximal ureter is hardly isolable for the presence of fibrosis. The renal pelvis is fixed to the psoas due to fibrotic tissue that is cut with scissors. Once the pelvis and the ureter are separated from the psoas, the surgery proceeds with the liberation of the pelvis from the adipose tissue and fibrosis that surround it. The pieloureteral obstruction is not easily identifiable. The renal pelvis is opened at the level of the ureteral junction, the ureter is spatulated on its medial side. The scar tissue is removed until well vascularized tissue is seen. The anastomosis between the ureter and pelvis is performed with 2 semicontinuous running sutures. Once the anterior plate of the anastomosis is completed a cystoscopic retrograde DJ ureteral stent insertion is performed. The procedure ends with the packaging of the posterior plate of the anastomosis with the second running suture. The operation lasted 180 minutes. The postoperative course was uneventful, the drain was removed on the second day and the bladder catheter on the 4th. The patient was discharged on the 5th day and the DJ ureteral stent was removed on the 21st post-operative day. The laparoscopic reoperation in patients with previous open surgery interventions is definitely difficult. This kind of surgery has to be carried out after having gained considerable laparoscopy experience. Specifically, the reoperation of laparoscopic pyeloplasty after 2 previous intervention poses the following difficulties: the creation of appropriate space, dissection of the ureter and pelvis from the psoas muscle, appropriate mobilization of the lower pole of the kidney to get a "tension free" anastomosis, liberation of the pelvis and ureter from the tenaciously adherent fibrotic tissue, identification of the stenotic ureteropelvic junction. Laparoscopic pyeloplasty after failure of past interventions remains a difficult procedure that should only be performed after major laparoscopic experience. In experienced hands, redo laparoscopic pyeloplasty provides high success rates.

Percutaneous antegrade nephroscopic holmium laser pyelotomy: Novel endourologic technique for removal of extruded ureteral stent

Ureteral stent malposition outside of the urinary tract is a very uncommon complication of retrograde or antegrade ureteral stent insertion. There are few reports of open, laparoscopic or endourologic approaches to remove malpositioned stents. We present a novel technique for the removal of an extruded retroperitoneal ureteral stent using percutaneous antegrade nephroscopic holmium laser pyelotomy. This previously undescribed procedure represents a new soft tissue application of the holmium laser.