Riñón pélvico fusionado con uréter único, hidrometrocolpos y ano imperforado: conjunción de malformaciones infrecuentes en una adolescente / Pancake kidney with a single ureter, hydrometrocolpos, and imperforate anus: a set of uncommon malformations in a female adolescent

Una niña de 11 años de edad con antecedentes de ano imperforado, infección urinaria y episodios de constipación intermitentes se presentó a la consulta con cólicos abdominales y náuseas de una semana de evolución. Estudios radiológicos revelaron hidrometrocolpos y fusión renal pélvica con uréter único hidronefrótico. El examen vaginal evidenció un tabique transverso no permeable. Se evacuó temporalmente la colección con resolución de los síntomas. La paciente fue programada para cirugía vaginal reconstructiva definitiva. Se destaca en este caso no solo la asociación de malformaciones infrecuentes, sino una sintomatología muy común en la práctica pediátrica a causa de una patología rara vez considerada en el diagnóstico diferencial, y la importancia de una evaluación precoz y completa de este tipo de malformaciones para un tratamiento oportuno.

An 11-year-old girl with a history of imperforate anus, urinary tract infection, and intermittent episodes of constipation presented with abdominal pain and nausea for 1 week. The x-rays revealed hydrometrocolpos and fused pelvic kidney with a single hydronephrotic ureter. The vaginal examination revealed a non-permeable transverse vaginal septum. The collection was temporarily drained and symptoms resolved. The patient was scheduled for definitive vaginal reconstructive surgery. In this case, it is worth noting the association of infrequent malformations and also the signs and symptoms very common in pediatric practice due to a pathology rarely considered in the differential diagnosis, and the importance of an early and complete assessment of this type of malformations for a timely treatment.

Le pseudo kyste abdominal: une complication de la dérivation ventricule péritonéale à propos d'un cas / The abdominal pseudocyst: a complication of ventriculoperitoneal bypass about a case

Le pseudokyste abdominal est une complication rare pouvant survenir chez les sujets porteurs d'une dérivation ventriculo-péritonéale (DVP). Nous rapportons le cas d'un adolescent de 11 ans, chez qui une DVP a été réalisée pour une hydrocéphalie congénitale. Il présentait une distension abdominale progressive sans notion de troubles de transit. L'imagerie (échographie, urosacnner) a permis de mettre en évidence un épanchement péritonéal de grande abondance organisé, à paroi fine et régulière, exerçant un effet de masse sur la vessie et les uretères, responsable d'une urétérohydronéphrose bilatérale. Le bout distal du cathéter de DVP a été visualisé dans la collection

The abdominal pseudocyst is a rare complication that can occur in subjects with a ventriculoperitoneal drain (VPD). We report the case of an 11-year-old adolescent with congenital hydrocephalus antecedent, for whom a ventriculoperitoneal shunt was made. He presented a progressive abdominal distension without notion of transit disorders. Abdominal ultrasound and uroscanner revealed an organized peritoneal effusion of great abundance, thin and regular wall, exerting a mass effect on the bladder and the ureters responsible for bilateral uretero-hydronephrosis. Above all, it has made it possible to individualize the distal ventriculo-peritoneal bypass catheter projecting in the effusion

Ureteroscopy Outcome and Its Determinants in a Resource-Limited Setting

Ureteroscopy is a major diagnostic and therapeutic technique for lesions of the ureter and intrarenal collecting system. METHODS: A retrospective chart review was done at St. Paul's Hospital Millennium Medical College, Ethiopia to determine the outcome of ureteroscopy and factors affecting it. The study period was from January 2018 to April 2018. Multivariate analysis was done to determine factors affecting stone clearance and success rate. RESULT: One hundred six patients who underwent semirigid ureteroscopy were included in the study. The male-to-female ratio was 1.8:1. The mean age of the patients was 36.4 years (±12.6). Ninety-six (90.6%) patients were found to have ureteric stones, while 9(8.5%) patients had a ureteric stricture. Ureteroscopy therapeutic interventions for stones were successful in 89 (92.7%) patients. The mean procedure time and postoperative hospital stay were 44 minutes (±23.7) and 2.5 days (±2.5) respectively. Intraoperative complications (ureteric avulsion, hemorrhage, and ureteral perforations) occurred in 6(5.7%) patients. The stone clearance rate was 54.7% (52). The site of obstruction was passed in 93 patients making the success rate of the procedure 87.7%. The absence of intraoperative complications was significantly associated with success rate. Patients with intraoperative complications have low success rate (20%) compared to patients without complications (92.3%), p=0.42. CONCLUSION: Semirigid ureteroscopy had a good success rate, especially for stones in the distal ureter and if there is no flexible ureteroscope, it is an acceptable alternative

Intravenous infusion of methylene blue to visualize the ureter in laparoscopic colorectal surgery / 中华胃肠外科杂志

Objective: Intraoperative localization of the ureter can contribute to accurate dissection and minimize ureteral injury in colorectal surgery. We aim to summarize a single center's experience of fluorescence ureteral visualization using methylene blue (MB) and explore its visualization efficiency. Methods: This is a descriptive case-series-study. Clinical data of patients who had undergone laparoscopic colorectal surgery and fluorescence visualization of the ureter in the Gastrointestinal Surgery Department of Guangdong Provincial People's Hospital from March 2022 to May 2022 were retrospectively collected. Patients with incomplete surgery videos, renal insufficiency, or allergic reactions were excluded. MB was infused with 0.9% NaCl at 1.0 mg/kg in 100 mL of normal saline for 5 to 15 minutes during laparoscopic exploration. Imaging was performed using a device developed in-house by OptoMedic (Guangdong, China) that operates at 660nm to achieve excitation of MB. Clinical information, MB dosage, rate of successful fluorescence, time to fluorescence, operation time, blood loss, intraoperative blood oxygen levels, pathological staging, changes in renal function, and post-operative complications were retrospectively analyzed. Results: The study cohort comprised 27 patients (24 men and 3 women) with an average age of (60.25±16.95) years and an average body mass index of (21.72±3.42) kg/m2. The dosage of MB was 0.3-1.0 mg/kg and the infusion time was 5-15 minutes. Fluorescence signals were detected in all patients. The median time to signal detection was 20 (range, 10 to 40) minutes after MB infusion. The range of intraoperative blood oxygen fluctuation averaged 2.5% (range, 0 to 7.0%). The median change in creatine concentration was -1.3 (range, -17.2 to 29.2) µmol/L. No patients had complications associated with use of MB. Fluorescence visualization of the ureter was very valuable clinically in two patients (thick mesentery, stage T4). Conclusion: MB is a safe and effective means of visualizing the ureter by fluorescence during laparoscopic colorectal surgery, especially when the procedure is difficult. MB in a dosage of less than 1 mg/kg can slowly infused for more than 5 minutes during laparoscopic exploration. During the infusion, attention must be paid to blood oxygen fluctuations.

Mysterious ureteral migration of a wooden toothpick from the digestive tract: case report and diagnostic considerations

ABSTRACT Migration of foreign bodies into the urinary tract is a rare event. In certain instances, to unravel the way that objects arrived in the urinary tract is not easy. We report the case of an accidentally swallowed wooden toothpick that migrated and was found in the left ureterovesical junction, protruding into the bladder. Even though the computed tomography scan is widely employed to evaluate the urinary tract, this resource does not have a good sensitivity for detecting foreign bodies. Our report presents an insight into the best imaging approach if wooden toothpicks are suspected. In the present case, the endoscopic treatment was possible with an uneventful outcome and a complete resolution of symptoms.

How we do it: robotic-assisted distal ureterectomy with ureteral reimplantation

ABSTRACT Background: High risk upper tract urothelial carcinoma (UTUC) is typically managed with radical nephroureterectomy, however, renal preservation can be attempted when UTUC is localized to the distal ureter in the presence of chronic kidney disease (1-3). Distal ureterectomy is typically managed with a ureteral reimplantation and psoas hitch in order to maintain urothelial continuity, to avoid comprising the contralateral ureter, and reducing risk of chronic urinary tract infections and electrolyte abnormalities (4). We present our case of distal ureteral UTUC managed robotically with a distal ureterectomy with ureteral reimplantation. Technique and Follow-Up: Initially, an Orandi needle on a resectoscope circumscribed the left ureteral orifice. Next, robotically, the retroperitoneum was exposed and a left sided pelvic lymphadenectomy was completed. The left ureter was mobilized and the diseased ureteral segment was transected. The mobilized bladder was sutured to psoas fascia. After a cystotomy, the ureter was re-anastomosed to the bladder. The patient was discharged on postoperative day three and re-evaluated one week later with a cystogram. Final pathology was downgraded to non-invasive low-grade papillary urothelial carcinoma with negative lymph nodes and margins. Conclusion: High risk UTUC localized to the distal ureter in the setting of chronic kidney disease can be managed with a distal ureterectomy (3). Robotic distal ureterectomy with ureteral reimplantation can be assisted by an Orandi needle to achieve negative margins. Utilizing a robotic technique can offer challenges with the ureteral spatulation and reanastomosis (5-7). By fixating the ureter to the bladder prior to reanastomosis, our technique offers a solution for these difficulties.

Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys?

ABSTRACT Introduction: Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach. Materials and Methods: Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump. Results: Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78). Conclusion: Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.

How I do it open distal ureteroureterostomy for ectopic ureters in infants with duplex systems and no vesicoureteral reflux under 6 months of age

ABSTRACT We describe a step by step technique for open distal ureteroureterostomy (UU) in infants less than 6 months presenting with duplex collecting system and upper pole ectopic ureter in the absence of vesicoureteral reflux (VUR).

The effects of pregabalin, solifenacin and their combination therapy on ureteral double-J stent-related symptoms: A randomized controlled clinical trial

ABSTRACT Background: Many medical therapies have been tested to deal with urinary stent-related symptoms (USRS). Several preventive and pharmaceutical methods have been already used for better compatibility of stents. However, the existing evidence for pharmacological treatment is still controversial. This study aims to evaluate the effects of pregabalin, solifenacin, and combination therapy on ureteral double-J stent-related symptoms following ureteroscopy and transureteral lithotripsy (TUL). Materials and methods: In a randomized controlled clinical trial, from November 2017 to March 2019, 256 patients who underwent ureteroscopy were enrolled. Patients were randomly divided into four groups including: group A received pregabalin 75mg BID (twice daily), group B received solifenacin 5mg orally once daily, group C received combination of pregabalin and solifenacin and the group D (control) given no drugs. Results: One hundred and fifty-one (58.9%) males and 101 (41.1%) females were enrolled in this study with a mean age of 43.47±7 (p=0.32, p=0.67). USSQ domains score such as urinary symptoms, pain, general condition, work performance, sexual matters and additional problems were significantly differenced during second and fourth week of follow-up among study groups (p <0.0001). In Tukey's multiple comparison test, urinary symptoms (p=0.735), pain (p=0.954) and sexual matters (p=0.080) in second week and work performance in forth week in group B was not significantly better than group D. Only group C in all indexes of USSQ showed significantly beneficial effects over group D (p <0.0001). Conclusion: Combination therapy of pregabalin and solifenacin has a significant effect on stent-related symptoms and is preferred over monotherapy of the respected medications.

Patients with encrusted ureteral stents can be treated by a single session combined endourological approach

ABSTRACT Purpose: To describe our experience in the management of retained encrusted ureteral stents using a single session combined endourological approach. Materials and Methods: Patients with retained encrusted ureteral stents who had been submitted to a single session combined endourological approach from June 2010 to June 2018 were prospectively evaluated. Patients were divided according to the Forgotten-Encrusted-Calcified (FECal) classification. The stone burden, surgical intervention, number of interventions until stone free status, operation time, hospital stay, complications, stone analysis, and stone-free rate were compared between groups. ANOVA was used to compare numerical variables, and the Mann-Whitney or Chi-square test to compare categorical variables between groups. Results: We evaluated 50 patients with a mean follow-up of 2.9±1.4 years (mean±SD). The groups were comparable in terms of age, sex, laterality, BMI, comorbidities, ASA, reason for stent passage, and indwelling time. The stone burden was higher for grades IV and V (p=0.027). Percutaneous nephrolithotomy was the most common procedure (p=0.004) for grades IV and V. The number of procedures until the patients were stone-free was 1.92±1.40, and the hospital stay (4.2±2.5 days), complications (22%), and stone analysis (66% calcium oxalate) were similar between groups. The stone-free rate was lower in grades III to V (60%, 54.5%, and 50%). Conclusions: The endoscopic combined approach in the supine position is a safe and feasible technique that allows removal of retained and encrusted stents in a single procedure. The FECal classification seems to be useful for surgical planning.

High pressure endoscopic irrigation: impact on renal histology

ABSTRACT Purpose: High intra-renal pressures during flexible ureteroscopy have been associated with adverse renal tissue changes as well as pyelovenous backflow. Our objective was to investigate the effect of various intra-renal pressures on histologic changes and fluid extravasation during simulated ureteroscopy. Materials and Methods: Twenty-four juvenile pig kidneys with intact ureters were cannulated with an Olympus flexible ureteroscope with and without a ureteral access sheath and subjected to India ink-infused saline irrigation for 30 minutes at constant pressures ranging from sphygmomanometer settings of 50mm, 100mm and 200mmHg. Renal tissue samples were collected, processed and stained, and were evaluated by a blinded pathologist for depth of ink penetration into renal parenchyma as a percentage of total parenchymal thickness from urothelium to renal capsule. Results: The mean percentage of tissue penetration for kidneys with ink present in the cortical tubules at sphygmomanometer pressure settings of 50, 100, and 200mm Hg without a ureteral access sheath was 33.1, 31.0 and 99.3%, respectively and with ureteral access sheath was 0, 0 and 18.8%, respectively. Overall, kidneys with an access sheath demonstrated a smaller mean tissue penetration among all pressure compared to kidneys without a sheath (6.3% vs. 54.5%, p=0.0354). Of kidneys with sheath placement, 11% demonstrated any ink compared to 56% of kidneys without sheath placement. Conclusions: Pressurized endoscopic irrigation leads to significant extravasation of fluid into the renal parenchyma. Higher intra-renal pressures were associated with increased penetration of irrigant during ureteroscopy in an ex-vivo porcine model.

Sheep urinary tract architecture is not affected by acute urethral obstruction / A arquitetura do trato urinário de ovinos não é afetada pela obstrução uretral aguda

Urolithiasis affects the urinary tract of small ruminants, thereby requiring the animal to prematurely terminate breeding. Morphometric study of organs can be used as a diagnostic method. Thus, this study aimed to describe the macroscopic, histopathological, and histomorphometric changes in the urinary tract of sheep with urolithiasis. For this purpose, 14 healthy male Santa Inês sheep, approximately 90 days old, were studied and fed an experimental diet. After the development of urolithiasis, the animals were reorganized into two groups, D1 (without urolithiasis) and D2 (with urolithiasis) for comparative data analysis. Sheep were necropsied to evaluate the pathological changes, followed by macroscopic morphometric analysis, and the histopathological and histomorphometric characteristics were described. Urethral necrosis and a full urinary bladder were observed in all animals that developed the disease. The comparison between sheep with and without urolithiasis showed no significant difference (P < 0.05) in the evaluated macroscopic morphometric variables, except for the right ureter width. Regarding the histopathological evaluation, multifocal areas of mild to moderate congestion within the glomerular tufts and protein in the tubular lumen of the kidneys were observed. In the liver, mild to moderate fatty degeneration was noted in the centrolobular regions, and an ulcerated focal area in the bladder mucosa was observed in only one animal. The present study demonstrated that the formulated diet was effective in inducing clinical disease. In acute obstructive urolithiasis in sheep tissue, lesions in the liver and urinary tract were observed, although there were no significant histomorphometric changes.(AU)

Urolitíase acomete o trato urinário de pequenos ruminantes causando a saída prematura de animais destinados à reprodução. O estudo morfométrico dos órgãos pode ser empregado como método de auxílio diagnóstico. Assim, este estudo objetivou descrever as alterações macroscópicas, histopatológicas e histomorfométricas do trato urinário de ovinos com urolitíase. Com esse fim, foram utilizados 14 ovinos hígidos, machos, da raça Santa Inês com idade aproximada de 90 dias, que receberam dieta experimental. Após o desenvolvimento da urolitíase os animais foram reorganizados em dois grupos experimentais distintos D1 (sem urolitíase) e D2 (com urolitíase) para a análise comparada dos dados. Os ovinos foram necropsiados para descrição das alterações patológicas, seguindo-se a análise morfométrica macroscópica e descrição quanto as características histopatológicas e histomorfométricas. Necrose de processo uretral e bexiga urinária repleta foram observados em todos os animais que desenvolveram a doença. Na comparação entre os ovinos com e sem urolitíase não houve diferença significativa (P < 0,05) nas variáveis morfométricas macroscópicas avaliadas, a exceção da largura do ureter direito. Quanto à avaliação histopatológica, foram observadas áreas multifocais de discreta a moderada congestão dos tufos glomerulares e proteína no lúmen tubular nos rins. No fígado, observou-se nas regiões centrolobulares, discreta a moderada degeneração gordurosa e apenas em um animal foi observada, macro e microscopicamente, área focal ulcerada na mucosa da bexiga. Os achados da presente pesquisa demonstraram que a dieta formulada foi eficaz na indução da doença clínica. Na urolitíase obstrutiva aguda em ovinos, lesões teciduais em fígado e trato urinário são observadas, mas não há alterações histomorfométricas significativas.(AU)