Intraparenchymal hematoma as a late complication of retrograde intrarenal surgery

ABSTRACT A 34 year-old woman was admitted to our hospital with left flank pain. A non-contrast enhanced computerized tomography (NCCT) revealed a 1.5x2cm left proximal ureter stone. Patient was scheduled for ureterorenoscopy (URS) and stone removal. She was submitted to retrograde intrarenal surgery (RIRS). At the postoperative 1st day, the patient began to suffer from left flank pain. A NCCT was taken, which revealed a subcapsular hematoma and perirenal fluid. The patient was managed conservatively with intravenous fluid, antibiotic and non-steroidal anti-inflammatory drug therapy and was discharged at the postoperative 6th day. Two weeks after the discharge the patient was admitted to emergency department with severe left flank pain, palpitation and malaise. KUB (kidney-ureter-bladder) radiography showed double-J stent (DJS) to be repositioned to the proximal ureter. Patient was evaluated with contrast enhanced CT which revealed an 8cm intraparenchymal hematoma/abscess in the middle part of the kidney. A percutaneous drainage catheter was inserted into the collection. The percutaneous drainage catheter and the DJS were removed at the 10th day of second hospitalization. RIRS surgery is an effective and feasible choice for renal stones with high success and acceptable complication rates. However, clinician should be alert to possible complications.

Ureteral stricture formation after ureteroscope treatment of impacted calculi: A prospective study

PURPOSE: Urinary calculi is a familiar disease. A well-known complication of endourological treatment for impacted ureteral stones is the formation of ureteral strictures, which has been reported to occur in 14.2% to 24% of cases. MATERIALS AND METHODS: This was a prospective study. Ureterotripsy treatment was used on patients with impacted ureteral stones. Then, after 3 months and 6 months, the condition of these patients was assessed by means of a kidney-ureter-bladder (KUB) ultrasound. If the KUB ultrasound indicated moderate to serious hydronephrosis, the patient was further assessed by means of a computed tomography intravenous urogram or retrograde pyelogram to confirm the occurrence of ureteral strictures. RESULTS: Of the 77 patients who participated in the study, 5 developed ureteral strictures. Thus, the stricture rate was 7.8%. An analysis of the intraoperative risk factors including perforation of the ureter, damage to the mucous membrane, and residual stone impacted within the ureter mucosa revealed that none of these factors contributed significantly to the formation of the ureteric strictures. The stone-related risk factors that were taken into consideration were stone size, stone impaction site, and duration of impaction. These stone factors also did not contribute significantly to the formation of the ureteral strictures. CONCLUSIONS: This prospective study failed to identify any predictable factors for ureteral stricture formation. It is proposed that all patients undergo a simple postoperative KUB ultrasound screening 3 months after undergoing endoscopic treatment for impacted ureteral stones.

Litotricia extracorpórea versus ureterolitectomía endoscópica para el manejo de litiasis de uréter distal. Costos asociados. Experiencia del Hospital Militar de Santiago / Extracorporeal shock wave lithotripsy versus endoscopic ureterolithectomy for management of distal ureteral stones. Associated costs. Experience the Military Hospital of Santiago

INTRODUCCIÓN: La ureterolitiasis distal (UD) es una patología prevalente. Su tratamiento quirúrgico es con litotricia extracorpórea(LEC) o ureteroscopía (URS), ambas con tasa libre de cálculo (TLC) sobre 90% y mínimas complicaciones. El objetivode este trabajo es comparar la TLC luego de la primera intervención y su costo asociado. Además, comparar el costo totaltratándolos con LEC o URS. PACIENTES Y MÉTODOS: Estudio descriptivo comparativo, que muestra el costo económicode LEC vs URS para tratamiento de UD entre 2009 y 2013. Se incluyeron 107 pacientes; 47 URS y 60 LEC. Se analizaronnúmero de días hospitalizados, necesidad de reintervención y costo total de atención médica. Los costos se ajustaron alvalor actual de la prestación. Se describió la TLC en ambos procedimientos. Se obtuvo el costo total de hospitalizacióny se compararon las variables de interés. RESULTADOS: l tamaño de litiasis fue 8.21mm versus 7.39mm para URS y LEC,respectivamente (p=0.24). Luego de la primera intervención, la TLC fue 97.8% para URS y 80% para LEC (p=0.007). En LEC,12 pacientes requirieron retratamiento elevando la TLC a 95%, (p=0.13). Se instaló catéter JJ en 53.1% y 18.3% para URS yLEC, respectivamente (p<0.001). El costo de honorarios médicos, insumos y derecho a pabellón, es $460.838 para URS y$1.243.075 para LEC. El número de días de hospitalización post procedimiento fue 1.6 y 1.71 días para URS y LEC, respectivamente(p=0.86). En relación con los costos totales, la LEC en promedio, es un 132% más cara respecto a la URS (p<0.001)...

INTRODUCTION: Distal ureterolithiasis (UD) is a common disorder. Its treatment is surgical either with extracorporeal lithotripsy(LEC) or ureteroscopy (URS), both with a stone free (TLC) over 90% and minimal complications. The aim of this studyis to compare the TLC after the rst intervention and its associated cost. Also, compare the total costs of treatment with LECor URS. PATIENTS AND METHODS: A comparative descriptive study, which shows the economic cost of LEC vs UD URS fortreatments performed between 2009 and 2013. 107 patients were included; 47 URS and 60 LEC. Number of hospitalizationdays, reoperation and total cost of care were analyzed. Costs were adjusted to present charges for the same procedures. TLC was described in both proceedings. The total cost of hospitalization was obtained and the variables of interest werecompared. RESULTS: Stone size was 8.21mm versus 7.39mm URS and LEC, respectively (p = 0.24). After the rst intervention,TLC was 97.8% for URS and 80% for LEC (p = 0.007). In LEC, 12 patients required retreatment raising the TLC to 95% (p = 0.13).JJ catheter was installed in 53.1% URS and 18.3% LEC, respectively (p <0.001). The cost of medical supplies, operation roomand physician fees was $460.838 for URS and $1.243.075 for LEC. The number of hospitalization days post procedure was1.6 and 1.71 days for URS and LEC, respectively (p = 0.86). In relation to total costs, LEC is on average, 132% more expensivewhen compared to URS (p <0.001)...

Extravasación urinaria renal espontánea / Spontaneous renal urinary extravasation

La extravasación espontánea de orina, descrita por Albarrán y publicada por Sole se consideraba como un hallazgo radiológico poco frecuente y la definió en 198 como la salida de orina fuera del tracto urinario en ausencia de trauma, de intervención quirúrgica previa o reciente y tampoco sin antecedente de instrumentación urológica o de urografía excretora practicada con compresión externa. Se presenta a un paciente de 28 años, sin antecedentes de interés, que acudió con cuadro astenia de 1 mes de evolución, asociado a dolor en fosa lumbar izquierda. Que fue estudiado mediante ecografía y tomografía computarizada (TC). Las exploraciones radiológicas identificaron múltiples litiasis en uréter proximal y distal izquierdo. Voluminosa colección de baja densidad rodeando al riñón izquierdo, limitada por la fascia pararrenal sugestiva de urinoma, identificando solución de continuidad en cáliz superior, que se comunica con el urinoma. El tratamiento inicial del paciente fue la colocación de Nefrostomía percutánea de urgencia, para realizar posteriormente, ureteroscopia con ascensión de las litiasis y extracción de estas mediante pielolitotomía abierta. Conclusión: El conocimiento de la clínica y de los hallazgos radiológicos de la extravasación urinaria espontánea por litiasis ureteral en las distintas pruebas de imágenes son cruciales para el manejo de los pacientes afectados por esta infrecuente complicación...

Spontaneous extravasation of urine, described by Albarran and published by Sole was considered a rare radiological finding in 198 and defined as the flow of urine out of the urinary tract in the absence of trauma, previous surgery or recent nor no history of urological instrumentation or excretory urography performed with external compression. We report a patient of 28 years, with no history of interest came with asthenia of 1 month’s duration, associated with pain in left lumbar fossa. That was studied by ultrasound and computed tomography (CT). The radiological identified multiple stones in proximal and distal left ureter. Collection bulky low density surrounding the left kidney limited by suggesting pararenal urinoma fascia, identifying continuity solution upper calyx, which communicates with the urinoma. The patient’s initial treatment was percutaneous nephrostomy placement of urgency for later ascension of the stones with ureteroscopy and removal of these by open pyelolithotomy. The knowledge of the clinical and radiological findings of spontaneous urinary extravasation with ureteral stones in various imaging tests are crucial for the management of patients affected by this rare complication...

Tratamiento endoscópico de cálculos ureterales: experiencia en una serie de 102 casos / Endoscopic treatment of ureteral stones: experience in a series of 102 cases

INTRODUCCIÓN: La ureterolitectomía endoscópica (URS) es una técnica validada para el manejo de cálculos ureterales, ya que tiene alto poder resolutivo y es poco invasiva. El desarrollo de instrumentos flexibles ha facilitado el manejo endoscópico de los cálculos en uréter medio y proximal. El objetivo de este trabajo es describir la experiencia de nuestro centro en URS. Material y metodos: Análisis retrospectivo de las URS realizadas en nuestro centro entre Diciembre 2009 y Mayo 2012. Se consignaron las características del cálculo, el método de fragmentación, la efectividad del procedimiento y las complicaciones. Se utilizaron los ureteroscopios semirrígido Wolf (6,0-9,5 Fr) y flexible Karl Storz Flex X2. Resultados: Se revisaron 102 ureteroscopías, 85 con ureteroscopio semirrígido y 17 con flexible. Los cálculos tuvieron un promedio de 5,7 mm y 642 UH. El 89,4 por ciento de los cálculos resueltos mediante URS semirrígida se localizaban en uréter distal y 52,9 por ciento de los resueltos con URS flexible en uréter proximal. Se realizó litotripsia con láser Holmium en un 25,9 por ciento y 70,6 por ciento de los casos con URS semirrígida y flexible, respectivamente. Se utilizó litotripsia pneumática en un 4,7 por ciento de los casos de URS semirrígida. En URS semirrígida y flexible, la tasa de stone-free + fragmentos < 2 mm fue de 89,4 por ciento y 88,2 por ciento, respectivamente. Sólo hubo una complicación en nuestra serie (infección urinaria febril en 1 caso con URS flexible). La mediana de hospitalización fue de 1 día (rango 1-5 días). Conclusion: Nuestros resultados reafirman a la URS como una técnica eficaz, segura y poco invasiva para el tratamiento de los cálculos ureterales.

INTRODUCTION: The endoscopic ureterolithotomy (URS) is a validated technique for the management of ureteral calculi, which is highly resolutive and minimally invasive. The development of flexible instruments has facilitated the endoscopic management of stones in the mid and proximal segments of the ureter. The aim of this paper is to describe the experience of our center in endoscopic ureterolithotomy. Material and methods: Retrospective analysis of URS performed at our center between December 2009 and May 2012. We recorded the characteristics of the stones, the fragmentation method, the effectiveness of the procedure and complications. The Wolf semi-rigid (6.0 to 9.5 Fr) and the flexible Karl Storz Flex X2 ureteroscopes were used. RESULTS: We reviewed 102 URS, 85 with semi-rigid and 17 with flexible ureteroscope. The calculi were 5.7 mm and 642 HU in average. 89.4 percent of the stones treated with a semi-rigid URS were localized in the distal ureter and 52.9 percent of the calculi treated with a flexible URS were in the proximal ureter. Holmium laser lithotripsy was performed in 25.9 percent and 70.6 percent of the cases of semi-rigid and flexible URS, respectively. Pneumatic lithotripsy was used in 4.7 percent of the semi-rigid URS. In semi-rigid and flexible URS, the rate of stone-free + fragments < 2 mm was 89.4 percent and 88.2 percent, respectively. There was only one complication in our series (febrile urinary tract infection in 1 case of flexible URS). The median length of stay was 1 day (range 1-5 days). CONCLUSION: Our results confirm that URS is an effective, safe and minimally invasive treatment for ureteral calculi.

Laparoscopic ureterolithotomy: an experience of 15 cases

To review our experience of laparoscopic ureterolithotomy and revisit its indications in the current era of minimally invasive urologic surgery. A descriptive study. The study was conducted at the department of Urology, Foundation University Medical College and Fauji Foundation Hospital, Rawalpindi from January 2007 to December 2009. We performed laparoscopic ureterolithotomies on fifteen patients for large [1.5-2.5 cm], impacted upper and middle ureteric calculi. In 10 patients laparoscopic ureterolithotomy was adopted as a primary procedure, four patients had stones resistant to Extracorporeal Shockwave Lithotripsy [ESWL], while one patient had failed ureterorenoscopy [URS]. An extraperitoneal approach was selected in all the patients. There were 11 patients with upper ureteric calculi and four with midureteric calculi, the procedure was successful in 14 cases. One patient required conversion to open ureterolithotomy. The average operating time was 50 minutes. The average hospital stay was 2.5 days. There was no major complication. One patient had persistent drain for four days. IVU at three months follow-up was normal in all cases. Laparoscopic ureterolithotomy in selected cases is a good minimally invasive procedure. Large, impacted, hard calculi which are resistant to ESWL and difficult to fragment endoscopically without flexible ureteroscopes and holmium laser can be managed by this technique

Alergia à lidocaína: relato de caso / Lidocaine allergy: case report

JUSTIFICATIVA E OBJETIVOS: Embora pareça ser extremamente rara, a real incidência de alergia à lidocaína é desconhecida. Eventos adversos como toxicidade ou reações fóbicas são freqüentemente interpretados como reações alérgicas. As respostas alérgicas geralmente acontecem devido a conservantes ou antioxidantes presentes nos agentes anestésicos. O objetivo deste relato é apresentar um caso de reação alérgica à lidocaína injetada por via subaracnóidea, no intuito de alertar profissionais da área de saúde para esta possibilidade com diagnóstico rápido e início precoce do tratamento. RELATO DO CASO: Paciente do sexo feminino, 16 anos, submetida a ureterolitotripsia a laser para ressecção de cálculo ureteral sob sedação e bloqueio subaracnóideo com lidocaína a 5 por cento (50 mg). Minutos após, a paciente apresentou placas eritematosas e pruriginosas no pescoço e tronco e edema discreto nas pálpebras e nos lábios. Foi tratada com prometazina, com reversão completa do quadro. Posteriormente, foi encaminhada ao serviço de Imunopediatria onde foram realizados testes de desencadeamento alérgico. Apresentou teste intradérmico positivo, sendo confirmada a hipótese de alergia à lidocaína. CONCLUSÕES: A reação alérgica à lidocaína é rara, no entanto é necessário que os profissionais da área de saúde estejam sempre alertas para essa ocorrência.