The Rendezvous Technique: A Minimally Invasive Non-Surgical Approach for the Management of Iatrogenic Ureteral Injuries.

Background/Objectives: The aim of our study is to evaluate the feasibility and efficacy of the rendezvous technique for the treatment of iatrogenic ureteral injuries. Methods: From 2014 to 2019, 29 patients treated with the rendezvous technique for mono- or bilateral iatrogenic ureteral injuries were enrolled in this retrospective study. All the leaks were previously assessed by CT-urography and antegrade pyelography. Ureteral continuity was restored by performing the rendezvous technique, combining antegrade trans-nephrostomic access and a retrograde trans-cystostomic approach. A double J stent was antegradely inserted, and a nephrostomy tube was kept in place at the end of the procedure. A post-procedure CT-urography and a 30-day nephrostogram follow-up were performed. In the absence of a contrast leak, the nephrostomy tube was removed. Patient follow-up was set with CT-urography at 3, 6, and 12 months and stent substitution every 4 months. The CT-urography was performed to confirm the restored integrity of the ureter before stent removal. Results: The rendezvous technique was successful in all cases with the resolution of the ureteral leak. No major complications were observed. In all the patients, the nephrostomy tube was removed after 30 days. After performing CT-urography, the stent was removed permanently after 12 months. Only three cases showed local post-treatment stenosis treated with surgical ureteral reimplantation. Conclusions: The rendezvous technique is a safe and effective minimally invasive procedure that can be used to restore the continuity of the ureter, avoiding open surgery and providing valuable support for the management of complications after gynecological surgery.

Uretero-uterine fistula following Manual Vacuum Aspiration for Incomplete abortion: A rare case report.

Genitourinary fistulas are a well-recognized complication of various gynecological, obstetrical, and endourological interventions. The incidence of uretero-uterine fistula is very rare compared to other genitourinary fistulas. Few cases are reported in literature regarding the uretero- uterine fistula following manual vacuum aspiration of retained product of placenta. We report a case of 28 year multi-parous women who had presented with complain of involuntary passage of urine following manual vacuum aspiration for retained product of conception. Common tests for suspicion of uretero-uterine fistula include cystoscopy, triple swab test, and CT urography. Our patient was diagnosed in CT urography and was managed by exploratory laparotomy with end-to-end anastomosis of the right ureter, DJ stenting, and repair of a uterine perforation. Due to relatively rare incidence of this condition, there has not been a specific guideline for management. A multimodality and multidisciplinary approach have been proposed for the management of uretero-uterine fistulas.

Is the excretory phase necessary to identify upper tract urothelial neoplasms at CT urography? A 10-year population-based study.

PURPOSE: To assess the proportion of upper tract urothelial carcinomas (UTUC) that are evident without the excretory phase at CT urography (CTU), and the proportion of potentially avoidable radiation. METHODS: UTUCs diagnosed between January 2008-December 2017 were retrospectively identified from a population-based cancer registry. For each patient, US, non-urographic CT, and MRI exams were assessed for a primary mass and secondary imaging findings (hydronephrosis, urinary tract thickening, luminal distention, fat stranding, and lymphadenopathy/metastatic disease). CTUs were assessed for primary and secondary findings, and whether the tumor was evident as a filling defect on excretory phase. The dose-length product (DLP) of potentially avoidable excretory phases was calculated as a fraction of total DLP. RESULTS: 288 patients (mean age, 72±11 years, 165 males) and 545 imaging examinations were included. Of 192 patients imaged with 370 non-urographic CTs, a primary mass was evident in 154 (80.2%), secondary findings were evident in 172 (89.6%), and primary or secondary findings were evident in 179 (93.2%). Of 175 CTUs, primary and secondary findings were evident in 157 (89.7%) and 166 (94.9%) examinations, respectively, and primary or secondary findings were evident in 170/175 (97.1%). 131/175 (74.9%) UTUCs were evident as a filling defect, including the 5/175 (2.9%) UTUCs without primary or secondary findings. Of 144 CTUs with available DLP data, the proportion of potentially avoidable radiation was 103.7/235.8 (44.0%) Gy⋅cm. CONCLUSION: In our population, almost all UTUCs were evident via primary or secondary imaging findings without requiring the excretory phase. These results support streamlining protocols and pathways.

Quantitative differentiation of non-invasive bladder urothelial carcinoma and inverted papilloma based on CT urography.

PURPOSE: To investigate the value of CT urography (CTU) indicators in the quantitative differential diagnosis of bladder urothelial carcinoma (BUC) and inverted papilloma of the bladder (IPB). MATERIAL AND METHODS: The clinical and preoperative CTU imaging data of continuous 103 patients with histologically confirmed BUC or IPB were retrospectively analyzed. The imaging data included 6 qualitative indicators and 7 quantitative measures. The recorded clinical information and imaging features were subjected to univariate and multivariate logistic regression analysis to find independent risk factors for BUC, and a combined multi-indicator prediction model was constructed, and the prediction model was visualized using nomogram. ROC curve analysis was used to calculate and compare the predictive efficacy of independent risk factors and nomogram. RESULTS: Junction smoothness, maximum longitudinal diameter, tumor-wall interface and arterial reinforcement rate were independent risk factors for distinguishing BUC from IPB. The AUC of the combined model was 0.934 (sensitivity = 0.808, specificity = 0.920, accuracy = 0.835), and its diagnostic efficiency was higher than that of junction smoothness (AUC=0.667, sensitivity = 0.654, specificity = 0.680, accuracy = 0.660), maximum longitudinal diameter (AUC=0.757, sensitivity = 0.833, specificity = 0.604, accuracy = 0.786), tumor-wall interface (AUC=0.888, sensitivity = 0.755, specificity = 0.808, accuracy = 0.816) and Arterial reinforcement rate (AUC=0.786, sensitivity = 0.936, specificity = 0.640, accuracy = 0.864). CONCLUSION: Above qualitative and quantitative indicators based on CTU and the combination of them may be helpful to the differential diagnosis of BUC and IPB, thus better assisting in clinical decision-making. KEY POINTS: 1. Bladder urothelial carcinoma (BUC) and inverted papilloma of the bladder (IPB) exhibit similar clinical symptoms and imaging presentations. 2. The diagnostic value of CT urography (CTU) in distinguishing between BUC and IPB has not been documented. 3. BUC and IPB differ in lesion size, growth pattern and blood supply. 4. The diagnostic efficiency is optimized by integrating multiple independent risk factors into the prediction model.

Urethral entrapment by an overlapping dislocation of the pubic symphysis in a cat.

Case summary: A 1-year-old neutered male domestic shorthair cat was referred with suspected uroperitoneum. Ultrasonography showed peritoneal effusion. CT further revealed a bilateral sacroiliac joint disruption associated with an overlapped dislocation of the pubic symphysis, resulting in an abnormal trajectory of the urethra with extramural urethral compression. An open reduction and internal fixation of the pubis with correction of the urethral trajectory was performed under general anaesthesia. The uroperitoneum was determined to originate from a cystocentesis. Relevance and novel information: This report describes an unusual case of urethral obstruction secondary to overlapping dislocation of the pubic symphysis with urethral entrapment and concurrent bilateral sacroiliac luxation. To the authors' knowledge, acute urethral obstruction owing to fractures of the pubis, without urethral laceration, has never been described.

Unraveling recurrent urinary tract infection in adulthood: a rare case report of unilateral partial duplex collecting system with ureterocele.

Introduction: Duplication of the renal collecting system, known as the duplex collecting system, is a common congenital anomaly of the urinary tract. It can be partial or complete and affects 0.7-4% of the population, with a higher incidence in females. Ureteroceles are cystic dilations of the distal ureter and are often asymptomatic, particularly in adults. Case presentation: The authors present a case of a newly diagnosed partial duplex collecting system of the left kidney and left intravesical ureterocele, which was diagnosed for the first time at the age of 47 years, along with a history of symptoms suggestive of recurrent urinary tract infection and a urethral calculus which was surgically managed 5 years ago. Clinical discussion: The presence of a duplex collecting system can be observed even in males, with the possibility of recurrent urinary tract infection and the rare occurrence of an intravesical ureterocele. While ureteroceles are typically considered a congenital condition, they can also be diagnosed in adults. Conclusion: A partial duplex collecting system of the left kidney with left intravesical ureterocele in the age of 47 years in a male is a rare occurrence. Diagnosis and management of such urological cases can be challenging especially in a resource limited setting, which can be mitigated by awareness of unusual presentations, proper antenatal care, and access to proper diagnostic tools.

Computed Tomography Urography: State of the Art and Beyond.

Computed Tomography Urography (CTU) is a multiphase CT examination optimized for imaging kidneys, ureters, and bladder, complemented by post-contrast excretory phase imaging. Different protocols are available for contrast administration and image acquisition and timing, with different strengths and limits, mainly related to kidney enhancement, ureters distension and opacification, and radiation exposure. The availability of new reconstruction algorithms, such as iterative and deep-learning-based reconstruction has dramatically improved the image quality and reducing radiation exposure at the same time. Dual-Energy Computed Tomography also has an important role in this type of examination, with the possibility of renal stone characterization, the availability of synthetic unenhanced phases to reduce radiation dose, and the availability of iodine maps for a better interpretation of renal masses. We also describe the new artificial intelligence applications for CTU, focusing on radiomics to predict tumor grading and patients' outcome for a personalized therapeutic approach. In this narrative review, we provide a comprehensive overview of CTU from the traditional to the newest acquisition techniques and reconstruction algorithms, and the possibility of advanced imaging interpretation to provide an up-to-date guide for radiologists who want to better comprehend this technique.

Use of dual energy CT urography in evaluation of urinary stone and complex cyst.

BACKGROUND: Dual-energy computed tomography scans can provide significant benefits to the urinary system. The aim of this study is to determine the limitations and benefits of using dual energy CT urography in patients with urinary system stones and cysts. METHODS: In the analysis of the images, the virtual noncontrasted images obtained from the combined nephrogenicexcretory phase and the true noncontrasted images were evaluated. The true noncontrast images were accepted as the gold standard for stone detection. RESULTS: Eighty-three different stones were detected in 26 of the 115 patients included in the study. Sensibilities of virtual noncontrast images in detecting urinary system stones were 66.7% and 65.4% according to the first and second radiologists, respectively. In this study, 32 hyperdense cysts were detected. According to iodine map images, there was no enhancement in 26 of 32 cysts; only 5 cysts showed minimal contrast enhancement. One patient could not decide on contrast enhancement. DISCUSSION: As a result, if CT urography is performed with dual energy, it can provide additional information in patients with urinary system disorder.

Diagnostic evaluation of upper tract urothelial carcinoma: can we safely omit diagnostic ureteroscopy?

OBJECTIVE: To identify clinicopathological or radiological factors that may predict a diagnosis of upper urinary tract urothelial cell carcinoma (UTUC) to inform which patients can proceed directly to radical nephroureterectomy (RNU) without the delay for diagnostic ureteroscopy (URS). PATIENTS AND METHODS: All consecutive patients investigated for suspected UTUC in a high-volume UK centre between 2011 and 2017 were identified through retrospective analysis of surgical logbooks and a prospectively maintained pathology database. Details on clinical presentation, radiological findings, and URS/RNU histopathology results were evaluated. Multivariate regression analysis was performed to evaluate predictors of a final diagnosis of UTUC. RESULTS: In all, 260 patients were investigated, of whom 230 (89.2%) underwent URS. RNU was performed in 131 patients (50.4%), of whom 25 (9.6%) proceeded directly without URS - all of whom had a final histopathological diagnosis of UTUC - and 15 (11.5%) underwent RNU after URS despite no conclusive histopathological confirmation of UTUC. Major surgery was avoided in 77 patients (33.5%) where a benign or alternative diagnosis was made on URS, and 14 patients (6.1%) underwent nephron-sparing surgery. Overall, 178 patients (68.5%) had a final diagnosis of UTUC confirmed on URS/RNU histopathology. On multivariate logistic regression analysis, a presenting complaint of visible haematuria (hazard ratio [HR] 5.17, confidence interval [CI] 1.91-14.0; P = 0.001), a solid lesion reported on imaging (HR 37.8, CI = 11.7-122.1; P < 0.001) and a history of smoking (HR 3.07, CI 1.35-6.97; P = 0.007), were predictive of a final diagnosis of UTUC. From this cohort, 51 (96.2%) of 53 smokers who presented with visible haematuria and who had a solid lesion on computed tomography urogram had UTUC on final histopathology. CONCLUSION: We identified specific factors which may assist clinicians in selecting which patients may reliably proceed to RNU without the delay of diagnostic URS. These findings may inform a prospective multicentre analysis including additional variables such as urinary cytology.

Optimizing Upper-Tract Imaging for Non-Visible Haematuria.

INTRODUCTION: Non-visible haematuria (NVH) is associated with a small risk of upper-tract urothelial carcinoma (UTUC), though there is little consensus on its investigation, particularly with regard to upper-tract imaging. This study aimed to determine whether the presentation of UTUC can guide investigation of NVH in patients under 60 years old. METHODS: All patients investigated at our one-stop haematuria clinics under a cancer pathway were reviewed during a 5-year period, with all patients undergoing cystoscopy and upper-tract imaging. Retrospective analysis of all UTUC cases from our urological cancer multidisciplinary team meeting database over a 10-year period was also undertaken. RESULTS: 2,129 patients with a median age of 67 years underwent urgent investigation for haematuria between March 2015 and February 2020. 449 cases presented with NVH, of whom 124 (27.6%) were under 60. Out of 21 cases of UTUC, only 2 presented with NVH; both were over the age of 60 years. Factors that independently predicted diagnosis with urinary-tract malignancy were age ≥60 (OR 3.70, p < 0.001), visible haematuria (OR 2.50, p = 0.006), and suspicious cystoscopic findings (OR 58.06, p < 0.001). Review of all 119 UTUC cases over 10 years found 6 cases (5.0%) presenting with NVH, with one (0.8%) also presenting under 60 years. CONCLUSION: Diagnosis with UTUC is rare in patients presenting with NVH under the age of 60 years. Routine use of CTU in this low-risk group is best avoided, with ultrasonography constituting a safer first-line upper-tract imaging modality. Guidelines that risk-stratify NVH patients may be effective in reducing unnecessary investigations.

Quantitative assessment of renal obstruction in multi-phase CTU using automatic 3D segmentation of the renal parenchyma and renal pelvis: A proof of concept.

Purpose: Quantitative evaluation of renal obstruction is crucial for preventing renal atrophy. This study presents a novel method for diagnosing renal obstruction by automatically extracting objective indicators from routine multi-phase CT Urography (CTU). Material and methods: The study included multi-phase CTU examinations of 6 hydronephrotic kidneys and 24 non-hydronephrotic kidneys (23,164 slices). The developed algorithm segmented the renal parenchyma and the renal pelvis of each kidney in each CTU slice. Following a 3D reconstruction of the parenchyma and renal pelvis, the algorithm evaluated the amount of the contrast media in both components in each phase. Finally, the algorithm evaluated two indicators for assessing renal obstruction: the change in the total amount of contrast media in both components during the CTU phases, and the drainage time, "T1/2", from the renal parenchyma. Results: The algorithm segmented the parenchyma and renal pelvis with an average dice coefficient of 0.97 and 0.92 respectively. In all the hydronephrotic kidneys the total amount of contrast media did not decrease during the CTU examination and the T1/2 value was longer than 20 min. Both indicators yielded a statistically significant difference (p < 0.001) between hydronephrotic and normal kidneys, and combining both indicators yielded 100% accuracy. Conclusions: The novel algorithm enables accurate 3D segmentation of the renal parenchyma and pelvis and estimates the amount of contrast media in multi-phase CTU examinations. This serves as a proof-of-concept for the ability to extract from routine CTU indicators that alert to the presence of renal obstruction and estimate its severity.

Ureterovaginal Fistula Post Vaginal Hysterectomy.

Middle-aged women with ureterovaginal fistula (UVF) after hysterectomy represent a painful condition for the patients in the community. Accurate diagnosis and proper planning before surgery are essential for effective outcomes. CT urography is the modality of choice in diagnosing ureterovaginal fistula. CT urography helps in evaluating the fistula as well the associated renal complications following the condition. Here we present a case of ureterovaginal fistula reported with a history of vaginal hysterectomy for subserosal fibroid in December 2021.

The importance of CT Urography in early diagnosis of anatomical variations in urogenital tract: case presentation.

Anatomic variations in the urogenital tract have generally been diagnosed through intravenous urography as a modality of choice. In recent years, computerized tomography (CT) urogram has replaced the traditional intravenous imaging of the genitourinary tract. Hematuria, tumoral mass, obstructive uropathy, and congenital collecting system abnormalities are indications for CT imaging. In this report, we present a young woman with intermittent right flank pain and recent urinary tract infection. Her history was also positive for spontaneous abortion. She was referred to the Radiology Clinic for a CT urography. Our aim, in this case report, is to highlight the role of CT urography in the early diagnosis of anatomical variations of the urogenital system and appropriate prevention of clinical progression.

CT-urography: a nationwide survey by the Italian Board of Urogenital Radiology.

Computed tomography-urography is currently the imaging modality of choice for the assessment of the whole urinary tract, giving the possibility to detect and characterize benign and malignant conditions. In particular, computed tomography-urography takes advantage from an improved visualization of the urinary collecting system due to acquisition of delayed scan obtained after excretion of intravenous contrast medium from the kidneys. Nevertheless, the remaining scans are of great help for identification, characterization, and staging of urological tumors. Considering the high number of diseases, urinary segment potentially involved and patients' features, scanning protocols of computed tomography-urography largely vary from one clinical case to another as well as selection and previous preparation of the patient. According to the supramentioned considerations, radiation exposure is also of particular concern. Italian radiologists were asked to express their opinions about computed tomography-urography performance and about its role in their daily practice through an online survey. This paper collects and summarizes the results.

Uro-lymphatic fistula associated with urolithiasis: A case report.

Uro-lymphatic fistulas are rare, and involve communication between the renal collecting system and the lymphatic system. The disorder is usually caused by the obstruction of lymphatic vessels due to several diseases, leading to chyluria. Here, we report the case of a patient with a uro-lymphatic fistula, considered to be associated with urolithiasis.

Difficulties in Diagnosing Extraperitoneal Ureteroinguinal Hernias: A Review of the Literature and Clinical Experience of a Rare Encounter in Acute Surgical Care Settings.

Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely.

Ureteral fibroepithelial polyp: A case report.

Ureteral fibroepithelial polyps are rare, accounting for approximately 2-6% of all ureteral tumors. They can be diagnosed by ultrasonography, computed tomography, and retrograde pyelography; however, diagnosis can be difficult. Management is by resection of the polyp, and endoscopic resection is the standard treatment. Partial ureteral resection and ureteral reconstruction may be necessary depending on the size and location of the polyp. Imaging follow-ups for approximately a year post-surgery are recommended. This clinical case report aimed to highlight a case of a fibroepithelial ureteral polyp that was managed by endoscopic resection.

Imaging of ureter: a primer for the emergency radiologist.

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Benign ureteral polyps causing upper urinary tract obstruction.

Ureteral fibroepithelial polyps are benign, mesodermal neoplasms that can cause upper urinary tract obstruction. The preoperative diagnosis of this disease is challenging, but multidetector computed tomography (CT), particularly CT urography in the excretory phase, can be used to detect the features of ureteral polyps. We illustrated a case preoperatively diagnosed as upper ureteral tract obstruction due to ureteral tumor based on clinical presentation and CT imaging. However, the histopathological report revealed ureteral fibroepithelial polyps. Ureteral fibroepithelial polyps should be considered as a rare cause of urinary obstruction when the clinical presentation and imaging findings are atypical for more common etiologies.

Comparison of quality of urinary bladder filling in CT urography with different doses of furosemide in the work-up of patients with macroscopic hematuria.

INTRODUCTION: The protocol for preparation of computed tomography urography (CTU) examinations at our hospital was changed in 2013 to improve the quality of urinary bladder filling in the excretory phase. The aim of this study was to evaluate the quality of urinary bladder filling on CTU after different doses of furosemide were administered to patients with macroscopic hematuria. METHODS: The cohort was 215 patients who underwent elective CTU due to macroscopic hematuria between 2014 and 2018. 5 mg furosemide were administrated to 100 patients, 2.5 mg to 100 patients and 0 mg to 15 patients. Contrast medium layered bladders were excluded, leaving 193 patients: 92, 89 and 12 in each group. Urinary bladder volume was calculated in corticomedullary (CMP) and excretory phase (EP). Bladder distension was classified as satisfactory or not. Attenuation of bladder content in EP was noted. RESULTS: Average volume in EP was 370 ± 224 ml (28-1052) after 5 mg furosemide, 274 ± 120 ml (43-628) after 2.5 mg and 180 ± 104 ml (53-351) after 0 mg. 85% of the bladders were satisfactory distended after 5 mg, 80% after 2.5 mg and 58% after 0 mg. Average attenuation was 266 ± 89 HU (103-524) after 5 mg, 362 ± 156 HU (118-948) after 2.5 mg and 761 ± 331 HU (347-1206) after 0 mg. The differences in volume and attenuation were significant. CONCLUSION: 5 mg furosemide is preferred rather than 2.5 mg in preparation for CTU examinations of patients with macroscopic hematuria. There was no difference between the doses concerning rate of satisfactory bladder distension, but the higher dose resulted in larger bladder volume and more suitable attenuation of bladder content. IMPLICATIONS FOR PRACTICE: Development of CTU-image quality could improve bladder cancer diagnostics.