Prediction of Intraoperative Urinary Collecting System Entry in Patients with Peripheral Renal Tumors Undergoing Partial Nephrectomy: Usefulness of Tumor-Centered Multiplanar Reconstruction.

OBJECTIVE: To assess the usefulness of tumor-centered multiplanar reconstruction (TC-MPR) for predicting intraoperative urinary collecting system (UCS) entry in patients with peripheral renal tumors undergoing partial nephrectomy (PN). METHODS: Dynamic computed tomography images of 50 peripheral cT1 renal tumors treated with laparoendoscopic PN were analyzed. TC-MPR generated a digital cross-sectional image showing the tumor center and the closest calyx on a same plane. Patients and tumor characteristics including the distance from the tumor margin to the closest calyx (MPR-distance), and the angle formed by 2 tangent lines from the closest calyx to the tumor (MPR-angle) were assessed. RESULTS: Intraoperative UCS entry was observed in 15 patients (30%). The patients who experienced intraoperative UCS entry had a higher RENAL score, wider MPR-angle, and shorter MPR-distance than those who did not (p = 0.04, p = 0.001, p < 0.001, respectively). Multivariate analysis identified MPR-angle as an independent factor for intraoperative UCS entry (p < 0.001). CONCLUSIONS: The spatial information assessed using TC-MPR serves as a predictive factor for intraoperative UCS entry during PN.

Primary Report of Totally Tubeless Percutaneous Nephrolithotomy Despite Pelvi-calyceal Perforations.

PURPOSE: Nephrostomy tube insertion and/or a ureteral stent placement is advised when pelvi-calyceal perforations are encountered during percutaneous nephrolithotomy (PNL) nevertheless totally tubeless PNL is a possible exit strategy in percutaneous renal surgery therefore case series on the short term clinical outcomes of noninvasive management of iatrogenic pelvicalyceal perforations encountered during PNL is presented. PATIENTS AND METHODS: During retrospective analysis of 1271 PNL procedures, 25 incidents of accidental ureteral catheter/ jj stent dislodgement during first 24 post-operative hours were identified in patient who had pelvi calyceal perforations and had no nephrostomy tube (tubeless). Thirteen patients could not be re-stented nor a nephrostomytube could have been placed for them mainly due to patient refusal or comorbid conditions. The main outcome was rate of successful noninvasive management. RESULTS: Eighteen Patients bearing mucosal tears (grade I trauma) or visible peri-pelvic fat (grade II) successfully recovered without need for ureteral stenting or nephrostomy (72.0%). In seven (28.0%) cases of extension of the perforation into the peri-pelvic fat (grade III), either nephrostomy insertion or JJ stenting was needed for resolution of fever and urinoma. The major limitation was the necessity to exclude patients and manage them in the standard fashion according to clinical guidelines. CONCLUSION: Iatrogenic perforations of the collecting system are quite diverse in terms of severity that result in different natural histories and not all might need urinary diversion via nephrostomy or ureteral stenting.Low grade perforations may be successfully managed in totally tubeless fashion nevertheless further prospective investigations seem warranted.

Rupture of the maternal renal calyx secondary to fetal malpresentation: a case report.

BACKGROUND: Rupture of the renal collecting system is a potentially life-threatening condition in pregnancy. Most cases are associated with obstruction from nephrolithiasis or diseased renal parenchyma. CASE: A 24-year-old, nulliparous, African American woman at 38 weeks + 3 days' gestation presented with left flank pain refractory to conservative pain management. Computed tomography was negative for a stone but significant for infrarenal fluid and rupture of a left renal calyx. The fetal head was not flexed and appeared to be compressing the left ureter. A face presentation became apparent during her labor course, and she underwent a cesarean delivery when labor did not progress. CONCLUSION: This represents the first reported case of a ruptured renal collecting system secondary to fetal malpresentation. A high index of suspicion is essential to diagnose collecting system rupture, and it may occur in the absence of parenchymal disease or stones.

Endovascular management of vascular complications after percutaneous nephrolithotomy.

BACKGROUND: Bleeding is one of the most common and most important complications of percutaneous nephrolithotomy (PCNL), which is mainly controlled with conservative treatment options. Transcatheter arterial embolization is required in less than 1 % of the patients undergoing PCNL. There are only a few studies about endovascular treatment of vascular complications of PCNL. The purpose of this study was to evaluate renal arterial complications of PCNL and treatment outcomes with endovascular coil embolization. PATIENTS AND METHODS: This retrospective study evaluated 16 patients who underwent endovascular management for complications after PCNL, including diagnostic angiography. We analyzed the angiographic appearances of the vascular lesions that caused hemorrhages, treatment outcomes for endovascular coil embolization, and renal parenchymal loss rate following this treatment. RESULTS: Seven patients had a pseudoaneurysm, two patients had an arteriocaliceal fistula (ACF), five patients had a pseudoaneurysm and an arteriovenous fistula (AVF), and two patients had a pseudoaneurysm and an ACF. Of the 14 patients with pseudoaneurysms, five had more than one pseudoaneurysm. Endovascular coil embolization was successful in all patients, and it was able to stop the bleeding. After embolization, 12 patients had less than 10 % parenchymal loss, and 4 patients had 10-20 % parenchymal loss. Mean hospital stay after embolization was 2.3 ± 0.7 days (range, 1 to 3 days). CONCLUSIONS: The injuries seen in the intrarenal arterial system during the PCNL procedure can result in pseudoaneurysms and/or AVFs and/or ACFs, and more than one artery can be harmed. Arterial complications of PCNL can be treated with endovascular coil embolization while preserving renal function at a maximum level.

Ruptured renal calyx mimicking leaking abdominal aortic aneurysm.

The case of an 81-year-old man with a known 5.2 cm abdominal aortic aneurysm (AAA) and transitional cell carcinoma of the bladder who presented to the emergency department in painful clot retention is described. Approximately 5 h after starting bladder irrigation he developed a sudden onset of severe abdominal pain radiating to his back. Urgent CT scan (AAA protocol) revealed a rupture of the lower pole calyx of his right kidney and a stable aneurysm. Bladder irrigation was stopped and the patient settled with a catheter and simple analgesia. Given his significant co-morbidities, it was felt that surgical intervention for the underlying malignancy was inappropriate and the patient was discharged home. At last outpatient review, his renal function was at its baseline and he was suffering no ill-effects from the ruptured kidney.

Neonato com ascite urinária e ruptura de cálice renal secundárias a válvula de uretra posterior: diagnóstico ultrassonográfico / Newborn with urinary ascites and renal calyx rupture secondary to posterior urethral valve: sonographic diagnosis

A literatura relata somente alguns casos de recém-nascidos com ascite urinária, geralmente secundária a ruptura de bexiga urinária e não de um cálice renal. Este relato de caso descreve um caso raro de ascite urinária em recém-nascido com válvula de uretra posterior que teve ruptura de um cálice renal, neste caso diagnosticada, até onde sabemos, pela primeira vez por ultrassonografia.

The literature reports only rare cases of urinary ascites, usually secondary to rupture of the bladder and not to renal calyx rupture. The present report describes an uncommon case of posterior urethral valve in a newborn with ascites caused by the rupture of a renal calyx that, to our knowledge, was diagnosed for the first time by ultrasonography.

[Causes and course of fornix rupture]. / Ursachen und Verlauf bei Fornixruptur.

PURPOSE: Fornix rupture is a urological emergency situation. In most cases ureteral stones represent the underlying cause. We present the largest series ever reported. MATERIAL AND METHODS: Between 1994 bis 2005 a total of 162 patients were diagnosed with a fornix rupture. There were 121 men and 41 women with a median age of 53 years (range: 20-79 years). We investigated the following parameters: underlying cause of fornix rupture, symptoms, diagnostic and therapeutic procedures. RESULTS: In 60% of cases a ureteral stone was found as cause and in another 28% we found no reason for fornix rupture. 93% of patients had one or more symptoms at the time of diagnosis. In all patients primary endoscopic therapy (96%) or insertion of a nephrostomy tube was performed (4%). Also, antibiotic treatment was given in 92% of patients. No patient developed a perirenal abscess or other relevant complication requiring open operative revision. CONCLUSIONS: We confirm that ureteral stones are the most frequent causes of fornix rupture. With a low pressure system and antibiotic treatment, secondary complications can be effectively prevented.

Hand-assisted laparoscopic partial nephrectomy combined with caliceal ureterostomy for the treatment of post-traumatic ureteropelvic junction disruption.

Ureteropelvic junction (UPJ) disruption seldom occurs in patients with blunt abdominal trauma. The diagnosis of UPJ disruption is delayed in more than 50% of patients, and it can lead to difficulty in further treatment or increase the risk of nephrectomy. We present a 25-year-old man who was found to have left UPJ disruption 2 months after blunt abdominal trauma and who was successfully treated by partial nephrectomy combined with caliceal ureterostomy under hand-assisted laparoscopy. We review the literature and discuss the possible images to help early diagnosis of UPJ disruption. As a reconstructive procedure, caliceal ureterostomy under hand-assisted laparoscopy can be an effective and facilitated option.

Litiasis sintomática en divertículo calicial / No disponible

No disponible

Renal cryoablation and radio frequency ablation: an evaluation of worst case scenarios in a porcine model.

PURPOSE: Although ablative technologies, including radio frequency (RF) ablation (RFA) and cryoablation (CA), are being used to treat renal masses, complications associated with injury to vital renal structures are not well understood. We investigated these worst case scenarios by deliberately targeting vital renal structures with CA or RFA in a porcine model. MATERIALS AND METHODS: Following surgical exposure of the right kidney in female pigs a cryoneedle or an RF probe was deliberately placed under visual and ultrasound guidance in the renal pelvis (CA in 5 pigs and RFA in 7), major calix (CA and RFA in 5 each) or subsegmental renal vessels (CA in 5 pigs and RFA in 7). Cryo-energy or RF energy was then applied to create a 3 cm lesion. After 10 days the kidneys underwent gross and histological examination for urine and blood extravasation, cell death and injury. Ex vivo retrograde pyelography was performed to evaluate for urinary fistulas. RESULTS: All pigs tolerated the treatment and no procedure related deaths occurred. No significant bleeding was noted. RFA and CA created reproducible lesions and areas of cell death and necrosis. Despite significant intentional injury to the collecting system no urinary fistulas were demonstrated in CA specimens (0 of 15). In contrast, damage to the renal pelvis (4 of 7) by dry (3 of 4) or wet (1 of 3) RFA was associated with a high likelihood of urinary extravasation. CONCLUSIONS: This short-term study demonstrates that CA is safe, effective and not associated with urinary extravasation. In contrast, RFA to the renal pelvis is associated with urinary extravasation. Further studies are needed to support these findings.

Complete pyelo-calyceal avulsion as a result of blunt abdominal trauma.

We present a rare case of complete avulsion of the kidney collecting system as a result of blunt abdominal trauma. Emergency celiotomy precluded radiographic studies. Perinephric hematoma was mild, the lesion was not detected and this later led to a nephrectomy. Pelvis disruption diagnosis is frequently delayed, and this compromises surgical reconstruction.

[Renal hematoma as a result of internal ureteral catheterization]. / Hematoma renal como consecuencia de la cateterización ureteral interna.

INTRODUCTION AND OBJECTIVE: Urinary catheterization by means of an internal ureteral catheter in an usual procedure that may present complications. In this article we presented a case of perforation and later renal subcapsular hematoma after the placement of a "double-J" catheter. CONCLUSIONS: This complication, although rare, should be kept in mind. The manner of avoiding it is to maintain the tightness of the guidewire while inserting the ureteral catheter. Usually, the consequences are not life-threatening and are solved with conservative treatment. The administration of LFRE should be delayed until the resolution of the hematoma.

Lower pole calicostomy for the management of iatrogenic ureteropelvic junction obstruction.

It is often possible to use endoscopic techniques for the management of iatrogenic upper ureteral or ureteropelvic junction obstruction. However, in some cases with severe stricture disease or significant ischemic injury open surgical reconstruction is necessary. We report our experience with ileal ureter-lower pole calicostomy for the management of these complex urological injuries. During the last 3 years we treated 3 patients with severe ureteral/ureteropelvic junction obstruction secondary to iatrogenic injuries, including ureteral avulsion during ureteroscopic stone extraction, ureteral laceration during dilation for diagnostic ureteropyeloscopy, and ureteral ligation with ureteropelvic junction disruption and large peri-pelvic urinoma. In all cases unsuccessful attempts at endoscopic management necessitated open repair. Lower pole heminephrectomy was performed in all patients to expose the lower pole calix and ileal ureter-lower pole calicostomy was created due to the injury of large segments of the ureter. Satisfactory results were demonstrated on postoperative excretory urography and by a lack of symptoms. Followup averaged 23 months (range 20 to 26) with stable renal function in all patients. We believe that ileal ureter-lower pole calicostomy represents an attractive alternative for the management of severe ischemic, iatrogenic upper ureteral or ureteropelvic junction obstruction when endoscopic maneuvers are not possible or ineffective.

Arteriocaliceal fistula from prolonged nephrostomy tube drainage.

We report a case of an arteriocaliceal fistula that occurred after 21 months of continuous nephrostomy drainage. Hemorrhage was successfully controlled with selective angiography and embolization. Although unusual, arterial injury should be considered when patients with indwelling nephrostomy tubes present with new onset of bleeding.

Endourologic management of obstructed hydrocalyx after blunt renal trauma.

Significant renal injuries caused by blunt trauma can produce early and delayed complications. We report a case of blunt trauma that resulted in what appeared to be a persistent encapsulated hematoma, but was in reality an obstructed hydrocalyx. Communication with the collecting system was re-established percutaneously by a method similar to that used in the management of caliceal diverticula.