Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney.

OBJECTIVE: To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney. PATIENTS AND METHODS: Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome. RESULTS: Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted. CONCLUSION: Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m2 is considered relative contraindication.

Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties.

INTRODUCTION AND HYPOTHESIS: We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney. METHODS: A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups. RESULTS: Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis. CONCLUSION: Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE: In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification. METHODS: A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS®. RESULTS: Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality. CONCLUSION: Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Coincidental Bladder Cuff Transitional Cell Carcinoma in Nephroureterectomy Specimens: Risk Factors, Prognosis and Clinical Implementation.

PURPOSE: There is a lack of reporting of the bladder cuff pathology in the literature and ongoing debate regarding the role of bladder cuff excision (BCE) in the prognosis in patients with upper tract urothelial carcinoma (UTUC). We aimed to know the risk factors, the survival, and the clinical course of such pathology. MATERIALS AND METHODS: The study was retrospective, from 1983-2013 on 305 patients who had diagnosed with UTUC. Patients were managed by radical open/ laparoscopic nephroureterectomy with bladder cuff excision. The tumor was staged using 1997 TNM classification and the 3-tiered WHO grading system was used for grading. Patients who found to have a malignant bladder cuff on the final pathology were further analyzed for the risk factors for such disease and its effect on survivaltheir outcomes. RESULTS: 13/ 281 (4.6%) cases were found to have malignant bladder cuff. Regarding tumor stage; one case was diagnosed with Tis, eight had T1 and four cases had T2 malignant bladder cuff. All cases were with pure ureteric or multifocalcentric tumors, and none had pure pelvicalyceal tumors (p = .001).Local recurrence at the surgical site and distant metastasis were significantly higher among patients with malignant bladder cuff (p = .001 and .002 respectively), and the last sustained its significance in multivariate analysis. Those patients had a poor prognosis when compared to non-malignant bladder cuff cases (Log Rank test, p = .001)Conclusion: Ureteric tumor is the only independent risk factor for malignant bladder cuff at the final pathology and is associated with increased risks for invasive bladder tumor, distant metastasis and poor survival in comparison with non-malignant bladder cuff. In a clinical implementation, BCE is considered as a mandatory step in management of ureteric tumors, while it could be omitted in pure and low grade renal pelvis tumors.

Non-transitional cell carcinoma of the upper urinary tract: A case series among 305 cases at a tertiary urology institute.

Non-transitional cell carcinomas (non-TCC) of the upper urinary tract as squamous cell carcinoma (SCC), adenocarcinoma, and small cell carcinoma (SmCC) are rare with few case reports in the literature. We retrospectively reviewed our patients who surgically treated for upper tract urothelial carcinoma from 1983 to 2013 for non-TCC pathological cancer characteristics and survival. Among 305 patients, only 5 (1.6%) cases were found: One case of SmCC, another had adenocarcinoma, and 3 SCC cases. None of them had intravesical recurrence and the cancer-specific survival for non-TCC cohort is markedly decreased (log-rank = 0.01) compared to TCC patients.

Umbilical cord prolapsed through urethra: An unusual presentation of a vesico-uterine fistula.

Umbilical cord prolapse occurs when a loop of cord is present below the presenting part when the amniotic membranes are ruptured. The incidence is 0.2% of total births. The case presented here is unusual because the definition of cord prolapse cannot be applied to it and the lady did not complain of any history of urinary incontinence or hematuria. The presentation of umbilical cord through maternal urethra led to the speculation of an opening between the anterior uterine wall and the bladder. Fetal demise was diagnosed by abdominal ultrasound. At laprotomy, a communication was found between the bladder and the uterus thus letting the cord traverse through the bladder.

Adrenal tumors with venous thrombosis: a single-institution experience.

OBJECTIVE: To assess the incidence, imaging, surgical approach and prognosis of adrenal tumors associated with venous thrombosis. MATERIAL AND METHODS: Charts of 206 patients who underwent adrenal surgery were reviewed. Data of patients with pathologically confirmed venous thrombosis, utilized diagnostic modalities, operative treatment and prognosis were reviewed and analyzed. RESULTS: Venous thrombosis was confirmed pathologically in 6 patients (2.9%). All were of male gender with age ranging between 2 and 54 years. The mean size of the masses was 11.5 ± 5.2 cm. Venous thrombosis was diagnosed preoperatively in 2 patients, adrenal vein thrombosis in 1 patient, and renal vein thrombosis in the others. Masses were successfully excised via an open approach in association with nephrectomy in 3 cases. There was no operative mortality or gross morbidity. Pathologically, thrombosis was limited to the adrenal vein in 4 patients and extended to the renal vein in 2. Pathology of the masses revealed neuroblastoma in 2, pheochromocytoma in 2, adrenocortical carcinoma in 1, and pleomorphic sarcoma in 1 case. Metastasis developed within 6 months in 3 of these patients. CONCLUSION: Venous thrombosis with adrenal tumors is a rare pathological condition in which open surgery is the standard of care. Primary malignant adrenal masses with venous thrombosis have a poor prognostic outcome.

Percutaneous adrenal biopsy for indeterminate adrenal lesion: complications and diagnostic accuracy.

PURPOSE: To critically analyze the role, accuracy and safety of percutaneous adrenal biopsy for indeterminate adrenal lesions. MATERIALS AND METHODS: Adrenal biopsies were performed in 15 among 214 patients (7%) diagnosed with adrenal masses being indeterminate on preoperative imaging. Definitive histopathology was obtained in all and overall sensitivity and negative predictive value were calculated. Safety of the procedure was reported. RESULTS: The study included 8 male and 7 female patients with a mean age of 33.3 +/- 20.3 years (range 7-65). Biopsy was carried out under computed tomography and ultrasound guidance in 12 and 3 patients, respectively. There were 2 nonrepresentative biopsies that were proved to be adrenocortical carcinoma and myelolipoma after adrenalectomy. Results of biopsy in the remaining 13 patients provided accurate diagnosis as proved by definitive histopathology in all but 2 in whom the final diagnosis was established as adrenocortical carcinoma while biopsy was paraganglioma in one and cortical adenoma in the other. Overall sensitivity and negative predictive value of adrenal biopsy was 73.3 and 60%, respectively. Apart from two mild hypertensive episodes following silent pheochromocytoma biopsy, no complications were reported. CONCLUSIONS: Percutaneous biopsy is a safe procedure for the diagnosis of pathologic conditions of the adrenal gland with a reasonable diagnostic aid.

TOT for treatment of stress urinary incontinence: how should we assess its equivalence with TVT?

INTRODUCTION AND HYPOTHESIS: Synthetic mid-urethral slings are currently considered the treatment of choice for stress urinary incontinence (SUI). In this study, two types of slings are compared: TVT vs. TOT. METHODS: In a prospective randomized study, 40 patients underwent either TVT (19 patients) or TOT (21 patients). Stress-specific and overall success was evaluated. Perioperative complications were classified according to Clavien's classification. RESULTS: Mean duration of follow-up was 20 months. At last follow-up, stress-specific success rate was 94.6% in TVT vs. 81% in TOT. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. Thigh pain represented the main complication in the TOT group. CONCLUSIONS: Both TVT and TOT are effective procedures for treatment of SUI. When compared to each other, TOT seems to be inferior to TVT in terms of efficacy, causing less serious complications.

Diagnosis and treatment of adrenal tumors: a single-center experience with 238 cases.

OBJECTIVE: It was the aim of this study to review and analyze clinical data on the diagnosis and management of patients with adrenal masses. PATIENTS AND METHODS: Between 1976 and 2005, 238 patients admitted to our institute with adrenal masses were reviewed. Incidence, clinical features, imaging technique findings, surgical approaches, morbidity and mortality, as well as pathological diagnoses were reported. RESULTS: The series comprised 134 males and 104 females (mean age 33.3 +/- 20.3 years). Right-sided masses were more common (63.4%), with a mean size of 7.7 +/- 4 cm. Pain was the most frequent presenting symptom (53.4%), while 62 (26%) had a functional tumor. Incidentaloma was diagnosed in 49 patients (20.6%). Both computed tomography and magnetic resonance imaging showed a high diagnostic yield (sensitivities of 98.9 and 100%, respectively). Open adrenalectomy was performed in 153 patients (64.3%), while a laparoscopic approach was employed in 53 patients (22.3%). The intraoperative complication rate was 14.7%, the postoperative complication rate 6.1% and perioperative mortality 1.7%. Most of the excised masses were pheochromocytomas (26.4%). CONCLUSIONS: Computed tomography is recommended as the first diagnostic modality to define and characterize adrenal masses. Laparoscopic adrenalectomy is currently replacing open surgery as the standard surgical management of adrenal masses.

Prediction of survival after radical cystectomy for invasive bladder carcinoma: risk group stratification, nomograms or artificial neural networks?

PURPOSE: We compared 3 predictive models for survival after radical cystectomy, risk group stratification, nomogram and artificial neural networks, in terms of their accuracy, performance and level of complexity. MATERIALS AND METHODS: Between 1996 and 2002, 1,133 patients were treated with single stage radical cystectomy as monotherapy for invasive bladder cancer. A randomly selected 776 cases (70%) were used as a reference series. The remaining 357 cases (test series) were used for external validation. Survival estimates were analyzed using univariate and then multivariate appraisal. The results of multivariate analysis were used for risk group stratification and construction of a nomogram, whereas all studied variables were entered directly into the artificial neural networks. RESULTS: Overall 5-year disease-free survival was 64.5% with no statistical difference between the reference and test series. Comparisons of the 3 predictive models revealed that artificial neural networks outperformed the other 2 models in terms of the value of the area under the receiver operator characteristic curve, sensitivity and specificity, as well as positive and negative predictive values. CONCLUSIONS: In this study artificial neural networks outperformed the risk group stratification model and nomogram construction in predicting patient 5-year survival probability, and in terms of sensitivity and specificity.

Comparison between a serous-lined extramural tunnel and T-limb ileal procedure as an antireflux technique in orthotopic ileal substitutes: a prospective randomized trial.

OBJECTIVE: To compare the functional results from a prospective randomized trial of two different reflux-prevention techniques for ileal bladder substitution. PATIENTS AND METHODS: In all, 60 patients with invasive bladder cancer were randomized to receive either a serous-lined extramural tunnel (group 1) or T-limb ileal procedure (group 2) as an antireflux technique for the ileal substitute. The preoperative evaluation included intravenous urography, radioisotope renography to evaluate glomerular filtration rates (GFRs) and renal cortical imaging with 99mTc- dimercaptosuccinic acid to assess parenchymal scarring. Evaluable patients were re-assessed by the same imaging, and by ascending studies. RESULTS: The follow-up included 27 patients (49 units) in group 1 and 23 (45 units) in group 2, with a mean (sd) follow-up of 6.3 (0.5) and 7.4 (1.9), respectively. Uretero-ileal strictures were diagnosed in one renal unit in each group (P = 0.5). Ascending studies showed no reflux in any patients in group 1, while 13 renal units (29%) in group 2 were refluxing (P < 0.01). There was progressive cortical scarring with or with no significant reduction in GFR (>25%) in three and four renal units in groups 1 and 2, respectively. Among the 13 refluxing units in group 2, three showed a significant deterioration in GFR and one renal unit was diagnosed with progressive cortical scarring. CONCLUSION: Both procedures provided a low rate of anastomotic stricture, with acceptable preservation of renal function. The serous-lined extramural tunnel provided a more effective antireflux mechanism.

Surgical management of adrenal cysts: single-institution experience.

OBJECTIVES: To assess the safety and efficacy of different surgical procedures used for managing benign adrenal cysts. PATIENTS AND METHODS: The files of 245 patients presenting with adrenal masses was reviewed retrospectively; all had a thorough history taken and a physical examination. The radiological evaluation included abdominal plain X-rays, grey-scale abdominal ultrasonography and computed tomography with contrast medium. According to their clinical situation, patients had surgical open, laparoscopic intervention or were managed conservatively. The short- and long-term outcome of the open and laparoscopic techniques were evaluated. RESULTS: Twenty-six (11%) patients presented with adrenal cysts; the mean (sd, range) age at the time of presentation for adults was 41.4 (15, 17-82) years, while a 1-month female neonate and 1-year-old boy presented with an adrenal cyst. The mean (sd, range) size of the cysts was 10 (3.5, 5-18) cm. Surgical intervention was the treatment of choice in 21 patients; 11 (42%) had open adrenalectomy, while 10 (38%) had laparoscopic intervention. Both groups were comparable in the term of cyst size and operative time, while the laparoscopically managed group had a shorter hospital stay. Five patients were followed with no surgical intervention. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. Compared with open techniques it has the advantages of a shorter hospital stay, less blood loss and enhanced cosmesis. Unlike aspiration of cyst contents, the recurrence of adrenal cysts after surgical removal is unlikely.

Radical cystectomy for carcinoma of the bladder: 2,720 consecutive cases 5 years later.

PURPOSE: We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. MATERIALS AND METHODS: Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. RESULTS: Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. CONCLUSIONS: Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders.

OBJECTIVE: To assess the benefit of an antireflux system in patients with orthotopic ileal neobladders, as there is controversy about whether reflux prevention offers any advantages. PATIENTS AND METHODS: We conducted a randomized prospective study between January 2002 and March 2004, on 60 patients (53 men and seven women) with a mean (sd) age of 52.7 (7.3) years, who were candidates for orthotopic neobladders. Patients with comorbidities were excluded. Preoperative evaluation included intravenous urography (IVU), cystoscopic biopsy and radioisotope renography to evaluate the differential glomerular filtration rates (GFRs). Cases with normal kidneys and ureters, and with similar GFRs, were enrolled. Surgery comprised a standard radical cystectomy with pelvic lymphadenectomy. The ureters were randomized to either a direct anastomosis into a 5-cm ileal chimney on one side, or to be implanted using the antireflux serous-lined extramural tunnel on the contralateral side in the same patient. Regular follow-up included IVU and renography every 6 months in cancer-free patients. RESULTS: The mean (sd) follow-up was 23 (9.6) months. There was prolonged urinary leak from a refluxing ureter in one patient that was treated with a temporary percutaneous nephrostomy. Symptomatic pelvic collections required tube drainage in six cases. Six ureters developed early anastomotic strictures (one direct and five antirefluxing), and were treated with endoscopic ureterotomy in three and open revision in three. Serum creatinine levels were normal in all patients throughout the observation period. GFRs were similar in the two groups. The mean GFRs before surgery and at 6, 12, 18, and 24 months after cystectomy were: 55.1, 50.7, 49.4, 52.2 and 53.9 mL/min for the direct side; and 56.1, 53, 52.4, 53.2 and 50.4 mL/min for renal units with antirefluxing implantation. There was a significant deterioration of the GFRs due to anastomotic strictures, from 48.6 (6.7) mL/min before surgery to 31.8 (15.9) mL/min after the revision (P = 0.01). CONCLUSIONS: The antireflux procedures were associated with a higher incidence of anastomotic strictures than the direct methods and there was a significant deterioration of renal function after obstruction. The long-term follow-up data are awaited.

Surgical complications in live-donor pediatric and adolescent renal transplantation: study of risk factors.

UNLABELLED: To report the surgical complications among our pediatric and adolescent renal transplants and to analyze the different factors that may influence the occurrence of such complications. METHODS: A total of 250 pediatric and adolescent renal transplants were included in this study. Of these patients, there were 154 boys and 96 girls with a mean age of 15.4+/-3.7 yr (range 5-20 yr). All patients received their kidneys from living donors. Four patients underwent renal retransplantation. Surgical complications were reported and their incidence was correlated with several pretransplant, technical and post-transplant risk factors by both univariate and multivariate analyses. The impact of surgical complications on graft and patient survival was computed using the Kaplan-Meier technique. RESULTS: Among the 250 patients, 35 surgical complications were encountered in 33 patients. These complications included urinary leakage in 10 patients, ureteric stricture in 11 patients, complicated lymphocele in eight patients, hematoma necessitating surgical exploration in two patients, wound dehiscence in one patient, stone of the graft ureter in one patient and renal artery stenosis in two patients. The incidence of urological complications (ureteral stenosis, urinary leakage and stone disease) was 8.8% and vascular complications 0.8%. Small ureteric leakage (four patients) was treated by endourologic techniques, whereas leaks associated with ureteral necrosis required open revision. Endourologic treatment was attempted in early and mild cases of ureteric obstruction. In late and severe cases, surgery was performed. On univariate analysis, the factors that significantly affected the incidence of surgical complications were recipient's age, lower urinary tract abnormalities, the type of primary urinary recontinuity, the time to diuresis, and height and weight of the patients. On multivariate analysis, the type of primary urinary continuity was the only factor that sustained statistical significance. Neither patient nor graft survival was affected by the occurrence of surgical complications. CONCLUSION: Primary urinary continuity is the only risk factor that affects the incidence of surgical complications among pediatric and adolescent live donor renal transplants, with the extravesical technique of Lich-Gregoir providing the best results. Surgical complications in pediatric and adolescent renal transplantation can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication is paramount to graft and patient survival.