Congenital Giant Megaureter in a 16-Year-Old Female Presenting With Abdominal Pain: A Case Report and Review of Literature.

We describe a case of congenital giant megaureter in a 16-year-old female. She presented with a 5-day history of abdominal distention, right flank pain and tenderness. Right pyelonephritis was suspected. Computerized tomography showed a large cystic abdominal mass with no appreciably functioning left kidney causing secondary compression of the contralateral right ureter. A left upper nephroureterectomy was performed, draining over 3.5 L of fluid. Our experience suggests that congenital giant megaureter should be considered in the differential for pediatric patients presenting with a cystic abdominal mass.

La hernia ureteroinguinal: una condición infrecuente a tener en cuenta / The ureteroinguinal hernia: An infrequent condition to keep in mind

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Investigation of a novel brachytherapy ureteral stent: trial studies on normal beagle dogs.

PURPOSE: To evaluate the safety and feasibility of a newly designed 125I brachytherapy ureteral stent (BUS) in normal dogs. METHODS: A BUS loaded with 10 125I seeds (Group A: 0.8 mCi, Group B: 0.4 mCi, Group C: 0 mCi) was designed and tested in 27 normal beagle dogs. Routine blood tests, gross observations, cumulative radiation doses, tissue reaction assessed by hematoxylin-eosin/Masson staining, mRNA analysis by RT-qPCR and protein expression of Caspase-3, Collagen I, PCNA, and α-SMA were performed at 2, 4 and 8 weeks. RESULTS: The BUS was implanted successfully in all dogs (27/27) without surgery-related death. The ureter diameter and radiation injury score increased along with radiation accumulation (p < 0.05). Histopathologic analysis showed necrotic tissue and lateral fibrosis to different extents in the ureteral walls that gradually increased in all groups (p < 0.05); however, epithelial cell proliferation in groups A and B was lighter than that in the control group (p < 0.05). CONCLUSION: Placement of the newly designed 125I BUS was safe and feasible in dogs, and clinical studies are required to test its use in humans.

A Novel Technique for Management of Simultaneous Fibro-Epithelial Polyp and Blind-Ending Branch in a Duplicated Ureter: A Case Report With 23-year Follow-Up.

Ureteral duplication with a blind-ending branch (BEB) is rare anomaly. The presence of fibro-epithelial polyps in duplicated ureters is also infrequent. Despite the noticeability of endoscopic polypectomy, further recurrence of polyps and persistence of pain increase the probability of further ureteral resection with surgical procedures. In such cases, BEB of duplicated ureter is an excellent reservoir to save the function of the kidney. This is the first case with concomitant presence of fibro-epithelial polyps and BEB in duplicated ureter managed with novel surgical technique of uretero-pelvic junction and BEB branch anastomosis. We followed-up the patient for 23 years.

Four-dimensional CT excretory urography is an accurate technique for diagnosis of canine ureteral ectopia.

Computed tomographic (CT) excretory urography is commonly used to investigate canine ureteral ectopia (UE). Modern technology allows time-resolved CT imaging (four-dimensional CT excretory urography [4D-CTEU]) over a distance exceeding the detector collimation. Objectives of this prospective, observational, diagnostic accuracy study were to evaluate the diagnostic accuracy of CT excretory urography (CTEU) and 4D-CTEU for UE in dogs with lower urinary tract signs, assess the influence of pelvis positioning, and to determine the significance of the ureterovesical junction (UVJ) angle for UE diagnosis. Thirty-six dogs, with a total of 42 normotopic ureters, 27 intramural ectopic ureters, and three extramural ectopic ureters, underwent CTEU and 4D-CTEU with randomized pelvis positioning. Randomized CTEU and 4D-CTEU studies were scored by two observers for ureteral papilla location and murality on a grading scheme. Interobserver agreement, sensitivity, and specificity for ureter topia status and diagnosis were calculated. Computed tomographic excretory urography showed moderate interobserver agreement for the left ureter and perfect for the right ureter, whereas 4D-CTEU showed bilateral nearly perfect agreement between both observers. When comparing CTEU versus confirmed diagnosis, there was a sensitivity and specificity of 73% and 90.2%, respectively, whereas 4D-CTEU showed a sensitivity and specificity of 97% and 94.6%, respectively. An obtuse UVJ angle is significantly more commonly observed in ectopic intramural than normotopic ureters and is significantly associated with increased diagnostic confidence of UE. The use of a wedge to angle the pelvis did not increase the diagnostic confidence in determining ureteral opening position. Four-dimensional CT excretory urography is an accurate and reliable diagnostic technique to investigate UE as cause of urinary incontinence in dogs that is slightly superior to CTEU.

Bilateral ureteral endometriosis-an indolent, aggressive, and dangerous condition.

OBJECTIVE: To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making. DESIGN: Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board. SETTING: Tertiary referral center. PATIENTS: Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen. INTERVENTION: The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig. 3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side. MAIN OUTCOME MEASURE(S): Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch. RESULTS: The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable. CONCLUSION: Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.

The effect of botulinum toxin on ureteral inflammation.

PURPOSE: The impact of onabotulinum toxin type A (BoNT-A) on bladder afferent nerve pathways and chemosensory functions is an active area of investigation. There may be a role for BoNT-A in disorders of the ureter; however, no histologic studies have assessed the effects of BoNT-A on ureteral tissue. Our objective was to develop an animal model of ureteral inflammation and determine the impact of ureteral BoNT-A instillation on known mechanisms of inflammation. METHODS: The safety and feasibility of a novel animal model of ureteral inflammation was assessed. Through open cystotomy, the effect of ureteral BoNT-A instillation on inflammation was determined through H&E, masson's trichrome, Ki-67 stain, and prostaglandin E (PGE) synthase expression, a known marker of pain and inflammation in ureteral tissue. Urothelial microstructure was assessed using electron microscopy and standard histologic techniques. RESULTS: All experiments were carried to completion, and no systemic signs of botulinum toxicity were seen. BoNT-A exposure was associated with a decrease in PGE synthase expression in a dose-dependent fashion. BoNT-A exposure was not found to impact collagen deposition or cell proliferation. Disruption of tight junctions between urothelial cells was observed under conditions of inflammation. CONCLUSION: We describe the feasibility of a novel in vivo model of ureteral inflammation and report the first histologic study of the effects of BoNT-A on the ureter. Preliminary findings show that BoNT-A attenuates ureteral PGE synthase expression under conditions of inflammation. The application of BoNT-A may provide anti-inflammatory and analgesic effects in the context of ureteral disorders.

Amyloid Deposition of the Bilateral Ureters in a Patient With Chronic Systemic AL Amyloidosis.

Amyloid of the ureter is a rare disease with less than 25 cases reported in the literature. Despite being rare, it remains an important entity as it is typically confused with a primary neoplastic process of the urinary system. We report a case of a 68-year-old male with a history of cutaneous amyloid with late presentation of bilateral ureteral involvement.

Bilateral Ureterovaginal Fistulas and Vesicovaginal Fistula in Setting of Retained Pessary.

Urogenital fistulas in the setting of foreign body are rare. Isolated vesicovaginal fistula is the most common and has been reported in the setting of retained intraureterine device,1,2 neglected pessary3,4 and atypical insertions related mostly to sexual activity or underlying psychiatric disorders.5-7 Combined vesicovaginal and ureterovaginal fistulas related to foreign body are extremely rare. To our knowledge, we present the first reported case of bilateral ureterovaginal fistula and concurrent vesicovaginal fistula in the setting of retained pessary.

A Rare Case of Extensive Unilateral Ureteritis Cystica.

Ureteritis cystica is rare, benign entity that associates with chronic urothelial irritation such as recurrent urinary tract infection or nephrolithiasis. It is often diagnosed incidentally on routine imaging or ureteroscopy in asymptomatic individuals. In this case report, we present the retrograde pyelogram and ureteroscopy images of a rare case of extensive unilateral ureteritis cystica in a 78-year-old female presenting for elective stone surgery.

Termino-terminal Ureteral Laparoscopic Anastomosis in a Case of Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: Laparoscopic termino-terminal ureteral anastomosis has all the advantages of a minimally invasive approach in addition to the treatment of the pathologic condition [1]. Ureteral deep endometriosis can lead to severe consequences, such as hydroureteronephrosis and renal failure [2,3]. The main objective of this video is to present our surgical strategy and technique for cases of ureteral deep infiltrating endometriosis, which could help surgeons to understand and perform this surgery in a safe way in patients. DESIGN: Video demonstration of the technique. SETTING: French university tertiary-care hospital. INTERVENTIONS: This video presents a termino-terminal laparoscopic ureteral anastomosis and shows our team's strategy for surgical treatment in a 42-year-old woman with deep infiltrating ureteral left endometriosis, with consequent stenosis and left hydroureteronephrosis. A full resection of the endometriotic ureteral nodule was performed, followed by a termino-terminal anastomosis of the ureter. The use of intravenous indocyanine green to assess the postanastomotic ureteral perfusion and its risk of leakage or fistula are described in the video [2-5]. CONCLUSION: Ureteral endometriosis can lead to severe consequences, and the surgical treatment can be difficult and, most times, incomplete. This video gives a detailed example of the strategy our team used to perform a termino-terminal ureteral laparoscopic anastomosis in a structured way.

Comparison of Yang-Monti ileal ureter-bladder anastomosis versus Yang-Monti ileal ureter-ureteral anastomosis for the treatment of ureteral stenosis: a randomized controlled trial in a miniature pig model.

BACKGROUND: The aim of the present study was to establish an animal model of Yang-Monti ileal ureter-bladder anastomosis and Yang-Monti ileal ureter-ureteral anastomosis and compare the advantages and disadvantages of the two surgical methods. METHODS: Fourteen 12-month-old male Chinese miniature pigs weighing 21 ± 1.38 kg were randomly divided into two groups. Group A (n = 7) underwent end-to-end anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and left lower ureter; group B (n = 7) underwent anastomosis of the left Yang-Monti ileal ureter, left ileal ureter and bladder. In both groups, the contralateral kidney was removed at 1 week postoperatively. The incision length and operation time of the two groups were compared. Changes in serum creatinine and urea nitrogen were observed preoperatively, and at 2, 6 and 12 weeks postoperatively. Venous pyelography and cystography were performed at 12 weeks postoperatively to determine the ureteral patency and vesicoureteral reflux. At 12 months postoperatively, urinary culture was performed, and the diameter and histological changes of the intestinal ureter were assessed. RESULTS: Surgery was successfully completed in all 14 pigs. In group A, one pig died due to an anesthetic accident, and one pig died from a lung infection on postoperative day 4. In group B, one pig died from adhesive intestinal obstruction on postoperative day 7. The overall survival rate was 78.6%, and the 11 surviving pigs had no urinary or intestinal fistulae. Compared with group B, group A had a significantly longer surgical incision (30.86 ± 2.41 cm versus 26.71 ± 3.64 cm; p = 0.01) and shorter operation time (181.29 ± 15.10 min versus 157.71 ± 20.49 min; p = 0.02). The serum creatinine and urea nitrogen concentrations did not significantly differ between groups. All pigs had normal renal function pre- and postoperatively. There was no stenosis or obstruction on venous pyelography. The narrowest diameter of the ureter was significantly smaller in group B (5.90 ± 0.30 mm) than in group A (7.26 ± 1.06 mm; p = 0.01), but no contrast agent returned to the upper urinary tract in either group. Escherichia coli was detected on urine culture. In group A, one pig had obstruction of the ureteral ureter, while another had stenosis of the lower ureteral anastomosis. In group B, one pig had pelvic and intestinal ureteral dilatation; however, all anastomoses were patent. The ileal ureteral diameter was significantly larger in group A (9.40 ± 2.35 mm) than group B (6.62 ± 0.37 mm; p = 0.02). Two pigs in group A had separation of the transitional epithelium and columnar epithelial mucosa, with granulation tissue hyperplasia. The pigs with stenosis and obstruction had smooth fibrous tissue and smooth muscle of the anastomosis. In both groups, the two types of epithelial tissue were close together, and the intestinal villi were mildly atrophied and shortened. CONCLUSIONS: An animal model of Yang-Monti ileal ureter-bladder anastomosis was successfully established. Compared with Yang-Monti ileal ureter-ureteral anastomosis, Yang-Monti ileal ureter-bladder anastomosis is simpler, more reliable, and results in fewer complications.

Ureteral endometriosis in patients with deep infiltrating endometriosis: characteristics and management from a single-center retrospective study.

PURPOSE: As a serious type of deep infiltrating endometriosis (DIE), ureteral endometriosis (UE) can result in decreased kidney function. The aims of this study are to investigate risk factors and surgical treatments for UE. METHODS: The study enrolled 329 patients with deep infiltrating endometriosis, who were treated with laparoscopic surgery between January 2014 to September 2018. All patients were divided into one of two groups: UE or non-UE. Clinical information and other surgery variables of the two groups were examined. RESULT: Out of 329 patients with DIE, 68 (20.67%) cases of UE were diagnosed. Among them, 37 patients also had hydroureteronephrosis. In a multivariate analysis, the variables revised American Fertility Society (rAFS) stage IV, uterosacral ligament (USL) DIE lesion ≥ 3 cm in diameter and previous surgery for endometriosis significantly increased the risk of UE. A total of 27.03% (10/37) of patients with UE and hydroureteronephrosis showed decreased kidney function. Ureterolysis was performed in 59 patients, and an ureteroneocystostomy was performed in 9 patients. A double-J stent was placed in 37 patients with UE. Only 1 patient developed acute pyelonephritis postoperatively. During more than 2 years of follow-up, no patient experienced recurrence. CONCLUSIONS: The variables of rAFS stage IV, USL DIE lesion ≥ 3 cm in diameter and previous surgery for endometriosis significantly increased the risk of UE. Laparoscopic ureterolysis and ureteroneocystostomy are feasible and safe procedures with low complication and recurrence rates.

Prolapso uretral: imagen diagnóstica de una enfermedad poco frecuente / Urethral prolapse: Diagnostic image of a rare pathology

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Juvenile polymyositis associated with ureteral necrosis: a diagnostic and therapeutic dilemma-case report and review of the literature.

We describe an 11-year-old girl, diagnosed with juvenile polymyositis (JPM), who developed right ureteral obstruction secondary to necrosis. We emphasize the dilemmas regarding optimal timing for surgical intervention and medical treatment. Vascular involvement, which could be a part of juvenile dermatomyositis, may also be a feature of JPM. We discuss the association between vasculopathy and ureteral necrosis and review the literature regarding similar conditions. Whether the ureteral necrosis is a specific feature of vasculopathy, or a result of visceral calcinosis, needs to be further explored.

Macrophage-secreted TGF-ß1 contributes to fibroblast activation and ureteral stricture after ablation injury.

Iatrogenic injury to the healthy ureter during ureteroscope-guided ablation of malignant or nonmalignant disease can result in ureteral stricture. Transforming growth factor (TGF)-ß1-mediated scar formation is considered to underlie ureteral stricture, but the cellular sources of this cytokine and the sequelae preceding iatrogenic stricture formation are unknown. Using a swine model of ureteral injury with irreversible electroporation (IRE), we evaluated the cellular sources of TGF-ß1 and scar formation at the site of injury and examined in vitro whether the effects of TGF-ß1 could be attenuated by pirfenidone. We observed that proliferation and α-smooth muscle actin expression by fibroblasts were restricted to injured tissue and coincided with proliferation of macrophages. Collagen deposition and scarring of the ureter were associated with increased TGF-ß1 expression in both fibroblasts and macrophages. Using in vitro experiments, we demonstrated that macrophages stimulated by cells that were killed with IRE, but not LPS, secreted TGF-ß1, consistent with a wound healing phenotype. Furthermore, using 3T3 fibroblasts, we demonstrated that stimulation with paracrine TGF-ß1 is necessary and sufficient to promote differentiation of fibroblasts and increase collagen secretion. In vitro, we also showed that treatment with pirfenidone, which modulates TGF-ß1 activity, limits proliferation and TGF-ß1 secretion in macrophages and scar formation-related activity by fibroblasts. In conclusion, we identified wound healing-related macrophages to be an important source of TGF-ß1 in the injured ureter, which may be a paracrine source of TGF-ß1 driving scar formation by fibroblasts, resulting in stricture formation.

Intravenous urography findings in women with ureteric fistula.

INTRODUCTION: Ureteric fistula is one of the major morbidities that can arise from pelvic surgeries. It mainly results from gynaecological and obstetric procedures. Intravenous urography is an imaging modality for the upper urinary tract. Its features may be suggestive of ureteric fistula and it is of great value when medicolegal issues arise. It is however expensive and requires expertise. There are other useful and cheap methods for evaluating ureteric fistula including the use of dye test. There is need to determine if IVU (Intravenous urography) should be recommended for women with this disease. The aim of this study was to determine the features of intravenous urography among women with ureteric fistula and therefore determine its relevance in the management of such patients. METHODS: This was a retrospective study conducted at the National Obstetric Fistula Centre, Abakaliki between January 2012 and March 2017. All patients with ureteric fistula during the study period who were assessed with intravenous urography before surgery were included in this study. RESULTS: The mean age was 38 ± 16 years. Twelve (92.3%) were Christians. IVU showed hydroureters in 46.15% hydronephrosis in 53.85%, non-functioning kidney in 46.15% and ureteric stricture in 7.69%. IVU gave an insight into the side with ureteric fistula except in one who had normal result. CONCLUSION: Hydronephrosis, hydroureters and silent (non-functioning) kidneys are features of IVU in women with ureteric fistulas, however these features are not pathognomonic for the disease.

Synchronous urinothorax and uroperitoneum.

Urinothorax was first described in 1968 by Corriere et al. as the presence of urine in the pleural cavity due to retroperitoneal leakage of accumulated urine. Herein, we present a female patient, who complained of dyspnea due to urinothorax. This is the first case of urinothorax that developed so tardive after radiotherapy and was diagnosed due to high clinical evidence despite the negative scintigraphy.

Ureterocalicostomy with lower pole nephrectomy in a renal transplant: A case report.

As the number of kidney transplants continues to rise, so does the number and complexities of surgical-related complications, which may be associated with increased morbidity and potentially graft loss. Ureteral stenosis, the most prevalent urological complication, may require diverse techniques for surgical correction depending on several recipient and graft abnormalities. Here we report the surgical and clinical outcomes of a 62-year-old man with a posttransplant pyeloureterostomy stricture successfully treated with ureterocalicostomy after a lower pole nephrectomy. Although the resection of renal parenchyma may prevent a stenosis recurrence, surgeons can be reluctant to use this strategy due to the possible negative impact on renal function. We highlight some key steps of the surgical technique to prevent unnecessary allograft lesion and present short-term outcomes, suggesting that this rarely described procedure is a safe and effective alternative treatment for kidney transplant recipients with pyeloureterostomy stenosis.