Ureterorenoscopy: avoiding and managing the complications

Emergency treatment of symptomatic ureteral calculi: predictors of prolonged hospital stay

PURPOSE

To assess differences in the length of hospital stay (LOS) in patients who present emergently versus electively for a symptomatic ureteral stone and to explore underlying risk factors.

METHODS

Billing data were analyzed from patients with symptomatic ureteral calculi at our department from 2010 to 2021. Statistical analysis (U test, logistic regression) was performed.

RESULTS

2274 patients (72% male, 28% female) with ureteral stones were analyzed (mean age of 52.9y). 1578 patients (69.4%) presented in an emergency setting and 696 patients (30.6%) electively. Arterial hypertension was seen in 31%, diabetes mellitus in 11% and hyperuricemia in 5% of the whole cohort. 46.5% of emergency patients were desobstructed (DJ/PCN), 35.4% underwent emergency ureteroscopy (URS), 13.4% had spontaneous passage (SP), and 4.8% underwent emergency shock wave lithotripsy (SWL). Of the electively treated patients, 58.6% underwent URS, 21.3% SWL, 18.5% DJ/PCN, and 1.6% had SP. Emergency stone treatment was associated with a significantly longer LOS when compared to primary desobstruction for patients admitted emergently. Also, LOS was significantly longer for each intervention of stone treatment in emergency patients vs. electively treated patients. Arterial hypertension was associated with a 1.8-fold increased risk of a hospital stay longer than 3 days, irrespective of hospital admission mode, whereas metabolic disorders did not influence LOS in this cohort.

CONCLUSION

For emergency patients in contrast to the electively treated patients, the type of procedure had a significant impact on the length of hospital stay. Arterial hypertension is an independent significant risk factor for prolonged hospital stay.

Long-term outcome of non-antireflux robotic-assisted laparoscopic ureter reimplantation in ureteral obstruction

PURPOSE

Although robotic-assisted laparoscopic ureter reimplantation (RALUR) is a recognized alternative to open and laparoscopic ureter reimplantation in treating distal ureteral obstruction, there are limited data on long-term efficacy and safety outcomes of non-antireflux RALUR. We assessed patients undergoing RALUR, evaluating operative, functional and safety determinants.

MATERIALS AND METHODS

All consecutive patients undergoing non-antireflux RALUR between April 2015 and January 2020 were included in this retrospective cohort study. The primary outcome endpoint was recurrent distal ureteral obstruction.

RESULTS

Mean follow-up was 41.3 months (CI 95%, 33.3-49.2). Among the 26 included patients, none developed recurrent distal ureteral obstruction. Kidney function in terms of serum creatinine level (72.0 vs. 71.0 µmol/L, p=0.988) and glomerular filtration rate (92.0 vs. 91.0 mL/min, p=0.831) was stable between the preoperative period and the last follow-up. Renal pelvis dilatation decreased significantly postoperatively, from grade 2 to grade 0 (p<0.001). Most patients (73.1%) remained free from any clinical symptoms of reflux during the follow-up. The rate of postoperative complications (Clavien-Dindo grade ≥II) was 23.1%. All complications resolved without sequelae. No recurring urinary tract infections were reported.

CONCLUSIONS

Non-antireflux RALUR appears to be safe and effective in the management of distal ureteral obstruction. There was no recurrent ureteral obstruction after RALUR in our cohort during a mean follow-up of more than 3 years. Non-antireflux reimplantation did not seem to have any notable impact on renal function during the follow-up period.

Should ureteroscopy be performed for patients after ureteral reconstruction with autologous onlay flap/graft?

Background

To analyze the safety and clinical significance of performing ureteroscopy after ureteral reconstruction with autologous onlay/graft. To describe the ureteroscopic appearances of the appendiceal onlay flap and lingual mucosa graft.

Methods

Beginning in August 2018, we conducted a prospective cohort study of autologous onlay/graft techniques to repair ureteral strictures. The perioperative data of 42 patients who had undergone surgery more than 6 months prior were collected prospectively. During the postoperative follow-up, ureteroscopy was performed in 27 patients (64.3%) after surgery (group A), and ureteroscopy was not performed in the other 15 patients (35.7%) (group B). We carried out a comparative study of these two groups of patients. Analyses were conducted mainly on complications related to ureteroscopy and the success rate of ureteral reconstruction surgery.

Results

There were no significant differences in patient demographic data or the length of ureteral reconstruction between the two groups (P>0.05). For the ureteroscopy group, the median time from repair surgery to ureteroscopy was 3 (range, 2-7) months, there was no poor healing of the anastomosis, and the ureteral lumen of all patients was unobstructed. Some expected observations can be found in the ureteral lumen, such as mucosa edema, stones, follicles and granulation tissue. Among the 27 patients, one patient (3.7%) developed bleeding intraoperatively and 7 patients (25.9%) were found to have low-grade (Clavien-Dindo I and II) postoperative complications, including 5 cases of fever and 2 cases of bleeding. The mean follow-up times of patients in group A and group B were 16.7±6.4 and 19.0±10.1 months, respectively. The objective success (imaging showed hydronephrosis ease) rate of the two groups was 100%. The subjective success (symptom relief) rates of group A and group B were 96.3% and 100%, respectively.

Conclusions

Patients after autologous onlay flap/graft ureteroplasty do not need to undergo routine ureteroscopy unless there is aggravation of hydronephrosis or other indications for ureteroscopy, such as stones.

[OUTCOMES OF CHRONIC UNILATERAL HEMATURIA TREATED USING DIGITAL FLEXIBLE URETEROSCOPE]

(Objectives) We examined the treatment outcomes in cases of chronic unilateral hematuria treated using flexible ureteroscope for observation and hemostasis. (Methods) The study included 14 patients (7 men and 7 women) with a median age of 56.5 years who underwent ureteroscopy using a digital flexible ureteroscope for chronic unilateral hematuria between March 2014 and August 2019. All the patients presented with macroscopic hematuria as a clinical symptom, but in one patient, the hematuria was accompanied by anemia and required a blood transfusion. In addition, bleeding occurred on the left side in 8 patients and on the right side in 3 patients; however, for the remaining 3 patients, the affected side could not be identified. Fourteen patients were examined on the basis of the ureteroscopic findings, number of bleeding sites, hemostatic intervention, treatment effect, and presence or absence of recurrences. (Results) The ureteroscopic findings showed a hemangioma in 7 patients and minute venous rupture in 3, but the remaining 4 patients showed no clear findings. The site of the findings was in the superior calyces in 8 cases, middle calyces in 4 cases, inferior calyces in 4 cases, and renal pelvic wall in 1 case. In addition, the findings were located at multiple sites in 6 cases, including all renal calyces in 2 cases. Ten patients with findings underwent hemostatic interventions (electrocoagulation and laser treatment). The median postoperative follow-up period was 32.4 months (range, 6.4-65.4 months). In all the cases, the hematuria disappeared after treatment. One of the 2 patients with findings in all renal calyces showed recurrence of macroscopic hematuria at 1 year and 6 months, which disappeared after conservative treatment. (Conclusions) In this study, observation using digital flexible ureteroscope was useful in the treatment of chronic unilateral hematuria, and the hemostatic interventions performed on the bleeding sites in the renal pelvis were effective.

Buccal ureteroplasty for recurrent extended strictures and obliterations of distal ureter

At the current stage of development of urology, selection of the surgical method for cases of severe obstructive diseases of the upper urinary system remains a challenge. This study aimed to explore the results of application of a buccal graft (BG) to remedy extended recurrent strictures and obliterations of the distal ureter. Seven patients with the mentioned diseases had undergone surgery: for six of them, the method of choice was complete BG ureteroplasty, one had onlay ureteroplasty. One intervention was laparoscopic, the remaining surgeries were open. The length of the replaced ureteral defect was 5–8 cm. In five cases, the flap was additionally vascularized with the iliac muscle, in one we used omentum tissue, in another — both the iliac muscle and the omentum. There were no fatalities registered, nor severe complications as per the Clavien–Dindo classification. The patients were followed-up for 4–18 months; as of today, no recurrence cases were identified. Control examinations showed complete patency of the neoureter and good vascularization of the BG. Thus, this method can be an option in cases disallowing distal ureter restoration with tissues of the patient's own urinary tract or segments of the gastrointestinal tract.

Case report series: management of complete ureteral avulsion with review of the relevant literature

Background

Endoscopic operations and ureteroscopy have become the first choice for ureteral calculi and ureter-related operations. The ratios of the complications, which are mostly iatrogenic, range between 9 and 11%. Total ureteral avulsion during URS is quite rare with a prevalence of 0–0.3%. We present three total ureteral avulsions we experienced in our clinic during the last 2 years and their treatment.

Case presentation

During the last 2 years, we experienced three total ureteral avulsions: one of these occurred in our clinic and the other two occurred in an external center and were referred to us. In two cases, the omental flap was rotated after ureteral reimplantation and the ureter was completely wrapped inside the omental flap. In the third case, boari flap was formed from the bladder. Due to the presence of extrarenal wide renal pelvis, anastomosis was made with boari flap after a y–v flap was rotated on the renal pelvis. D-J stents of the patients were removed at the end of 3 months. Although there was mild hydronephrosis, parenchymal thinning and a significant decrease in functions were not observed. Ureteral avulsion of the patients was successfully managed without the need for nephrectomy.

Conclusion

Ureteral avulsion management is an extremely difficult condition for both the surgeon and the patient. So, the most important thing is to prevent ureteral avulsion. Ureteroplasty and omental flap treatment are applicable methods with quite successful results for complete ureteral avulsions.

Laparoscopic ureteroplasty with gonadal vein graft for long ureteral stenosis: A step by step video

Strictures of the ureter may occur from iatrogenic injury or impacted kidney stones. Complications from ureteroscopy may result in ureteral stricture in 0,5-2% of patients. New techniques are being described in order to minimize the morbidity associated with classic approaches. This is a step-by-step video of this novel technique: a successful laparoscopic ureteroplasty with gonadal vein graft for a iatrogenic long ureteral stenosis. A 16 year old female patient, with multiple previous ureteroscopies for ureteral stones, presented with severe left lumbar pain. An abdominal CT and a pyelography were performed showing a 3 cm left mid-proximal ureteral stricture with proximal hydronephrosis. The stenotic area was identified and an anterior left ureteral incision was made. Gonadal vein was removed and prepared, being sutured in the anterior surface of the ureter. Patient was discharged in the second post operative (PO). JJ stent was removed after 1 month. A 3 month PO pyelography was performed, showing no fistula and resolution of the stricture. Twelve months after surgery, the patient was painless with symptom resolution. The use of gonadal vein as a graft for ureteral strictures is a new possible approach, although more cases are necessary to evaluate its results.

A new technique for ureteral reconstruction using lingual mucosa grafts in a beagle model

PURPOSE

To investigate the feasibility of ureteral reconstruction using lingual mucosa graft (LMG) and evaluate the histological changes of the engrafted LMG in beagles.

METHODS

Twelve male beagle dogs were randomly divided into groups A, B and C (n = 4). A ventral ureteral defect was created by excising half of the ureteral wall. The length of the defect was 3 cm, 6 cm, and 10 cm in groups A, B, and C, respectively. The LMGs were harvested and employed to repair the ureteral defects in onlay fashion. Two dogs per group were sacrificed after 6 months, with additional two dogs per group sacrificed after 12 months. Intravenous urography (IVU) and macroscopic examination were performed to evaluate renal function and ureteral patency. Histological changes in the engrafted LMGs during the tissue incorporation process were assessed by histological analysis.

RESULTS

There were no postoperative complications. Only one dog in group C developed a mild stricture near the proximal anastomosis. In the remaining 11 animals, IVU showed normal renal function and a wide ureteral caliber without stricture or fistula. The diameter of the LMG-reconstructed ureter was greater than that of the proximal and distal ureter (each p value < 0.01). The LMGs survived in situ with newly formed capillaries. The epithelium of the lingual mucosa resembled the urothelium in postoperative 12 months.

CONCLUSION

This new technique for ureteral reconstruction using LMGs is feasible. This approach is a promising alternative clinical treatment for curing long ureteral strictures.

Prevention of stone retropulsion during ureteroscopy: Limitations in resources invites revival of old techniques

Objective

To compare a modified technique using the Dormia basket vs Stone Cone for stone entrapment to avoid proximal stone migration during ureteroscopic pneumatic lithotripsy of ureteric stones.

Patients and methods

Our study included all patients with ureteric stones of <15 mm who underwent ureteroscopic pneumatic lithotripsy from January 2015 to September 2018. The study had two arms that were conducted over two consecutive periods; the first included 72 patients in whom we used the Stone Cone (Group 1) and the second included 86 patients in whom we started to use a Dormia basket with a modification (Group 2) to guard against proximal stone migration.

Results

Both groups were comparable for gender, age, and stone characteristics. Lower ureteric stones were the most prevalent as they represented 62.5% and 60.5% in groups 1 and 2, respectively; while upper ureteric stones were respectively found in 16.7% and 17.4%. Chemical stone analysis revealed that calcium oxalate stones were most predominant accounting for 51.3% and 51.1% in groups 1 and 2, respectively. Most of the stones were radio-opaque stones representing 57% and 58.1% in groups 1 and 2, respectively. There was a significant difference in operative time, with a mean (SD) operative time was 50.9 (11.2) in Group 1 vs 58.3 (12.4) min in Group 2 (P < 0.001). The success rate, defined as no retropulsion of stone fragments, was 97.7% in Group 2 vs 91.7% in Group 1 (P < 0.01). Complications were minor and comparable between the groups. There was no difference in hospital stay between the groups, but the cost assessment favoured Group 2.

Conclusion

We found that our modified-basket stone entrapment technique compared favourably with the Stone Cone to guard against stone retropulsion during ureteroscopic pneumatic lithotripsy. Our modification to the basket was found to be feasible, efficient, safe, reproducible and cost-effective in preventing proximal stone migration. This procedure is particularly suitable in cost-limited environments.

Open ureteroplasty with buccal mucosa graft for long proximal strictures: A good option for a rare problem

Purpose

To report a single surgeon experience with one year follow-up after open ureteroplasty with buccal mucosa graft (OUBMG) in the rare situation of long segment proximal ureteral strictures.

Materials and Methods

Four patients with long segment proximal ureteral stricture underwent OU-BMG between February and July 2017. Functional outcome was assessed by pre- and postoperative serum creatinine, ultrasound and renal scintigraphy as well as patient reported outcomes.

Results

Four patients with an average stricture length of 4 cm underwent OU-BMG between February and July 2017. No major postoperative complications occurred. Retrograde uretero-pyelography 6 weeks postoperatively revealed a watertight anastomosis followed by immediate emptying of the renal pelvis and ureter in all four patients. Ureteroscopy at this time showed a wide lumen with well-vascularized pink mucosa. After a mean follow-up time of 12.5 (12–14) months, postoperative serum creatinine was unimpaired. Renal scintigraphy revealed no signs of renal obstruction. With regard to intraoral surgery, no difficulties with mouth opening or intraoral dryness or numbness were reported.

Conclusions

For patients with long segment ureteral strictures OU-BMG is a safe technique with excellent surgical and functional outcomes. Hence, the application of this technique should be encouraged and regarded as one of the standard options in case of this rare problem.

Robot-assisted distal ureteral reconstruction for benign pathology: Current state

Distal ureteral reconstruction for benign pathologies such as stricture disease or iatrogenic injury has posed a challenge for urologist as endoscopic procedures have poor long-term outcomes, requiring definitive open reconstruction. Over the past decade, there has been an increasing shift towards robot-assisted laparoscopy (RAL) with multiple institutions reporting their outcomes. In this article, we reviewed the current literature on RAL distal ureteral reconstruction, focusing on benign pathologies only. We present peri-operative data and outcomes on the most common technique, ureteral reimplantation, as well as adjunct procedures such as psoas hitch and Boari flap. Additionally, we present alternative techniques reported in the literature with some technical considerations. Lastly, we describe the outcomes of the comparative studies between open, laparoscopy, and RAL. Although the body of literature in this field is limited, RAL reconstruction of the distal ureter appears to be safe, feasible, and with some advantages over the traditional open approach.

Ureteral stricture after ureteroscopy for stones: A prospective study for the incidence and risk factors

Context:

A ureteral stricture is a serious complication of ureteroscopy (URS) that was reported in the literature in highly variable rates from 0.2% to 24%.

Aims:

Our aims are to estimate the incidence and to detect the risk factors of ureteral stricture after URS.

Settings and Design:

This is a prospective, case-series study.

Materials and Methods:

During the period from May 2015 to August 2016, 251 adult patients underwent 263 URS for the treatment of 304 ureteral stones. Postoperative regular follow-up was done for 12 months by ultrasound. Computed tomography urography and diuretic renogram were performed for the cases developed hydronephrosis to confirm and detect the level of the stricture.

Statistical Analysis:

IBM SPSS Statistics for Windows, Version 19.0, Armonk, NY: IBM Corp. used for data analysis. Chi-square and Fisher's exact tests were used to compare between qualitative variables. Mann–Whitney test was used to compare between two quantitative variables in case of nonparametric data. Multiple logistic regression analysis was done to measure the risk factors. P value was considered statistically significant when <0.05.

Results:

The mean age was 43.5 years (standard deviation [SD]: ±13.6), and the mean body mass index was 28.39 (±3.96). The mean total stone burden was 12.8 mm (SD: ±5.9). Bilateral URS was performed in 12 cases. The mean operative time was 54.8 min (SD: ±22.68). Initial and final stone-free rates were 83.3% and 100%, respectively. The overall complications rate was 28.1%. Stricture occurred in four cases (1.5%).

Conclusions:

In our experience, the incidence of post-URS ureteral stricture is low. The impacted stone is the most common cause of URS complications and hence stricture formation.

Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience

BACKGROUND

Ureterorenoscopy is the current standard treatment for ureteral and kidney stones, also stones greater than 2 cm can be removed. Complications linked to infectious processes or ureteral damage are the most frequently reported. Subcapsular renal hematoma is an extremely rare complication following this procedure.

METHODS

We report the retrospective experience of two urological referral units for stones disease by analyzing incidence, risk factors and management of subcapsular renal hematoma.

RESULTS

Between May 2011 and December 2017, 2497 consecutive ureteroscopies for urolithiasis were performed by 8 skilled endourologists. A subcapsular renal hematoma was diagnosed in four cases (0.12%). Symptoms appeared few hours after intervention in two patients and after 14 postoperative days in the remaining two. In all cases CT scan revealed a subcapsular renal hematoma without signs of active bleeding. Conservative treatment was successful. Two patients required blood transfusion. One patient developed renal hypotrophy.

CONCLUSIONS

Subcapsular renal hematoma represents a rare but potentially serious complication after ureterorenoscopic lithotripsy. Its real incidence and etiology still need to be clarified. The elevated intrarenal pressures play an important role. Persistent hematuria, flank pain and hemoglobin drop should guide prompt investigation to reach an early diagnosis. In most cases a conservative management is sufficient.

Extended Boari-flap technique as a reconstruction method of total ureteric avulsion

Indication has led ureteroscopy to be a worldwide technique, with the expected appearance of multiple complications. The ureteral avulsion is an uncommon severe urological complication of ureteroscopy (URS). Surgery in patients with a total ureteral loss is a demanding challenge for urologist. It requires usually immediate open or laparoscopic intervention. This case report was to present the treatment modality after ureteral avulsion. We have presented a case of 58-year-old male patient who underwent a successful repair of an upper ureteral injury. We have comprehensively described the effectiveness of an extended Boari-flap procedure for reconstruction after iatrogenic ureteral trauma. Particularly in an unexpected and casual situations, the presented extended Boari flap modification can be a great alternative for reconstructing a total ureteral loss. In conclusion we have recommend useful tips, how to counteract such unwanted events.

Perirenal Hematoma After Ureteroscopy: A Systematic Review

INTRODUCTION

With the broadening indications of ureteroscopy (URS) for complex stones and high-risk patients, more URS is being performed and hence there is an increasing risk of major potentially life-threatening complications. We wanted to define the incidence, predisposing factors, management, and long-term sequelae for post-URS perirenal hematoma (PRH).

MATERIAL AND METHODS

We conducted a systematic review of literature according to Cochrane and preferred reporting items for systematic reviews and meta-analysis guidelines for all studies reporting on post-URS PRH from 1980 to September 2016. A literature search was conducted through PubMed, EMBASE, CINAHL, and Cochrane Library for all English language articles.

RESULTS

Based on a literature search of 210 articles, seven studies (8929 patients) met the inclusion criteria with an incidence of post-URS PRH reported as 0.45% (40 patients, range: 0.15%-8.9% per study) with a mean age of 53 years and a mean stone size of 1.7 cm. The predisposing factors were moderate-severe hydronephrosis, thin renal cortex, prolonged operative duration, hypertension, and preoperative urinary tract infection (UTI). The management strategy varied from conservative management with blood transfusion and antibiotics (n = 22, 55%) to percutaneous drainage (n = 11, 27.5%). Surgical intervention was needed in seven (17.5%) patients. Two of these were emergency angiography of which one proceeded to open nephrectomy. Open surgery with clot removal was done in three patients, nephrostomy for severe hydronephrosis in one patient, and surgery to correct malpositioned stent in one patient. There was one mortality reported, wherein a patient who had postangiography nephrectomy died of multiple organ failure after the intervention.

CONCLUSION

URS related PRH is a rare, but potentially life threatening complication with a small risk of renal loss. Although most cases may be managed conservatively, incidence of PRH can be minimized by control of blood pressure, treatment of preoperative UTI, and reduction in intrarenal pressures and operative time duration.

Safety and efficacy of using the stone cone and an entrapment and extraction device in ureteroscopic lithotripsy for ureteric stones

Objective

To assess the safety and efficacy of using a stone cone and an entrapment and extraction device (N-Trap®, Cook Urological, Bloomington, IN, USA) to avoid stone retropulsion during ureteroscopic lithotripsy for ureteric stones.

Patients and methods

This retrospective comparative study included 436 patients treated with ureteroscopic lithotripsy for a single ureteric stone from February 2011 to January 2014. The diagnosis of a stone was confirmed by plain spiral computed tomography in all cases. Patients were divided according to the ureteric occlusion device applied to avoid stone retropulsion during pneumatic lithotripsy into three groups; group 1 (156) had no instruments used, group 2 (140) in whom the stone cone was applied, and group 3 (140) in whom the N-Trap was used. Patient demographics, stone criteria, operative duration and complications, and success rates (complete stone disintegration with no upward migration) were reported and analysed statistically.

Results

The stone was in the lower ureter in >55% of patients in all groups. The mean (SD) of maximum stone length was 9.8 (2.5), 10.4 (2.8) and 9.7 (2.9) in groups 1–3, respectively. The use of the stone cone or N-Trap did not significantly increase the operative duration (P = 0.13) or complication rates (P = 0.67). There was a statistically significant difference (P < 0.001) favouring groups 2 and 3 for retropulsion and success rates, being 83.3% in group 1, 97.1% in group 2 and 95.7% in group 3.

Conclusion

The stone cone and N-Trap gave high success rates in preventing stone retropulsion during ureteric pneumatic lithotripsy. Both devices caused no increase in operative duration or complications when used cautiously.

Possible complications of ureteroscopy in modern endourological era: two-point or "scabbard" avulsion

Indication has led ureteroscopy to be a worldwide technique, with the expected appearance of multiple types of complications. Severe complications are possible including ureteral perforation or avulsion. Ureteral avulsion has been described as an upper urinary tract injury related to the action of blunt trauma, especially from traffic accidents, being the mechanism of injury, the result of an acute deceleration/acceleration movement. With the advent of endourology, that term is also applied to the extensive degloving injury resulting from a mechanism of stretching of the ureter that eventually breaks at the most weakened site, or ureteral avulsion is referred to as a discontinuation of the full thickness of the ureter. The paper presents a case report and literature review of the two-point or "scabbard" avulsion. The loss of long segment of the upper ureter, when end-to-end anastomosis is not technically feasible, presents a challenge to the urological surgeon. In the era of small calibre ureteroscopes these complications, due to growing incidence of renal stones will become more and more actual. Our message to other urologists is to know such a complication, to know the ways of treatment, and to analyse ureteroscopic signs, when to stop or pay attention.

How to manage total avulsion of the ureter from both ends: our experience and literature review

OBJECTIVES

To evaluate the treatment alternatives of total avulsion of the ureter from both ends including ureteropelvic junction (UPJ) and ureterovesical junction (UVJ).

METHODS

Total ureteral avulsion on both ends of the ureter was examined in 4 cases performing ureteroscopy. In two male patients of the four cases, avulsion was noticed intraoperatively and ureteral re-anastomosis at UPJ and re-implantation at UVJ were performed immediately. Boari flap was performed for one female patient immediately and for the other female patient who was referred from another hospital after the ureteroscopy, 4 days later.

RESULTS

One patient who had ureteral re-implantation was followed with 3-month intervals by ultrasonography and abdominal X-ray. At the end of 1 year, it was determined that kidney parenchyma was normal and the patient had kidney and upper ureteral stones. Percutaneous nephrolithotomy was performed, and the patient was stone-free at the end of the operation. Two years after the surgery, both kidneys were normal. This is the only case who had a successful ureteral re-implantation in literature. The other patient turned up a year later for routine checks after the ureteral stent was removed. Then, hydronephrosis and renal atrophy were detected. The patient did not accept nephrectomy or any other intervention and he was lost to follow-up. Boari flap procedure was performed after UPJ repair for the other two female patients. Their kidneys were both normal 3 months after the operation.

CONCLUSIONS

In case of ureteral avulsion from both ends of the ureter in the male patients, as bladder capacity is not enough for a Boari flap, proximal anastomosis and distal re-implantation could be a good choice for the management of this untoward event. This new approach also saves time for reconstructive treatments if necessary. If bladder capacity is enough to reach UPJ, Boari flap could be a good choice in female patients.

Renal subcapsular hemorrhage complicating ureterolithotripsy: an unknown complication of a known day-to-day procedure

OBJECTIVE

To report the incidence, risk factors, and treatments of renal subcapsular hemorrhage (RSH) complicating ureteroscopic lithotripsy (URSL).

PATIENTS AND METHODS

Data from 1,918 URSLs performed between January 2004 and March 2012 were retrospectively analyzed. Patients' data included age, sex, relevant medical history, stone side, size, and degree of hydronephrosis.

RESULTS

All 8 patients were identified as having an RSH after URSL. There were 2 males and 6 females with a mean age of 45.6 years (range 30-62 years). The patients' relevant medical histories (renal calculi extracorporeal shock wave lithotripsy, renal operation and hypertension) were statistically different between those who did and did not develop an RSH. Acute onset of flank pain is the most common symptom. Three patients with infective and large hemorrhage were managed by percutaneous nephrostomy in 1 and percutaneous subcapsular drainage in 2. Five patients with small and uninfected hemorrhage were managed conservatively.

CONCLUSIONS

The rate of development of RSH complicating URSL is very low. RSH complicating URSL can occur in patients with underlying renal abnormalities. RSH is rarely associated with abrupt hemodynamic instability and usually not lethal. Treatment is selected based on the patient's hemodynamic state, infection, renal function, and the feasibility of treatment modality.

Considerations in minimally invasive surgery for renal and ureteric calculi: a bicenter quality control study

BACKGROUND

The use of minimally invasive surgery is increasing. Evaluating the quality of care brings new sights in the optimization of operating techniques.

METHODS

We included all procedures performed in two hospitals during 2010 and 2011. A total of 264 patients were included in the ureterorenoscopy (URS) group and 77 patients in the percutaneous nephrolitholapaxy (PCNL) group. Data were gathered by retrospectively reviewing medical records.

RESULTS

Mean stone diameter in the URS group was 9 mm. Patients suffered from a single stone in 79% of the cases. Calculi in the distal ureter, defined as the part of the ureter below the lower border of the sacroiliac joint, were most likely to be removed. A stone-free status was reached in 69% of the cases using URS. Mean stone diameter in the PCNL group was 23 mm. PCNL was successful in 70% of the cases in Haga Hospital versus 53% in Medisch Centrum Haaglanden. Incidence of complications was comparable between the hospitals (p = 0.5). Outcome and quality of both PCNL and URS was not influenced by sex, age or body mass index.

CONCLUSION

The clinical results were comparable with results in the literature. Further improvement can be made by optimization of technical aspects and centralization of treatment by urologists experienced in minimally invasive techniques.

The new digital flexible ureteroscopes: 'size does matter'--increased ureteric access sheath use!

OBJECTIVES

To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy.

METHODS

140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind.

RESULTS

157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group.

CONCLUSIONS

A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

[Anesthesia in endourological and robot-assisted interventions]

The improved drug therapy leads to increasingly older patients with complex comorbidities in the discipline of operative urology. Today, improved technical equipment provides new operational capabilities in the field of urology. The prone and lithotomy position during surgery leads to physiological changes that affect anesthesia management. The surgical risk of procedures such as transurethral surgery of the prostate or bladder is being altered by laser surgery and other new technologies. Although the incidence of transurethral resection (TUR) syndrome has been reduced in recent years, the intrusion of irrigation fluid still has to be considered during anesthesia. Robot-assisted surgery has successfully completed the experimental stage and is widely used so that new targets have to be challenged. Ureterorenoscopy is performed with flexible, small caliber ureteroscopes which even allow treatment of renal calculi under analgosedation within short time periods. Percutaneous nephrostomy and litholapaxy are still frequently performed in the prone position. With respect to the risks arising from patient positioning, supine or lateral positioning should be considered in individual cases. A good communication between the surgeon and anesthetist allows deviation from daily routine procedures if special indications require a modified approach. In conclusion, a profound knowledge of the (patho-)physiology of general anesthesia and endourological diseases enables anesthetists to provide a prospective type anesthesia, which should prevent the occurrence of life-threatening incidents.