Multimodality imaging of urinary tract tuberculosis.

Imaging is a key component of diagnosis and treatment response evaluation of urinary tract tuberculosis (UT TB). Tuberculosis can have a long latency, but if found early, one may have the opportunity to prevent complications such as ureteral strictures, obstructive nephropathy, contracted (thimble) bladder, renal parenchymal destruction/calcification, and renal failure. Imaging can aid in diagnosis and differential diagnoses, evaluate the extent of disease and complications, and guide image-directed biopsy, surgical planning, and evaluation of treatment response. Imaging abnormalities in the renal parenchyma and urinary tract at different stages of the disease, lymphadenopathy, and extra-urinary tract organ involvement are suggestive of UT TB. Recent advances in imaging modalities aid in UT TB diagnosis, follow-up, and guiding treatment.

Urothelial carcinoma associated with a long-term indwelling cystostomy component of a subcutaneous ureteral bypass device in a domestic shorthair cat.

Urothelial carcinoma (UC) occurs uncommonly in cats and no association has previously been observed with long-term indwelling urinary implants. An 18-year-old male castrated domestic shorthair cat initially was presented for hematuria, leading to the diagnosis of a right-sided ureterolithiasis and severe pyelectasia on ultrasound examination, prompting right-sided subcutaneous ureteral bypass (SUB) device placement. The cat subsequently had intermittent hematuria and dysuria, without ultrasonographic abnormality of the bladder or positive urine culture. Thirteen months later the patient developed refractory lower urinary tract signs, azotemia, a proliferative mass in the region of the cystostomy tube component of the SUB device and evidence of left ureteral obstruction. Cystostomy tube revision and left-sided SUB device placement were performed, as well as a partial cystectomy for removal of the mass. Upon histopathology, the mass was diagnosed as a UC. To our knowledge, UC associated with a long-term indwelling cystostomy catheter component of a SUB device has not been reported in veterinary medicine.

Surgical Management of Bilateral Single-System Ectopic Ureters (BSSEUs) in a Pediatric Patient: A Report of a Rare Case and Literature Review.

Bilateral single-system ectopic ureters (BSSEUs) are among the rarest entities encountered in pediatric urology. A BSSEU occurs when the ureteric buds originate cranially from the mesonephric ducts, causing a delay in their integration into the urogenital sinus. It presents as continuous incontinence in females, whereas symptoms like infection and discomfort are present in males. We describe a case involving a BSSEU opening into the vagina and urethra, with the patient experiencing continuous urinary incontinence, and its diagnosis and management. Here, We discuss a rare case of a four-year-old girl exhibiting continuous urinary incontinence or dribbling associated with recurrent urinary tract infections (UTIs) attributed to bilateral ectopic ureters. Imaging modalities, including contrast-enhanced computed tomography(CECT) and MRI, revealed the presence of BSSEUs accompanied by hydroureteronephrosis. The condition was managed with prompt surgical intervention involving bilateral ureteric reimplantation. Subsequent to the procedure, the patient experienced a significant improvement in continence mechanism and bladder capacity, obviating the requirement of urinary diversion procedure appendicovesicostomy or bladder neck reconstruction. Notably, while BSSEUs are an uncommon presentation, their timely and appropriate management is paramount in preventing potential renal damage. This case underscores the significance of vigilant monitoring and proactive intervention in addressing such complex urological anomalies in pediatric patients.

The role of ureteric indocyanine green fluorescence in colorectal surgery: a retrospective cohort study.

BACKGROUND: Ureteric injury (UI) is an infrequent but serious complication of colorectal surgery. Prophylactic ureteric stenting is employed to avoid UI, yet its efficacy remains debated. Intraoperative indocyanine green fluorescence imaging (ICG-FI) has been used to facilitate ureter detection. This study aimed to investigate the role of ICG-FI in identification of ureters during colorectal surgery and its impact on the incidence of UI. METHODS: A retrospective cohort study involving 556 consecutive patients who underwent colorectal surgery between 2018 and 2023 assessed the utility of routine prophylactic ureteric stenting with adjunctive ICG-FI. Patients with ICG-FI were compared to those without ICG-FI. Demographic data, operative details, and postoperative morbidity were analyzed. Statistical analysis included univariable regression. RESULTS: Ureteric ICG-FI was used in 312 (56.1%) patients, whereas 43.9% were controls. Both groups were comparable in terms of demographics except for a higher prevalence of prior abdominal surgeries in the ICG-FI group. Although intraoperative visualization was significantly higher in the ICG-FI group (95.3% vs 89.1%; p = 0.011), the incidence of UI was similar between groups (0.3% vs 0.8%; p = 0.585). Postoperative complications were similar between the two groups. Median stent insertion time was longer in the ICG-FI group (32 vs 25 min; p = 0.001). CONCLUSION: Ureteric ICG-FI improved intraoperative visualization of the ureters but was not associated with a reduced UI rate. Median stent insertion time increased with use of ureteric ICG-FI, but total operative time did not. Despite its limitations, this study is the largest of its kind suggesting that ureteric ICG-FI may be a valuable adjunct to facilitate  ureteric visualization during colorectal surgery.

Cystoscopic-guided laser ablation of intramural ectopic ureters in a female cat.

Case summary: An 8-month-old female spayed domestic shorthair cat was presented for chronic urinary incontinence (UI). Since being adopted 6 months earlier, the cat had a history of urine leakage during both activity and rest. Baseline blood work and urine culture showed no significant abnormalities and no evidence of a urinary tract infection. An abdominal CT with excretory urography followed by a focal urinary tract ultrasound revealed a suspected right intramural ectopic ureter (EU) and potential left EU. Cystoscopy confirmed bilateral intramural EUs. Cystoscopic-guided laser ablation (CLA) of both EUs was performed. The cat developed temporary urinary obstruction (UO) 36 h after the procedure, which was medically managed with prazosin and buprenorphine. Ultimately, the cat's urinary signs completely resolved with no UI recognized after the procedure and the cat has remained continent during 18 months of follow-up. Relevance and novel information: CLA of intramural EUs is routinely performed in dogs, but this technique has not been previously reported in cats with this condition. Although post-procedural urinary tract signs were initially present, the cat ultimately had an excellent outcome with resolution of UI after this procedure.

Bilateral single system ectopic ureters - A rare variant.

Bilateral single system ectopic ureters are a rare entity in paediatric urology. We report a girl child with bilateral single system ectopic ureters with right system opening into the vagina, who presented at 3.5 years with continuous dribbling of urine & a small capacity bladder. Renal scans and MRI were done which indicated bilateral single system ectopic ureters with hydroureteronephrosis. We managed her surgically by a right nephro-ureterectomy, bladder augmentation, left ureteric reimplantation and Mitrofanoff. Post op patient had acute on chronic renal failure, stabalised by haemodialysis. It is a rare presentation if managed promptly can prevent renal replacement therapy.

MRI diagnosis of tumor­like IgG4 masses in bilateral distal ureters: A case report.

IgG4 masses in the bilateral distal ureters are rare and frequently misdiagnosed. The present study reported the case of a 55-year-old male patient with IgG4-related disease (IgG4-RD) who had symmetrical soft tissue masses of the bilateral distal ureters found on magnetic resonance imaging (MRI) with a significant increase in the serum levels of IL-6, IgG4 and IgE. Regarding treatment, this patient received prednisone acetate tablets (40 mg/day) and mycophenolate mofetil dispersible tablets (1 g/day). During the follow-up, significant reductions in the levels of IgG4 and IgE were found after 30 days. MRI after 6 months indicated complete disappearance of the masses. The prognosis has been good so far. In clinical practice, it is necessary to consider the possibility of IgG4-RD in cases with soft tissue masses surrounding both ureters and elevated levels of serum IgG4.

The feasibility of ultrasound-guided mini-percutaneous nephrolithotomy for ESWL-resistant lower calyx renal stones of up to two centimeters: a single center experience.

Lower pole renal stones present a significant challenge in urologic practice due to difficulty in accessing the calyx and eliminating fragments. Management options for these stones include watchful waiting for asymptomatic stones, extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS), and percutaneous nephrolithotomy (PCNL). Mini-PCNL is a newer modification of conventional PCNL. The study aimed to assess the feasibility of mini-PCNL in treating lower pole renal stones equal to or less than 20mm that were not responsive to ESWL therapy. We included 42 patients (24 male and 18 female) with a mean age of 40±2.3 who underwent mini-PCNL at a single urology center between June 2020 and July 2022 and assessed operative and postoperative outcomes. The mean total operative time was 47±3.11 minutes, ranging from 40 to 60 minutes. The stone-free rate was 90%, and the overall complication rate was 26%, which included minor bleeding (5%), hematuria (7%), pain (12%), and fever (2%). The mean hospital stay was 80±3.34 hours (3-4 days). Our findings suggest that mini-PCNL is an effective treatment option for lower pole renal stones that are not responsive to ESWL therapy. The immediate stone-free rate was high, with minimum non-serious complications.

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study.

OBJECTIVE: To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. METHODS: We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. RESULTS: According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. CONCLUSIONS: Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

Incomplete ureteral quintuplication obstructed by proximal calculus: Case report and review of literature.

INTRODUCTION: Ureteral duplication is a common congenital anomaly, although multiple ureters is a rare disorder. Bifid ureter or multiple ureters are diagnosed incidentally and generally associated with obstruction by lithiasis. CASE PRESENTATION: We present a case of ureteral quintuplication converging into a sacculation obstructed by a 7 cm calculus. CONCLUSION: Two or more ureters are more common in women and it is mostly associated with asymptomatic presentation, excepting when related to complications of urinary tract infection or lithiasis. More than four ureters are extremely rare and our case is the first of incomplete quintuplication found so far in the literature.

Anatomical variations of the pelvis during abdominal hysterectomy for benign conditions.

BACKGROUND: Anatomical variations are defined as atypical morphologic and positional presentations of anatomical entities. Pelvic anatomical variations encountered during abdominal hysterectomy can be of clinical interest, given that misidentification of certain structures can lead to iatrogenic injuries and postoperative sequelae. The aim of the present study was to detect and highlight the anatomical structures of interest and their variations to the surgeon performing abdominal hysterectomy for benign conditions. MATERIALS AND METHODS: A narrative review of the literature was performed including reports of anatomical variations encountered in cadavers, by surgeons during abdominal hysterectomy and radiologists on computed tomography angiography, searching within a 10-year span on PubMed database. Studies regarding the treatment of malignant conditions requiring lymphadenectomy and different modes of surgical approach were reviewed with regards to the aspects relevant to benign conditions. The search was extended to the reference lists of all retrieved articles. RESULTS: Ureters and the uterine arteries, due to anatomical variations, are the anatomical structures most vulnerable during abdominal hysterectomy. Specifically, the ureters can present multiplications, retroiliac positionings and ureteric diverticula, whereas, the uterine arteries can present notable variability in their origins. Such variations can be detected preoperatively or intraoperatively. CONCLUSIONS: Although rare, the presence of anatomical variations of the uterine arteries and ureters can increase the possibility of complications should they escape detection. Intraoperative misidentification could lead to improper dissection or ligation of the affected structures. Knowledge of these variations, coupled with extensive preoperative investigation and intraoperative vigilance can minimise the risk of complications.

Renal stone density on native CT-scan as a predictor of treatment outcomes in shock wave lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) is considered a standard treatment for nephrolith or kidney stones measuring less than 20 mm. Anatomical, machine-related, and stone factors play pivotal roles in treatment outcomes, the latter being the leading role. This paper examined the relationship between stone density on native CT scans and ESWL treatment to remove renal stones concerning several treatments. One hundred and twenty patients (64 males and 56 females) were enrolled and completed the study from April 2019 to September 2020. Inclusion criteria were a single renal pelvis stone of 5-20 mm to be treated for the first time in adult patients with no urinary or musculoskeletal anatomical abnormalities. We assessed patients' renal function and obtained stone characteristics using a native CT scan. Patients were then scheduled for ESWL by the same machine and operator under fluoroscopy, with two-week intervals between treatment sessions when more than one treatment session was required. Before each new session, a new KUB-US was performed to reevaluate the stone. One hundred and twenty patient records were analyzed, 64 (53.3%) males and 56 (46.7%) females, with a mean age of 38.6 years and a mean stone size of 13.15 mm. Treatment with ESWL cleared stones in 76 (63.3%) patients, while 44 (36.7%) failed the treatment. The mean stone density in patients whose stones were cleared was significantly lower (661 vs. 1001) (P<0.001). Estimating renal calculus (or kidney stone) density on a native CT scan might help prognosticate ESWL treatment outcomes regarding stone clearance rates and the number of sessions required to clear a stone.

Complete duplication of the penis - A case report.

Penile duplication is a very rare urological entity. It may be associated with other congenital conditions such as urogenital, GI tract and musculoskeletal anomalies. Properly classifying the condition may dictate the final treatment options. Our current case is the complete true duplication in which we performed side-to-side urethra-urethral anastomosis. We spared the posterior urethra as it may end up with postoperative urinary incontinence.

A new method to visualize and to spare the ureters during SBRT for oligo metastatic patients.

This article describes a ureter-sparing procedure used to treat lymph node metastases with SBRT. We delivered 35 Gy in 5 fractions of 7 Gy to patients with lesions located less than 7 mm from the ureters using a urography CT scan for planification. Two dosimetry plans were created, one using a CT scan urography-based contour and the other using the native phase. PTV coverage were not statistically different but this technique was able to significantly reduce median delivered Dmax to the ureters. These preliminary results demonstrate the feasibility of locating the ureters in a planning CT scan to protect them.

[A total replacement of the both ureters and urinary bladder by ileal conduit in a woman with contracted bladder and Ormonds disease].

A description of the successful surgical treatment of a patient with irreversible changes in both ureters and bladder resulting from a severe form of Ormond's disease and interstitial cystitis, resulting in contracted bladder, is presented. For the first time in clinical practice, a one-stage cystectomy, a bilateral ureterectomy with complete replacement of both ureters and the bladder with two isoperistaltic small bowel segment was performed. The postoperative course was uneventful. Follow-up contrast-enhanced computed tomography of the kidneys and newly formed urinary tract revealed good excretory function. The patient was discharged in a satisfactory condition on the 22nd day after the procedure with recommendations for taking 10 g of an aqueous solution of soda daily. At the follow-up after 3 months, she had complaints of slight weakness and voided voluntary up to 8 times a day; clinical and biochemical blood tests were normal. This clinical observation indicates the presence of two different diseases in one patient, namely interstitial cystitis and Ormond's disease. The possibility of one-stage complete replacement of both ureters and the bladder with a good immediate result is shown.

Pediatric laparoscopic pyeloplasty of pelvic ectopic kidney with UPJO - A case report.

Prevalence of pelvic ectopic kidney with obstruction is not common. Associated anomalies may produce technical difficulties and surgical challenges in treatment. Diagnostic tools such as USG KUB, renal scintigraphic studies (DMSA, DTPA), MRI, and preoperative RGP are very informative examinations to properly decide the timing of the operation and method of it. The patient was under close surveillance from the detection of antenatal hydronephrosis until the development of UPJ obstruction. Herein, we report the case of a patient with this anomaly who successfully underwent laparoscopic reconstruction.

Usefulness of a long sheath in ureteral catheterization after failure of antegrade ureteral stent placement using a short sheath.

BACKGROUND: When antegrade ureteral intervention fails due to severe ureteral stricture or tortuosity, a longer sheath can be used to facilitate ureteral catheterization. PURPOSE: To evaluate the feasibility and effectiveness of the use of a long sheath in antegrade ureteral stent placement after failure of antegrade ureteral stent placement using a short sheath. MATERIAL AND METHODS: Among 1284 procedures in 934 patients who received ureteral stent placement, a long sheath was used after stricture negotiation failure using a short sheath in 57 (4.4%) procedures in 53 patients. The data of these 53 patients were retrospectively reviewed. RESULTS: The most common reasons for long sheath use were failure of balloon catheter (59.6%) or guidewire (29.8%) advancement across the stricture. Technical success, successful stricture negotiation after using a long sheath, was achieved in 50/57 (87.7%) procedures. In two of seven failed procedures, an additional TIPS sheath was used and the technical success rate improved to 91.2% (52/57). The technical success rate was significantly higher in the patients who have failed balloon catheter advancement (97.1%, 33/34) than the patients who have failed guidewire advancement (64.7%, 11/17) (Fisher's exact test, P = 0.004). Self-limiting hematoma occurred in one patient after use of the long sheath and was considered a minor complication. CONCLUSION: Ureteral catheterization using a long sheath is feasible and effective when antegrade ureteral intervention using a short sheath fails. When using a long sheath, the technical success rate was higher when advancing the balloon catheter over the guidewire than when advancing the guidewire through tight stricture.

Routine gynecological ultrasound: look at the bladder and the ureters!

BACKGROUND: To illustrate the technical feasibility and diagnostic value of including the assessment of the bladder and the ureters during a standard transvaginal ultrasound examination. METHODS: We present four cases illustrating ureter and bladder pathology diagnosed by transvaginal ultrasound. RESULTS: In a first case, transvaginal ultrasonography in a woman with lower abdominal pain showed a calculus in the left distal ureter. The small echogenic lesion was easily detectable within the ureter lumen. A second patient, presenting with suprapubic pain, urgency and back pain, was also diagnosed with a ureteral calculus and additionally a hydroureter. The presence of a hydroureter is part of the differential diagnosis of any cystic structure in the pelvis. In a third case, an elderly woman, referred with uterine prolapse, transvaginal ultrasound examination showed a tubular anechoic structure lateral in the pelvis due to a hydroureter, illustrating the differential diagnosis with a hydrosalpinx. A fourth patient, presenting with hematuria, showed an irregular and highly vascularized mass in the bladder and was diagnosed with a transitional cell carcinoma. CONCLUSION: The bladder and pelvic part of the ureters are easily identifiable on transvaginal scan. Important pathology of the lower urinary tract and the distal ureters can be readily diagnosed by transvaginal ultrasound examination. The evaluation of the bladder and the ureters should therefore be part of the standard gynecological ultrasound investigation.

Antegrade and Retrograde Endoscopic Approaches for Managing Obstructing Ureteral Calculi in Renal Transplant Patients: An Illustrative Case Series.

Purpose: To demonstrate the various antegrade and retrograde endourologic approaches that may be required for effectively treating kidney transplant recipients presenting with ureteral obstruction caused by urolithiasis. Materials and Methods: We prospectively evaluated endoscopic management techniques of renal transplant recipients referred to a national kidney transplant center with obstructing transplant ureteral calculi for a 12-month period (April 2019-April 2020). Results: Four kidney transplant recipients presented with ureteral obstruction caused by urolithiasis and the mean age was 66.6 (range: 62-71) years. The mean duration from renal transplantation was 16 (range: 6-25) years. Three patients presented with acute urosepsis and one patient presented with malaise and recurrent urinary tract infections. Two patients were definitively treated with percutaneous antegrade flexible ureteroscopic lithotripsy through a 16F minipercutaneous nephrolithotomy sheath. Two patients were definitively treated with retrograde flexible ureteroscopy (7F single-use disposable ureteroscope) and laser lithotripsy. Full stone clearance was achieved in all four patients and no perioperative complications occurred. Conclusion: Management of ureteral calculi in renal transplant recipients is challenging. A multimodal approach involving antegrade and retrograde endoscopic techniques may be required to achieve full stone clearance.

Diagnostic Imaging of the Avian Urinary Tract.

Due to the special anatomy and physiology of the avian urinary system, the value of diagnostic imaging techniques differs from the use in mammals. The diagnostic imaging methods regularly used in practice to evaluate the avian kidneys are often limited to traditional radiography and ultrasonography, whereas other imaging modalities (urography, scintigraphy, computed tomography, MRI) are rarely used. Furthermore endoscopy may be performed and taking a renal biopsy may be considered. The article describes common indications for imaging techniques used to diagnose urinary tract disease as well as its anatomic and pathologic demonstration.