[A Case of Urethral Foreign Body from 40 Years Ago with Scrotum Abscess and Urethroscrotal Fistula].

A 70-year-old male came to our clinic with a high fever and left scrotal swelling. Following a diagnosis of left-side epididymitis, antibiotic treatment was started, though the swelling did not improve. Since an additional examination revealed an abscess in the left scrotum, scrotal incision and drainage were performed. Although the symptoms subsided, urine outflow from the incision was observed. The patient then noted that he had inserted a glass ball into the urethral meatus when he was about 30 years old. It was considered that an abscess and fistula had formed due to inflammation caused by the foreign body. Thus a transurethral surgical procedure was used for crushing and removal. The fistula disappeared within three months after the operation and the patient has not been affected by dysuria since that time. Symptoms may appear several years following insertion of a foreign body into the urethra. To the best of our knowledge, the present case is the longest term of indwelling, approximately 40 years, following insertion of a foreign body reported in Japan.

Une Liaison Dangereuse: Spontaneous Pyeloduodenal Fistula.

We describe the case of a 76-year-old woman with a spontaneous nephroduodenal fistula. The patient was initially evaluated for gastrointestinal and urinary symptoms associated with fever and anemia, after which she was admitted with the diagnosis of right chronic pyelonephritis, hydronephrosis, and renal lithiasis. The fistula was diagnosed incidentally by percutaneous pyelography during a right nephrostomy and was later confirmed with an abdominal CT scan. A multidisciplinary decision was made to surgically treat the fistula (right nephrectomy plus duodenal repair); the surgery had a short-term positive outcome. We report a systematic review of the literature related to spontaneous pyeloduodenal fistulæ and their treatments.

A systematic review of management of ureteroarterial fistula.

OBJECTIVE: Ureteroarterial fistula (UAF) is lethal condition. However, no consensus has been reached regarding the diagnosis and treatment of UAF owing to its rarity. The aim of our report was to present an actual case of UAF and systematically review the symptoms, risk factors, diagnosis, and treatment of this condition. METHODS: The case study was of a 52-year-old woman who had experienced a massive hemorrhage during urinary stent replacement. For the systematic review of studies of UAF, those written in English and reported from 1939 to 2020 were searched for on PubMed using the keywords "uretero-arterial fistula," "arterio-ureteral fistula," and "hematuria." RESULTS: We included 121 studies with 235 patients (mean age, 66.0 years; 139 women [59.1%]) in our review. UAF had occurred most frequently in the common iliac artery (n = 112; 47.7%). Almost all patients (n = 232; 98.7%) had complained of hematuria. The risk factors for UAF were pelvic surgery (n = 205; 87.2%), the long-term use of urinary stents (n = 170; 72.3%), oncologic radiotherapy (n = 107; 45.5%), and malignancy (n = 159; 67.7%). Although computed tomography can detect various useful findings such as extravasation, pseudoaneurysm, hydronephrosis, and opacification of ureters, it was diagnostically useful for only one third of the cases. Angiography was useful for the diagnoses of UAF for 124 (66.3%) of the 187 patients (79.6%) who had undergone angiography. With regard to treatment, endovascular approaches have been widely used in recent years because their invasiveness is lesser than that of open surgical repair. In the era of endovascular therapy, the indications for open surgical repair include ureteral-intestinal fistula, abscess formation, and graft infection after endovascular therapy. CONCLUSIONS: Computed tomography can be recommended as the first examination for patients with risk factors for UAF because of its usefulness. Subsequently, angiography should be considered because UAF can be treated using an endovascular approach after diagnostic angiography. The diagnosis and treatment of UAF can often be difficult; therefore, the important first step of diagnosis is suspecting the occurrence of UAF and using a multidisciplinary approach.

Arterioureteral fistula after radical cystectomy and ureterocutaneostomy: two case reports and a systematic literature review.

BACKGROUND: Arterioureteral fistula (AUF) is a rare, life-threatening condition wherein communication occurs between a ureter and the common, internal, or external iliac artery. The sensitivity of common clinical imaging examination for AUF is low, which leads to a delayed diagnosis and increased mortality. In addition, the increased use of ureteral stents contributes to the growing frequency of AUF. CASE PRESENTATION: Our two patients were 74 and 65 years old males respectively. They both had a medical history of bladder cancer and underwent radical cystectomy with ureterocutaneostomy. The patients underwent routine catheter exchange during over 1 year postradical cystectomy and subsequently experienced intermittent gross pulsatile haematuria. After a series of imaging examinations failed to identify the cause, the patients were ultimately diagnosed with AUF and treated with interventional radiotherapy, followed by broad-spectrum antibiotics. Positive effects were found. CONCLUSIONS: The incidence of AUF is increased with the prolongation of survival in patients with related risk factors. This case report aims to highlight early diagnosis and management of AUF to lower the mortality.

Multiple vas deferens with polyorchidism and many congenital malformations in a symptomatic 11-year-old male patient: a rare case report.

BACKGROUND: Ductus deferens may manifest in a variety of anomalies such as its absence, duplication, ectopy, or diverticulum. Ectopic seminal tract opening has two main types, ectopic ejaculatory duct opening, and ectopic vas deferens opening. Generally, ductus deferens anomalies affect approximately 0.05% of the population. Patients may be asymptomatic or complaining of urinary tract infections and/or epididymitis. Most of these cases are associated with renal dysplasia. To confirm the diagnosis Cystourethroscopy catheterization and retrograde urethrogram should be performed, but the definitive diagnosis is done by vasography. The definitive treatment is complete surgical resection of the pathological urogenital connection. This case is commonly discovered while exploring other findings such as testicular torsion and inguinal hernia. CASE PRESENTATION: We report a rare case of an 11-year-old male who presented with gross hematuria and numerous congenital malformations including a left polydactyly clubfoot, polyorchidism, with several surgical procedures, and left kidney dysgenesis. Surgery was performed for a left inguinal hernia, during which a third undescended testicle was discovered incidentally and was eradicated. A retrograde urethrogram was performed to establish the diagnosis. A fistula- that is connected with the left ureter- was resected. The histopathologic findings confirmed the diagnosis of true duplication of the Vas deferens, with communication between the ureter and the vas deferens. By follow-up, the kidney function tests were within normal limits. CONCLUSIONS: This case report aims to highlight the early diagnosis and management of the duplicated vas deferens and the associated congenital malformations to improve the prognosis and kidney function and to avoid long-term complications.

Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes.

BACKGROUND: Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate. MATERIAL AND METHODS: From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed. RESULTS: All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1-84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment. CONCLUSION: AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence. ABBREVIATIONS: AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy.

Embolization of Urinary Tract Fistulae Using an AMPLATZER Vascular Plug and Glue.

Six patients (mean age, 57.7 y ± 19.7) with persistent urinary fistulae underwent 7 urinary tract embolizations with AMPLATZER Vascular Plugs (AVPs) and glue: 5 with concomitant cavity obliteration with glue and 2 without. A single procedure was successful in resolving urinary leakage in 5 patients (71%) at a mean follow-up of 27.3 wk ± 31.5 (median, 9.7 wk; range, 4.9-80 wk). Repeat cavity embolization was required in 2 instances to achieve clinical success. Mean survival was 42.3 wk (median, 16.4 wk; range, 11.7-104 wk). Combined AVP and glue embolization may prove to be a primary approach in the control of persistent fistulae.

Early detection and endoscopic management of post cesarean section ureterovaginal fistula: a case series study.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the endourologic management of post-cesarean section ureterovaginal fistula. METHODS: Between February 2016 and March 2019, eight patients presented because of vaginal leakage after cesarean section. All presented within 15 days from their original operations. Three of the patients had a vague lower abdominal pain, and five had ipsilateral flank pain; all had vaginal leakage. Physical examination, ultrasonography, and IVP were done to confirm the diagnosis. Ureteroscopy was the first treatment attempt, using two or three guide wires to find the proximal part of the ureter and insert a JJ stent. RESULTS: In six patients, we could insert guide wires, find the proximal part of the ureter, and finally insert a JJ stent. In two patients, we could not even pass a guide wire, so we changed the position, and ureteral reimplantation was done. The stents were removed after 6 weeks, and after 3 months an IVP was planned again that showed all fistulae had resolved with no evidence of ureteral stricture. CONCLUSION: In cases of ureterovaginal fistula after cesarean section, ultrasonography and IVP with lateral view x-ray films may confirm the diagnosis. The traditional treatment for ureterovaginal fistula is ureteral reimplantation, but endoscopic management may be a viable technique with less invasiveness and faster results and recovery. Thus, retrograde stenting can be accomplished in selected patients with ureterovaginal fistula after cesarean section and may eliminate the need for reimplantation of the ureter.

Midterm Results after Open Surgical and Endovascular Management of Arterioureteral Fistula.

BACKGROUND: Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. METHODS: We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up. RESULTS: Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. DISCUSSION: Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Endovascular and open surgical options in the treatment of uretero-arterial fistulas.

OBJECTIVE: To report and analyze the indications and results of endovascular and open surgical treatment for uretero-arterial fistula. METHODS: We retrospectively reviewed the clinical data of 25 consecutive patients with uretero-arterial fistulas admitted to our hospital from 2011 to 2020. Endpoints were technical success, freedom from open conversion, stent-graft/graft-related complications, and 30-day and one-year mortality. RESULTS: The study included 25 patients (68% female, n = 17) with 27 uretero-arterial fistulas by bilateral pathologies in two patients. The mean age was 61 ± 11 years (range 35-80). The most common predisposing factors for uretero-arterial fistula were history of pelvic operations for malignancy in 21 patients (84%), radiotherapy in 21 patients (84%), previous pelvic vascular bypass in 2 patients (8%), and iliac aneurysms in 2 patients (8%). On average, the period between the primary pelvic surgery and the diagnosis of uretero-arterial fistulas was 46 months (range 7-255). Twenty patients (80%) underwent endovascular treatment of the uretero-arterial fistulas. The primary technical success of the endovascular treatment was 95%, and the freedom from open conversion was 40% at six months and 30% at one year. Thirteen uretero-arterial fistulas (48%) underwent delayed open conversion due to recurrent bleeding in six cases (46%), stent-graft infection in three cases (23%), or pelvic abscess in four cases (31%). Primary open surgery was applied for five (20%) patients. After a mean follow-up of 34 months, early (<30 days) mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality was 24% (6/25). CONCLUSIONS: Uretero-arterial fistula is a late complication of prior pelvic surgery, radiation, and indwelling ureteral stents. Endovascular treatment remains an effective and less invasive modality in controlling the related life-threatening arterial bleeding of the uretero-arterial fistula. Open surgical treatment is still required for patients with local sepsis, previously failed endovascular treatment or infected stent-grafts.

Guided tour of hidden tracts in the pelvis: exploring pelvic fistulas.

BACKGROUND: Fistulas are an abnormal connection between two or more epithelial surfaces. When fistulization between adjacent structures occurs in the pelvis, there is almost invariably significant associated morbidity and impact on a patient's quality of life. Imaging may aid in the diagnosis of pelvic fistulas and is essential to identify any associated pathology, define the course of the fistula, and aid in pre-surgical planning. PURPOSE: This article aims to review the wide array of clinical and imaging presentations of fistulas in the pelvis, with a focus on the radiologists' role in managing this challenging entity. METHODS: This article will review each classification type of fistula. RESULTS: Pelvic fistula is a devastating condition that causes significant morbidity and evaluation can be challenging. CONCLUSIONS: Imaging, and particularly MRI, plays a vital role in the diagnosis, characterizing the course of a fistula and demonstrating associated complications, which are essential to guide treatment decisions.

Endovascular therapy of arterioureteral fistulas.

Background: Arterioureteral fistulas (AUFs) are severe pathologies of different origin and with increasing incidence frequently appear in patients with underlying extensive malignancy and after pelvic surgery. AUF therapy is challenging since symptoms are frequently non-specific and patients are often unsuitable surgical candidates due to comorbidities. Since experiences with endovascular treatment strategies are limited, the feasibility, effectiveness, and safety were evaluated in a consecutive case series. Patients and methods: A retrospective analysis of five patients with endovascular AUF exclusion was performed. Probable predisposing factors for an AUF included history of pelvic malignancy with oncologic surgery in four patients, radiotherapy in four patients, and indwelling ureteral stents in four patients. Clinical presentation, diagnostic management, and site of fistula were assessed. Furthermore, technical and clinical success as well as complications were evaluated. Results: All patients presented with gross haematuria. In four patients, haematuria occurred during endoscopic ureteral stent manipulation. Affected vessels were the internal pudendal artery in one, intrarenal segmental artery and external iliac artery in two, and internal iliac artery in another two patients. Treatment included coil embolisation (n = 2), plug embolisation (n = 3), particulate embolisation (n = 1), and covered stent implantation (n = 2). Technical success was achieved in all procedures. In two cases, re-intervention was necessary due to AUF recurrence, resulting in a clinical success rate of 60.0%. One major complication class D was documented. Conclusions: AUFs can be treated effectively and safely using endovascular techniques. Diagnostic and therapeutic management of this rare entity requires a high level of awareness for potential risk factors as well as an optimal multidisciplinary coordination.

[Indocyanine green fluorescence to visualize the ureteric vascularization of kidney transplants: An exploratory study]. / Visualiser la vascularisation urétérale des transplants rénaux par fluorescence au vert d'indocyanine : étude exploratoire.

INTRODUCTION: Urinary complications after kidney transplantation are common and can compromise renal function. While they are mainly attributed to ischemic lesions of the ureter, there is no existing method to evaluate its vascularization during surgery. The aim of the study was to evaluate if indocyanine green, revealed by infra-red light andused to visualize tissue perfusion, could provide an appreciation of the ureter's vascularization during kidney transplantation. METHODS: This feasibility study was conducted over one month, on eleven consecutive kidney transplants. During transplantation, an injection of indocyanine green enabled the surgeon to visualize in real time with an infra-red camera the ureter fluorescence. Its intensity was reported on a qualitative and semi-quantitative scale. Occurrence of urinary complications such as stenosis or ureteral fistula were collected during 6 months. RESULTS: In all of the 11 cases (100%), the last centimeters of the ureters were not fluorescent. Three (27%) ureters were poorly or partiallly fluorescent. Out of these three cases, only one case of urinary fistula occurred, followed by ureteric stenosis. In the series, two fistulas (18%) and two ureteric stenoses (18%) occurred. No side effects were observed. The low number of events did not allow statistical analysis. CONCLUSION: Infra-red fluorescence of indocyanine green could be a simple and innovative way to appreciate the transplant's ureteric vascularization during kidney transplantation. It could help surgeons to identify the level of ureter section and to decide the anastomosis technique, in order to limit urinary complications. LEVEL OF EVIDENCE: 3.

Transrenal Ureteral Occlusion for Palliation of Refractory Urine Leaks Using Vascular Plugs and Liquid Ethylene Vinyl Alcohol.

PURPOSE: To describe outcomes of transrenal embolization with vascular plugs and ethylene vinyl alcohol (EVOH) in a case series of patients with refractory urinary leak or fistula. MATERIALS AND METHODS: Fifteen ureteral occlusions performed over 53 months in 9 consecutive patients (56% female; mean age 61 y; range, 45-80 y) were reviewed retrospectively. The main indication was palliation for refractory fistula or leak in the setting of malignancy not responding to urine diversion by percutaneous nephrostomy tube or nephroureteral stent. Transrenal ureteral occlusion was performed using EVOH injected between vascular plugs placed distal and proximal to the leak or fistula. RESULTS: Technical success was 100%. Considerable reduction of urine leak or symptoms (clinical success) was achieved in 64% of ureters after mean follow-up of 105 days (range, 0-632 d). Complete ureteral occlusion on follow-up anterograde nephrostogram (imaging success) was achieved in 60% of ureters after mean follow-up of 139 days (range, 0-643 d). One patient with distal ureterovesical junction-perineal fistula had continued leak despite complete proximal occlusion of ureter owing to retrograde urine reflux from the bladder and was treated with endoscopic injection of intramural calcium hydroxyapatite to the ureteral segment distal to the fistula. Three ureters (33%) in 2 patients with vesicovaginal fistula had recanalization, requiring additional proximal embolization, yielding secondary success rates of 91% (clinical) and 90% (imaging) per ureter. One minor urinary tract infection and no major complications occurred. CONCLUSIONS: Transrenal anterograde ureteral occlusion using EVOH between vascular plugs could be considered a relatively safe and potentially valuable treatment option for refractory ureteral fistulae.

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract.

PURPOSE: To retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA). MATERIALS AND METHODS: Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT). RESULTS: In 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1-5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). There were no procedure-related complications. CONCLUSIONS: Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.

Imaging of Small Renal Masses before and after Thermal Ablation.

Thermal ablation of small renal masses is increasingly accepted as an alternative to partial nephrectomy, particularly in patients with multiple comorbidities. Many professional societies support this alternate treatment with updated guidelines. Before performing thermal ablation, it is important to stratify risk and assess technical feasibility by evaluating tumor imaging features such as size, location, and centrality. Routine postablation imaging with CT or MRI is necessary for assessment of residual or recurrent tumor, evidence of complications, or new renal masses outside the ablation zone. The normal spectrum and evolution of findings at CT and MRI include a halo appearance of the ablation zone, ablation zone contraction, and ablation zone calcifications. Tumor recurrence frequently manifests at CT or MRI as new nodular enhancement at the periphery of an expanding ablation zone, although it is normal for the ablation zone to enlarge within the first few months. Recognizing early tumor recurrence is important, as small renal masses are often easily treated with repeat ablations. Potential complications of thermal ablation include vascular injury, urine leak, ureteral stricture, nerve injury, and bowel perforation. The risk of these complications may be related to tumor size and location.©RSNA, 2019.

Comparison of diagnostic accuracy for fistulae at ultrasound and voiding cystourethrogram in neonates with anorectal malformation.

BACKGROUND: Recently, it has been reported that anorectal malformation with rectourethral fistula in male neonates can be managed by primary neonatal reconstruction without colostomy. To prevent urethral injury during anorectoplasty, the fistula's location is important. To date, the use of voiding cystourethrograms to determine the presence and location of fistulas in neonates with anorectal malformations has not been studied. OBJECTIVE: To compare the accuracy of ultrasound (US) and voiding cystourethrogram for determining the presence and location of fistulas in neonates with anorectal malformation. MATERIALS AND METHODS: We included 21 male neonates with anorectal malformation with rectourethral fistula (n=16), rectovesical fistula (n=1) or no fistula (n=4) who underwent US and voiding cystourethrogram preoperatively on the day of surgery. Fistula imaging was classified into three grades (0-2), and grades 1-2 were considered fistula positive. We compared the imaging-based location of the fistula with surgical findings. RESULTS: US performed significantly better than voiding cystourethrogram for determining the presence of fistulas (area under the receiver operating characteristic curve, 0.90 vs. 0.71, respectively; P=0.044) (diagnostic accuracy 85.7%, 95% confidence interval [95% CI] 63.7-97.0% and 52.4%, 95% CI 29.8-74.3%, respectively). In cases with fistulas detected by either modality, the accuracy of locating the fistula by US was 50.0% (95% CI 24.7-75.3%) and by voiding cystourethrogram was 100% (95% CI: 59.0-100%). CONCLUSION: US accurately detected, but did not accurately locate, fistulas in neonates with anorectal malformation. When planning primary neonatal reconstruction of anorectal malformation without colostomy, voiding cystourethrogram could provide additional information about fistula location.

Fact or myth? The long shared common wall between the fistula and the urethra in male anorectal malformation with urethral bulbar fistula.

AIM: It has long been considered surgical dogma that the length of the shared common wall (CW) between a fistula and the urethra in males with anorectal malformation (ARM) and rectourethral bulbar fistula (RUBF) is considerably longer than in males with ARM and rectourethral prostatic fistula (RUPF). This belief has led surgeons who perform laparoscopic-assisted anorectoplasty (LAARP) for RUPF to avoid LAARP for RUBF for risk of potential injury to the urethra or incomplete removal of the fistula. In this study, we compared CW between RUBF and RUPF using distal colostography (DCG) and direct intraoperative measurements. METHODS: DCG of rectourethral fistula patients (n = 63; RUBF: n = 44; RUPF: n = 19) were used to measure CW retrospectively. Results were expressed as a ratio of the height of L4; i.e., CW:L4. If less than 0.7, the CW was classified as being "short"; if 0.71-1.4, as being "medium"; and if greater than 1.41, as being "long". CW that could not be measured was classified as indeterminate. 24 of these patients also had CW measured intraoperatively during LAARP as previously described. The results obtained using both techniques were also compared. RESULTS: Surprisingly, CW:L4 in RUBF patients was short in 47.7%, medium in 27.3%, long in 20.5%, and indeterminate in 4.5% on DCG, equivalent to mean lengths of 7 mm, 8.5 mm, and 10.3 mm obtained using direct intraoperative measurement for short, medium, and long CW:L4 categories, respectively. CW:L4 in RUPF was short in 73.6%, medium in 10.5%, and long in 5.2% on DCG, while mean intraoperative measurements were 5 mm, 7 mm, and 10 mm, respectively. Differences in CW measured intraoperatively were not significantly different between RUBF and RUPF (p = NS). CONCLUSION: From our findings, 47.7% of CWs in RUBF were short using two independent methods, with only 20.5% being long. Thus, LAARP should be considered actively for treating selected RUBF cases and not be excluded on the basis of CW length.