Embedded upper end of double J stent at the site of renal pelvis injury following percutaneous nephrolithotomy: a rare complication.

BACKGROUND: Injury of the renal collecting system is a well-known complication of percutaneous nephrolithotomy (PNL). Large injuries may cause excessive bleeding and fluid extravasation and require adequate drainage using several modalities such placement of JJ stents. Herein, we report on two cases in which the upper coil of the JJ stent got buried in the fibrous tissues which formed due to an injury of the collecting system during PNL. CASE PRESENTATION: 40 years old male and 32 years old female underwent standard PNL for partial and total staghorn calculi, respectively. During the procedure in both cases, the renal pelvis was injured. In both cases, JJ stent was used to drain the collecting system. Trial to remove the JJ stent 6 weeks following the procedure failed because the upper coils of the stents were embedded in the fibrous tissues at the perforation site. Laser incision of the fibrous tissues and releasing the upper coil of the stents were performed using percutaneous approach in the first case and flexible ureterorenoscopy (fURS) in the second patient. The procedures were uneventful in both cases. CONCLUSION: This is the first report of embedded JJ stents which got buried by fibrous tissues at the site of collecting system injury that occurred during PNL. To prevent this complication in such cases, we suggest draining the collecting system using nephrostomy tube instead of JJ stent. Alternatively, the upper coil of the stent should be placed away from the injury site.

Vanin-1 in Renal Pelvic Urine Reflects Kidney Injury in a Rat Model of Hydronephrosis.

Urinary tract obstruction and the subsequent development of hydronephrosis can cause kidney injuries, which results in chronic kidney disease. Although it is important to detect kidney injuries at an early stage, new biomarkers of hydronephrosis have not been identified. In this study, we examined whether vanin-1 could be a potential biomarker for hydronephrosis. Male Sprague-Dawley rats were subjected to unilateral ureteral obstruction (UUO). On day 7 after UUO, when the histopathological renal tubular injuries became obvious, the vanin-1 level in the renal pelvic urine was significantly higher than that in voided urine from sham-operated rats. Furthermore, vanin-1 remained at the same level until day 14. There was no significant difference in the serum vanin-1 level between sham-operated rats and rats with UUO. In the kidney tissue, the mRNA and protein expressions of vanin-1 significantly decreased, whereas there was increased expression of transforming growth factor (TGF)-ß1 and Snail-1, which plays a pivotal role in the pathogenesis of renal fibrosis via epithelial-to-mesenchymal transition (EMT). These results suggest that vanin-1 in the renal pelvic urine is released from the renal tubular cells of UUO rats and reflects renal tubular injuries at an early stage. Urinary vanin-1 may serve as a candidate biomarker of renal tubular injury due to hydronephrosis.

[Bilateral spontaneous renal pelvis rupture during a computed tomography: Report of one case]. / Ruptura pieloureteral espontánea bilateral durante un urotac: Caso clínico.

Spontaneous rupture of the urinary excretory system is a rare condition. It is mainly associated with obstruction of the excretory system and is usually unilateral. We report a 58 years old male who, during the performance of a computed tomography of the urinary system, felt an intense lumbar pain. A bilateral rupture at the level of the fornix was found. The patient had an uneventful evolution thereafter. Fifteen days later a new computed tomography showed indemnity of the urinary excretory system.

Complications in percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is generally considered a safe technique offering the highest stone-free rates after the first treatment as compared to the other minimal invasive lithotripsy techniques. Still, serious complications although rare should be expected following this percutaneous procedure. In this work, the most common and important complications associated with PCNL are being reviewed focusing on the perioperative risk factors, current management, and preventing measures that need to be taken to reduce their incidence. In addition, complication reporting is being criticized given the absence of a universal consensus on PCNL complications description. Complications such as perioperative bleeding, urine leak from nephrocutaneous fistula, pelvicalyceal system injury, and pain are individually graded as complications by various authors and are responsible for a significant variation in the reported overall PCNL complication rate, rendering comparison of morbidity between studies almost impossible. Due to the latter, a universally accepted grading system specialized for the assessment of PCNL-related complications and standardized for each variation of PCNL technique is deemed necessary.

A novel endoscopic treatment for renal arteriopelvic fistula post-percutaneous nephrolithotomy (PCNL).

MAIN FINDINGS: We describe the use of a novel endoscopic approach in the management of unremitting gross hematuria following post-percutaneous nephrolithotomy (PCNL) in a 65-years-old male. This approach proved successful and cost-effective in managing haemorrhage post-PCNL when renal angiography failed to localize the source of bleeding. Case hypothesis: The recommended treatment modality for renal calculi ≥ 2cm is PCNL. It is essential that clinicians are aware of the various complications that can arise from PCNL, including arteriovenous fistula, which is typically managed with renal angio--embolization. The development of a renal arteriopelvic fistula (APF) is an extremely rare complication, and accounts of haemorrhage from renal APF and its treatment have not been well-described in the literature. We successfully hypothesized that the ureteroscopic localization, fulguration, and closure with a fibrin sealant at the site of the arterial bleed results in optimal treatment for this clinical presentation. We report this case in detail. Promising Future Implications: The successful and cost-effective endoscopic approach described here for treatment of post-PCNL renal APF and unremitting gross hematuria ought to be considered as an adjunct to renal angiography and embolization when the source of bleeding cannot be accurately identified using traditional imaging modalities.

[An urinary catheter slipped into the renal pelvis]. / Virtsakatetri luiskahti munuaisaltaaseen.

An elderly woman was referred to hospital because of fever and deterioration of her general condition. Due to urinary retention, the woman had undergone long term catheterization and had a urinary infection for years. In addition, the partial right hip prosthesis was found to be dislocated. While changing the catheter it slipped into the renal pelvis, and the balloon of the catheter was filled at the level of the ureteropelvic junction. The condition, observed in computed tomography scanning, was quickly restored, and the patient managed to avoid complications. Drifting of an urethral catheter into the upper urinary tract is a rare condition, but may lead to significant complications.

Complete ureteropelvic-junction disruption following renal trauma: conservative management. / Avulsión completa de la unión pieloureteral tras traumatismo renal: manejo conservador.

INTRODUCTION: Surgical exploration in complete ureteropelvic-junction disruption (CUPJD) is still recommended by many authors. Conservative approach to pediatric renal trauma (RT) includes minimally invasive techniques such as nephrostomy, angioembolization or double-J stent placement. CASE REPORT: A 14-year-old patient with CUPJD was treated conservatively. CT-scan revealed active bleeding of the renal artery and significant urine extravasation. Coil angioembolization and nephrostomy placement were performed. An attempt to place a double-J stent was unsuccessful and surgical reconstruction was scheduled. Before surgery, methylene-blue was injected through the nephrostomy observing blue urine output through urethra. Antegrade pyelogram revealed drainage from the urinoma to the ureter. A new attempt to place an internal-external double-J-stent was successful. After 5 weeks, it was removed with total restoration of the urinary tract. CONCLUSION: Complete urinary tract restoration in some cases of CUPJD following RT is possible through a nonoperative approach. It can be safe and effective, reducing the risk of complications associated with complex surgeries.

INTRODUCCION: Muchos autores siguen recomendando la exploración quirúrgica en casos de avulsión completa de la unión pieloureteral (ACUPU). El abordaje conservador del traumatismo renal (TR) pediátrico incluye técnicas mínimamente invasivas como la nefrostomía, la angioembolización o el catéter doble J. CASO CLINICO: Paciente de 14 años con ACUPU tratada de forma conservadora. El escáner reveló la presencia de una hemorragia activa en la arteria renal, además de una importante extravasación urinaria. Se practicó angioembolización con bobinas y nefrostomía. Se intentó colocar un catéter doble J, sin éxito, por lo que se programó reconstrucción quirúrgica. Antes de la cirugía, se inyectó azul de metileno a través de la nefrostomía, observándose salida de orina azul a través de la uretra. La realización de una pielografía anterógrada reveló la presencia de drenaje desde el urinoma hacia el uréter. El segundo intento de colocar un catéter doble J interno-externo sí resultó fructífero, retirándose al cabo de 5 semanas, con restauración total del tracto urinario. CONCLUSION: La restauración completa del tracto urinario en algunos casos de ACUPU tras TR es factible sin necesidad de recurrir al abordaje quirúrgico. Se trata de un proceso seguro y eficaz que disminuye el riesgo de las complicaciones propias de las cirugías complejas.

Bilateral ureteropelvic disruption following blunt abdominal trauma: case report.

BACKGROUND: Ureteral injury occurs in less than 1% of blunt abdominal trauma cases, partly because the ureters are relatively well protected in the retroperitoneum. Bilateral ureteral injury is extremely rare, with only 10 previously reported cases. Diagnosis may be delayed if ureteric injury is not suspected, and delay of 36 hours or longer has been observed in more than 50% of patients with ureteric injury following abdominal trauma, leading to increased morbidity. CASE PRESENTATION: A 29-year-old man was involved in a highway motor vehicle collision and was ejected from the front passenger seat even though wearing a seatbelt. He was in a preshock state at the scene of the accident. An intravenous line and left thoracic drain were inserted, and he was transported to our hospital by helicopter. Whole-body, contrast-enhanced computed tomography (CT) scan showed left diaphragmatic disruption, splenic injury, and a grade I injury to the left kidney with a retroperitoneal haematoma. He underwent emergency laparotomy. The left diaphragmatic and splenic injuries were repaired. Although a retroperitoneal haematoma was observed, his renal injury was treated conservatively because the haematoma was not expanding. In the intensive care unit, the patient's haemodynamic state was stable, but there was no urinary output for 9 hours after surgery. Anuresis prompted a review of the abdominal x-ray which had been performed after the contrast-enhanced CT. Leakage of contrast material from the ureteropelvic junctions was detected, and review of the repeat CT scan revealed contrast retention in the perirenal retroperitoneum bilaterally. He underwent cystoscopy and bilateral retrograde pyelography, which showed bilateral complete ureteral disruption, preventing placement of ureteral stents. Diagnostic laparotomy revealed complete disruption of the ureteropelvic junctions bilaterally. Double-J ureteral stents were placed bilaterally and ureteropelvic anastomoses were performed. The patient's postoperative progress was satisfactory and he was discharged on the 23rd day. CONCLUSION: Diagnosis of ureteral injury was delayed, although delayed phase contrast-enhanced CT and abdominal x-rays performed after CT revealed the diagnosis early. Prompt detection and early repair prevented permanent renal damage and the necessity for nephrectomy.

Delayed Rupture of the Renal Collecting System Secondary to a Traumatic Hemorrhage in the Setting of Suspected Chronic Ureteropelvic Junction Obstruction.

Isolated rupture of the renal pelvis secondary to blunt trauma is rare, though there is increased incidence in the setting of a pre-existing renal abnormality that predisposes the kidney to injury. We report a case of post-traumatic hemorrhage into the renal collecting system leading to delayed rupture of the renal pelvis in the setting of suspected chronic ureteropelvic junction obstruction. This case illustrates the difficulty in diagnosis of acute hemorrhage into the renal collecting system. Special attention should be given to a kidney with a pre-existing abnormality in the setting of trauma to prevent complications. A literature review of hemorrhage into the collecting system along with appropriate imaging and management are discussed.

Hand-assisted laparoscopic partial nephrectomy combined with caliceal ureterostomy for the treatment of post-traumatic ureteropelvic junction disruption.

Ureteropelvic junction (UPJ) disruption seldom occurs in patients with blunt abdominal trauma. The diagnosis of UPJ disruption is delayed in more than 50% of patients, and it can lead to difficulty in further treatment or increase the risk of nephrectomy. We present a 25-year-old man who was found to have left UPJ disruption 2 months after blunt abdominal trauma and who was successfully treated by partial nephrectomy combined with caliceal ureterostomy under hand-assisted laparoscopy. We review the literature and discuss the possible images to help early diagnosis of UPJ disruption. As a reconstructive procedure, caliceal ureterostomy under hand-assisted laparoscopy can be an effective and facilitated option.

Ureteral injury from blunt abdominal trauma sustained in a bicycle accident.

Ureteral injuries from blunt abdominal trauma are rare. A 67-year-old man presented with left flank pain after blunt abdominal trauma sustained in a bicycle accident. Only two hours later he developed haematuria and pain in the left inguinal area. Contrast enhanced computed tomography scans revealed a partial disruption of the left uretero-pelvic junction.

[Comparison of the results of magnetic resonance urography and other examination methods in patients with iatrogenic injuries of the ureter and pelvis-ureteral segment].

MR urography was made in 25 patients (age 24-70, mean age 48.6 years, 20 females, 5 males) with iatrogenic injury of the upper urinary tract (UUT). A comparison group consisted of 15 patients without nephrostomic drainage who had no contraindications for intravenous contrast preparations. MR urography was performed in frontal and sagittal projections. The examination was made before and 20 min after intravenous injection of 20 mg diuretic. Five patients received additionally excretory MR urography with intravenous injection of magnevist (0.2 ml/kg, 3 ml/s just before the examination). Mean duration of urography was 21 (18-23) min. The results were compared to findings of ultrasound or x-ray investigations, diapevtic ureteroscopy or open surgical intervention. The results were similar to those of x-ray CT. In patients with ureteral obliteration MR urography was less informative than joint antegrade and retrograde ureteropyelography as the ureter could not be visualized beneath the injury. In 2 patients examined with intravenous urography and x-ray CT, definite length of ureteral stricture was obtained only with MR urography. In 5 patients with hydronephrotic transformation MR urography was much more informative than excretory urography. MR urography provided information sufficient for diagnosis. Sensitivity of MR urography and that with diuretic load was 86.8 and 92.3%, respectively. MR urography, even without contrast enhancement, provides images with high resolution sufficient for visualization of the ureter distally of the stricture and is a method of choice in patients with subnormal renal function, intolerance to iodine-containing contrast media, with hyperthyroidism and pregnant women after the first trimester.

Ureteral Access Sheath Deployment: How Much Force Is Too Much? Initial Studies with a Novel Ureteral Access Sheath Force Sensor in the Porcine Ureter.

Introduction and Objectives: Ureteral injuries can occur during ureteral access sheath (UAS) deployment. The force exerted during deployment and the amount of force that results in ureteral injury is yet to be accurately quantitated. In this feasibility study, we developed and then tested a novel force-sensing device in our animal laboratory to identify the threshold force that results in a porcine ureteral injury. Methods: With Institutional Animal Care and Use Committee approval, we measured ureteral dilator and UAS deployment force using our proprietary University of California, Irvine Ureteral Access Sheath Force Sensor (UAS-FS). The exerted force was measured during deployment from the moment that the tip of the UAS was passed into the urethral meatus until it reached the renal pelvis; progression of the UAS along the ureter was monitored with fluoroscopy. Ureteroscopic evaluation was performed after deployment of each catheter/sheath ≥8F to assess for ureteral injury using the Postureteroscopic Lesion Scale (PULS). Results: Six juvenile Yorkshire female pigs (12 ureters) were studied. No injuries were detected when the deployment force was <4 Newtons (N), which was the case when the catheter/access sheath was ≤13F. Increasing UAS size >13F resulted in greater peak forces. In five of the pigs, ureters selected for 14F UAS deployment without previous sequential dilation were injured (PULS ≥3) at a mean threshold force of 4.84 N. Serial dilation had a higher threshold for PULS ≥3 at 5.56 N. Overall, injury of PULS ≥3 was routinely noted when the force applied exceeded 8.1 N. Conclusions: The UAS-FS reliably measured forces while deploying a UAS. Significant ureteral injury can routinely be avoided if the applied force is <4.84 N; PULS ≥3 routinely occurred when forces exceeded 8.1 N. Serial dilation may allow safe passage at higher deployment forces, as much as 5.56 N.

CT scanning for diagnosing blunt ureteral and ureteropelvic junction injuries.

BACKGROUND: Blunt ureteral and ureteropelvic (UPJ) injuries are extremely rare and very difficult to diagnose. Many of these injuries are missed by the initial trauma evaluation. METHODS: Trauma registry data was used to identify all blunt trauma patients with ureteral or UPJ injuries, from 1 April 2001 to 30 November 2006. Demographics, injury information and outcomes were determined. Chart review was then performed to record initial clinical and all CT findings. RESULTS: Eight patients had ureteral or UPJ injuries. Subtle findings such as perinephric stranding and hematomas, and low density retroperitoneal fluid were evident on all initial scans, and prompted delayed excretory scans in 7/8 cases. As a result, ureteral and UPJ injuries were diagnosed immediately for these seven patients. These findings were initially missed in the eighth patient because significant associated visceral findings mandated emergency laparotomy. All ureteral and UPJ injuries have completely healed except for the case with the delay in diagnosis. CONCLUSION: Most blunt ureteral and UPJ injuries can be identified if delayed excretory CT scans are performed based on initial CT findings of perinephric stranding and hematomas, or the finding of low density retroperitoneal fluid.

[Injuries of the renal pelvis and ureter. Diagnosis and management]. / Verletzungen des Nierenbeckens und des Ureters. Diagnostik und Management.

About 5% of injuries of the urinary tract affect the renal pelvis and ureter and constitute a severe complication. Around 75% of these injuries are iatrogenic and only about 25% are caused by blunt abdominal trauma or perforation. To avoid complications and improve prognosis, immediate diagnosis and therapy are essential. The diagnostic accuracy of preoperative studies is low, therefore frequently injuries are detected during explorative laparotomy. The management of upper urinary tract lesions depends on severity and localization, whereas the ultimate ambition should always be the preservation of the kidney. As a basic rule, ureteral stenting is mostly sufficient for small lesions, and only larger injuries require open reconstructive techniques. Longitudinal studies document a high degree of functional reconstitution if adequate and immediate treatment is carried out.

Rupture of renal pelvis in an adult with congenital ureteropelvic junction obstruction after blunt abdominal trauma.

Isolated injury to the renal pelvis following blunt abdominal trauma is very rare. However, a pre-existing renal abnormality will increase the risk of rupture. We present a 24-year-old man with rupture of the left renal pelvis following blunt abdominal trauma. He had pre-existing left ureteropelvic junction (UPJ) obstruction. Delayed computed tomography scan with excretory phase revealed contrast medium extravasation from the left UPJ, and left renal pelvis rupture was diagnosed. He was managed successfully with ureteral double-J stenting for 2 months.