Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties.

INTRODUCTION AND HYPOTHESIS: We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney. METHODS: A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups. RESULTS: Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis. CONCLUSION: Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

Adrenal tumors with venous thrombosis: a single-institution experience.

OBJECTIVE: To assess the incidence, imaging, surgical approach and prognosis of adrenal tumors associated with venous thrombosis. MATERIAL AND METHODS: Charts of 206 patients who underwent adrenal surgery were reviewed. Data of patients with pathologically confirmed venous thrombosis, utilized diagnostic modalities, operative treatment and prognosis were reviewed and analyzed. RESULTS: Venous thrombosis was confirmed pathologically in 6 patients (2.9%). All were of male gender with age ranging between 2 and 54 years. The mean size of the masses was 11.5 ± 5.2 cm. Venous thrombosis was diagnosed preoperatively in 2 patients, adrenal vein thrombosis in 1 patient, and renal vein thrombosis in the others. Masses were successfully excised via an open approach in association with nephrectomy in 3 cases. There was no operative mortality or gross morbidity. Pathologically, thrombosis was limited to the adrenal vein in 4 patients and extended to the renal vein in 2. Pathology of the masses revealed neuroblastoma in 2, pheochromocytoma in 2, adrenocortical carcinoma in 1, and pleomorphic sarcoma in 1 case. Metastasis developed within 6 months in 3 of these patients. CONCLUSION: Venous thrombosis with adrenal tumors is a rare pathological condition in which open surgery is the standard of care. Primary malignant adrenal masses with venous thrombosis have a poor prognostic outcome.

Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney.

OBJECTIVE: To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney. PATIENTS AND METHODS: Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome. RESULTS: Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted. CONCLUSION: Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m2 is considered relative contraindication.

TOT for treatment of stress urinary incontinence: how should we assess its equivalence with TVT?

INTRODUCTION AND HYPOTHESIS: Synthetic mid-urethral slings are currently considered the treatment of choice for stress urinary incontinence (SUI). In this study, two types of slings are compared: TVT vs. TOT. METHODS: In a prospective randomized study, 40 patients underwent either TVT (19 patients) or TOT (21 patients). Stress-specific and overall success was evaluated. Perioperative complications were classified according to Clavien's classification. RESULTS: Mean duration of follow-up was 20 months. At last follow-up, stress-specific success rate was 94.6% in TVT vs. 81% in TOT. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. Thigh pain represented the main complication in the TOT group. CONCLUSIONS: Both TVT and TOT are effective procedures for treatment of SUI. When compared to each other, TOT seems to be inferior to TVT in terms of efficacy, causing less serious complications.

Percutaneous adrenal biopsy for indeterminate adrenal lesion: complications and diagnostic accuracy.

PURPOSE: To critically analyze the role, accuracy and safety of percutaneous adrenal biopsy for indeterminate adrenal lesions. MATERIALS AND METHODS: Adrenal biopsies were performed in 15 among 214 patients (7%) diagnosed with adrenal masses being indeterminate on preoperative imaging. Definitive histopathology was obtained in all and overall sensitivity and negative predictive value were calculated. Safety of the procedure was reported. RESULTS: The study included 8 male and 7 female patients with a mean age of 33.3 +/- 20.3 years (range 7-65). Biopsy was carried out under computed tomography and ultrasound guidance in 12 and 3 patients, respectively. There were 2 nonrepresentative biopsies that were proved to be adrenocortical carcinoma and myelolipoma after adrenalectomy. Results of biopsy in the remaining 13 patients provided accurate diagnosis as proved by definitive histopathology in all but 2 in whom the final diagnosis was established as adrenocortical carcinoma while biopsy was paraganglioma in one and cortical adenoma in the other. Overall sensitivity and negative predictive value of adrenal biopsy was 73.3 and 60%, respectively. Apart from two mild hypertensive episodes following silent pheochromocytoma biopsy, no complications were reported. CONCLUSIONS: Percutaneous biopsy is a safe procedure for the diagnosis of pathologic conditions of the adrenal gland with a reasonable diagnostic aid.

Prediction of survival after radical cystectomy for invasive bladder carcinoma: risk group stratification, nomograms or artificial neural networks?

PURPOSE: We compared 3 predictive models for survival after radical cystectomy, risk group stratification, nomogram and artificial neural networks, in terms of their accuracy, performance and level of complexity. MATERIALS AND METHODS: Between 1996 and 2002, 1,133 patients were treated with single stage radical cystectomy as monotherapy for invasive bladder cancer. A randomly selected 776 cases (70%) were used as a reference series. The remaining 357 cases (test series) were used for external validation. Survival estimates were analyzed using univariate and then multivariate appraisal. The results of multivariate analysis were used for risk group stratification and construction of a nomogram, whereas all studied variables were entered directly into the artificial neural networks. RESULTS: Overall 5-year disease-free survival was 64.5% with no statistical difference between the reference and test series. Comparisons of the 3 predictive models revealed that artificial neural networks outperformed the other 2 models in terms of the value of the area under the receiver operator characteristic curve, sensitivity and specificity, as well as positive and negative predictive values. CONCLUSIONS: In this study artificial neural networks outperformed the risk group stratification model and nomogram construction in predicting patient 5-year survival probability, and in terms of sensitivity and specificity.

Comparison between a serous-lined extramural tunnel and T-limb ileal procedure as an antireflux technique in orthotopic ileal substitutes: a prospective randomized trial.

OBJECTIVE: To compare the functional results from a prospective randomized trial of two different reflux-prevention techniques for ileal bladder substitution. PATIENTS AND METHODS: In all, 60 patients with invasive bladder cancer were randomized to receive either a serous-lined extramural tunnel (group 1) or T-limb ileal procedure (group 2) as an antireflux technique for the ileal substitute. The preoperative evaluation included intravenous urography, radioisotope renography to evaluate glomerular filtration rates (GFRs) and renal cortical imaging with 99mTc- dimercaptosuccinic acid to assess parenchymal scarring. Evaluable patients were re-assessed by the same imaging, and by ascending studies. RESULTS: The follow-up included 27 patients (49 units) in group 1 and 23 (45 units) in group 2, with a mean (sd) follow-up of 6.3 (0.5) and 7.4 (1.9), respectively. Uretero-ileal strictures were diagnosed in one renal unit in each group (P = 0.5). Ascending studies showed no reflux in any patients in group 1, while 13 renal units (29%) in group 2 were refluxing (P < 0.01). There was progressive cortical scarring with or with no significant reduction in GFR (>25%) in three and four renal units in groups 1 and 2, respectively. Among the 13 refluxing units in group 2, three showed a significant deterioration in GFR and one renal unit was diagnosed with progressive cortical scarring. CONCLUSION: Both procedures provided a low rate of anastomotic stricture, with acceptable preservation of renal function. The serous-lined extramural tunnel provided a more effective antireflux mechanism.

Surgical management of adrenal cysts: single-institution experience.

OBJECTIVES: To assess the safety and efficacy of different surgical procedures used for managing benign adrenal cysts. PATIENTS AND METHODS: The files of 245 patients presenting with adrenal masses was reviewed retrospectively; all had a thorough history taken and a physical examination. The radiological evaluation included abdominal plain X-rays, grey-scale abdominal ultrasonography and computed tomography with contrast medium. According to their clinical situation, patients had surgical open, laparoscopic intervention or were managed conservatively. The short- and long-term outcome of the open and laparoscopic techniques were evaluated. RESULTS: Twenty-six (11%) patients presented with adrenal cysts; the mean (sd, range) age at the time of presentation for adults was 41.4 (15, 17-82) years, while a 1-month female neonate and 1-year-old boy presented with an adrenal cyst. The mean (sd, range) size of the cysts was 10 (3.5, 5-18) cm. Surgical intervention was the treatment of choice in 21 patients; 11 (42%) had open adrenalectomy, while 10 (38%) had laparoscopic intervention. Both groups were comparable in the term of cyst size and operative time, while the laparoscopically managed group had a shorter hospital stay. Five patients were followed with no surgical intervention. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. Compared with open techniques it has the advantages of a shorter hospital stay, less blood loss and enhanced cosmesis. Unlike aspiration of cyst contents, the recurrence of adrenal cysts after surgical removal is unlikely.

Diagnosis and treatment of adrenal tumors: a single-center experience with 238 cases.

OBJECTIVE: It was the aim of this study to review and analyze clinical data on the diagnosis and management of patients with adrenal masses. PATIENTS AND METHODS: Between 1976 and 2005, 238 patients admitted to our institute with adrenal masses were reviewed. Incidence, clinical features, imaging technique findings, surgical approaches, morbidity and mortality, as well as pathological diagnoses were reported. RESULTS: The series comprised 134 males and 104 females (mean age 33.3 +/- 20.3 years). Right-sided masses were more common (63.4%), with a mean size of 7.7 +/- 4 cm. Pain was the most frequent presenting symptom (53.4%), while 62 (26%) had a functional tumor. Incidentaloma was diagnosed in 49 patients (20.6%). Both computed tomography and magnetic resonance imaging showed a high diagnostic yield (sensitivities of 98.9 and 100%, respectively). Open adrenalectomy was performed in 153 patients (64.3%), while a laparoscopic approach was employed in 53 patients (22.3%). The intraoperative complication rate was 14.7%, the postoperative complication rate 6.1% and perioperative mortality 1.7%. Most of the excised masses were pheochromocytomas (26.4%). CONCLUSIONS: Computed tomography is recommended as the first diagnostic modality to define and characterize adrenal masses. Laparoscopic adrenalectomy is currently replacing open surgery as the standard surgical management of adrenal masses.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE: In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification. METHODS: A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS®. RESULTS: Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality. CONCLUSION: Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.