The effect of body mass index on quality of life in modified single stoma cutaneous ureterostomy or ileal conduit after radical cystectomy.

OBJECTIVE: To explore the influence of postoperative body mass index (BMI) change on postoperative quality of life (QOL) in patients undergoing radical cystectomy (RC) plus modified single stoma cutaneous ureterostomy (MSSCU) or ileal conduit (IC). METHODS: Patients were divided into two groups according to different BMI change patterns: patients experiencing an elevated postoperative BMI level, along with a clinically significant increase in their BMI (an increase of more than 10%) were categorized as Group 1, while patients experiencing a decrease postoperative BMI level, along with a clinically significant reduction in their BMI (a decrease of more than 5%) were categorized as Group 2. Spearman correlation analysis was used to examine the correlations between quality-of-life scores and postoperative clinical parameters. RESULTS: Spearman correlation analysis showed that postoperative BMI, late complications and catheter-free state were significantly associated with postoperative global QoL and symptom scale in MSSCU and postoperative global QoL and physical scale in IC patients. Additionally, postoperative BMI, catheter-free state and the use of adjuvant therapy were associated with bad performance in many scales of QoL like body image, future perspective, social scale, future perspective (MSSCU), and abdominal bloating (IC) (Table 2, p<0.05). Patients in Group 2 with significant weight loss had a better Global QoL, a lower rate of stomal stricture and a higher catheter-free state compared with those in Group 1 in both IC and MSSCU patients. MSSCU patients in Group 2 could achieve a comparable Global QoL as to IC patients in Group 1. CONCLUSION: Controlling the substantial increase in body weight after surgery contributes to improving QoL, reducing the occurrence of stomal stricture, and ensuring a postoperative catheter-free state in BCa patients undergoing MSSCU.

Use of an Application to Increase Self-Care Ability, Improve Quality of Life, and Decrease Stoma Complications in Patients With Ileocystoplasty or Ureterostomy Due to Bladder Cancer.

BACKGROUND: Quality of life for patients after ileocystoplasty or ureterostomy due to a urinary bladder neoplasm can be limited after discharge from the hospital. PURPOSE: To add the real-time communication ability of an application (app) to the daily care of this patient population to enhance communication between doctors and patients and provide improved nursing interventions, thus improving patients' self-care abilities and quality of life while decreasing stoma complications. METHODS: A total of 67 patients who underwent urinary tract diversion after total cystectomy were randomly divided into 2 groups. Patients in the control group (n = 32) received regular telephone follow-ups when they were discharged from the hospital, once a week for the first 2 months and then once a month for the next 22 months; patients in the intervention group (n = 35) used an app in addition to receiving regular telephone follow-ups. After 24 months of the intervention, multivariate analyses were conducted regarding self-care ability, complication rate, and quality of life. RESULTS: Self-care ability and quality of life scores in the intervention group were significantly improved during the 24-month period, and the complication rate was significantly reduced. CONCLUSION: Interaction via an app improved patients' self-care ability and quality of life. In addition, stoma complications were reduced. Future studies with larger sample sizes and patients of different ages are needed.

A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy.

BACKGROUND: Robot-assisted radical cystectomy (RARC) and intracorporeal urinary diversion are less invasive than conventional procedures. However, for older patients, cutaneous ureterostomy (CUS) may be preferred because urinary diversion using the intestine has a high incidence of perioperative complications and is highly invasive. The purpose of this study was to demonstrate the safety and efficacy of intracorporeal ileal conduit (ICIC) compared with CUS in patients aged 75 years or older who underwent RARC. METHODS: From October 2014 to December 2021, 82 patients aged 75 years or older who underwent RARC at Tokushima University Hospital, Tokushima Prefectural Central Hospital, or Ehime Prefectural Central Hospital were retrospectively reviewed. Of these, 52 and 25 patients who underwent ICIC and CUS, respectively, were included. After adjusting the patients' characteristics using propensity score-matching, surgical results and prognoses were retrospectively compared. The propensity score was based on age, Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PS), American Society of Anesthesiologists physical status classification (ASA-PS), clinical tumor stage, and neoadjuvant chemotherapy. RESULTS: The median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30-90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group. CONCLUSION: In older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

Multicenter Analysis of Postoperative Complications in Octogenarians After Radical Cystectomy and Ureterocutaneostomy: The Role of the Frailty Index.

BACKGROUND: The purpose of this study was to assess patient frailty as a risk factor for radical cystectomy (RC) complications. MATERIALS AND METHODS: We performed an analysis of prospectively collected data of consecutive patients 80 years of age or older who underwent RC and ureterocutaneostomy in 6 primary care European urology centers. Frailty was measured using a simplified frailty index (sFI) with a 5-item score including: (1) diabetes mellitus; (2) functional status; (3) chronic obstructive pulmonary disease; (4) congestive cardiac failure; and (5) hypertension, with a maximum 5-item score meaning high level of frailty. Within 90 days surgical complications were scored according to the Clavien Classification System (CCS). sFI ≥3 was considered as poor frailty status. Clinical and pathological variables were analyzed as predictors of severe complications (CCS ≥3). RESULTS: One hundred seventeen patients were enrolled. Most patients reported an sFI score of 2 and 3, respectively, 31/117 (26.5%) and 45/117 patients (38.5%). CCS ≥3 occurred in 17/117 patients (14.5%). Patients with sFI ≥3 were significantly older than patients with sFI <3 (median age, 85 years [interquartile range (IQR), 82-86] versus 82 years [IQR, 80-84]; P = .001). Most CCS ≥3 scores occurred in patients with sFI ≥3: 13 (11.1%) versus 4 (3.4%; P = .02). No significative differences were detected in terms of length of hospital stay, pathological stage, and postoperative bowel canalization when related to sFI. sFI ≥3 was an independent risk factor of CCS ≥3 in univariate and multivariate analysis (respectively, odds ratio [OR], 3.81 [95% confidence interval (CI), 1.16-12.5; P = .02] and OR, 3.1 [95% CI, 0.7-13.7; P = .01]). Body mass index, age, American Society of Anesthesiologists score ≥3, and pathological stage were not related to CCS ≥3. CONCLUSION: RC appears feasible in elderly patients with an sFI <3. In cases of sFI ≥3, this choice should be carefully valued, discussed, and possibly avoided because of a higher risk of complications.

Laparoscopy-Assisted Cutaneous Ureterostomy in Children: Early Experience.

OBJECTIVE: Laparoscopy-assisted cutaneous ureterostomy (LA-CU) is a minimally invasive approach for temporary urinary diversion in children. We describe the technique, its feasibility, potential advantages, and outcomes in 12 children treated for a variety of conditions. METHODS: Three trocars were used transperitoneally, one transumbilical, and another placed at the later stoma site. In the semilateral position, with a panoramic view, the ureter of interest is easily identified, mobilized, and exteriorized for stoma creation. We retrospectively reviewed our experience at two tertiary-care centers and included both refluxing and end ureterostomies. The study period was between October 2014 and February 2017. Renal function and growth curves were noted at follow-up. RESULTS: Twelve children underwent LA-CU: 3 end and 9 refluxing ureterostomy. Mean age was 18.75 ± 17.60 months. Mean operating time was 94.44 ± 34.86 minutes. Follow-up ranged from 10 to 38 months. No major postoperative complications occurred. Renal function and growth curves improved in the majority of children. CONCLUSIONS: Primary surgical correction of obstructive or refluxing uropathy is the gold standard; however, temporary urinary diversion is useful in specific scenarios. In these patients, laparoscopic assistance may offer better and direct visualization, achieves accurate and rapid identification of ureter, and provides adequate mobilization, tension-free exteriorization, and excision of redundant ureter in some to optimize drainage. One trocar at the eventual stoma site minimizes scarring.

Duplicated Ureters in Transplantation-A Single-center, Retrospective Study.

BACKGROUND: Kidney transplantation remains the best therapeutic option for chronic renal failure. The objective of the study was to evaluate the impact of ureteral duplication in donor kidneys on transplantation outcome. METHODS: In this study we performed a retrospective analysis of 75 patients who had undergone renal transplantation. The evaluated parameters included frequency of occurrence and risk of reoperation and graftectomy, mortality, as well as dependency of early and long-term graft function on pyelocaliceal system duplication. RESULTS: Ureteral duplication was associated with more frequent double J stent catheter implantation (P < .05). There was no relationship detected between ureteral duplication, number of operations performed, and risk of graftectomy (P > .05). Early graft function with 2 ureters was similar to that of grafts with a single pyelocaliceal system. The long-term results were also comparable. CONCLUSION: Ureteral duplication should not be considered a contraindication for renal transplantation.

Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures.

INTRODUCTION/BACKGROUND: The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. OBJECTIVE: To compare postoperative outcomes of EI vs UNC. STUDY DESIGN: This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. RESULTS: The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P < 0.001), male (30 vs 20%, P < 0.001), and publicly insured (34 vs 29%, P < 0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P < 0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR = 4.45; 2.69 in 30 days; 90 days, P < 0.001) and to have postoperative ER visits (OR = 3.33; 2.26 in 30 days; 90 days, P < 0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR = 7.12, P < 0.001). DISCUSSIONS: Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. CONCLUSIONS: Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.

Atrophic bladder in long-term dialysis patients increases the risk for urological complications after kidney transplantation.

OBJECTIVES: To evaluate the risk for urological complications after kidney transplantation at a single medical center in Japan. METHODS: In the present study, 408 kidney recipients (255 men, 153 women) were enrolled. There were 349 living and 59 deceased donors. The average age of the recipients was 42.5 ± 13.5 years, and the average pretransplant dialysis period was 71.8 ± 88.2 months. Ureteroneocystostomy was carried out on 347 patients, and ureteroureterostomy on 61 patients. We investigated the relationship between pretransplant duration of dialysis and bladder capacity, and examined the risk factors for urological complication. We also evaluated the incidence of vesicoureteral reflux in 191 recipients who underwent ureteroneocystostomy during transplantation. RESULTS: The preoperative duration of dialysis therapy showed a significant negative correlation with bladder capacity (R2  = 0.33, P < 0.001). The overall urological complication rate was 3.4% (14 patients), including urinary leakage (12 patients) and ureteral stricture (two patients). Univariate analysis showed that atrophic bladder, long-term dialysis therapy, deceased donor and ureteroureterostomy were associated with a higher incidence of urological complications (odds ratio 8.05, 4.43, 3.42 and 3.35; P < 0.01, P = 0.01, P = 0.04 and P = 0.04, respectively). Furthermore, multivariate analysis showed that atrophic bladder was the only significant factor associated with urological complications (odds ratio 10.37; P = 0.01). Among 191 recipients, vesicoureteral reflux was observed in 32 (16.8%). The incidence of vesicoureteral reflux was significantly higher in patients with atrophic bladder. CONCLUSIONS: Bladder atrophy in renal transplant recipients after long-term dialysis therapy is associated with a higher risk of urological complications.

Ileal Neobladder: An Important Cause of Non-Anion Gap Metabolic Acidosis.

BACKGROUND: The differential diagnosis for a non-anion gap metabolic acidosis is probably less well known than the differential diagnosis for an anion gap metabolic acidosis. One etiology of a non-anion gap acidosis is the consequence of ileal neobladder urinary diversion for the treatment of bladder cancer. CASE REPORT: We present a case of a patient with an ileal neobladder with a severe non-anion gap metabolic acidosis caused by a urinary tract infection and ureteroenterostomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Part of the ileal neobladder surgery includes ureteroenterostomy and predisposes patients to several clinically significant metabolic derangements, including a non-anion gap metabolic acidosis. These patients have an increased chronic acid load, bicarbonate deficit, and hypokalemia, which should be appreciated when resuscitating these patients.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions.

BACKGROUND: Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. OBJECTIVE: To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. SURGICAL PROCEDURE: Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS: No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. CONCLUSIONS: Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. PATIENT SUMMARY: In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Laparoscopic Resection and End-to-End Ureteroureterostomy for Midureteral Obstruction in Children.

PURPOSE: Midureteral obstruction is an extremely rare condition. This retrospective study assessed the outcomes of laparoscopic ureteroureterostomy (UU) in 13 children with midureteral obstructions. METHODS: Records of patients with midureteral obstruction who underwent laparoscopic end-to-end UU between July 2011 and August 2015 were reviewed. The medical records comprised patient demographic data, intraoperative details, postoperative outcomes, and related complications. Renal ultrasound, magnetic resonance urography, and radioisotope renography were used for pre- and postoperative assessment. Success was defined as removal of symptomatic obstruction or improvement of hydronephrosis. RESULTS: Thirteen patients from 3.0 months to 12 years old were identified: 6 patients presented with asymptomatic hydronephrosis (according to the renal ultrasonography), 3 with intermittent abdominal pain, and 2 with gross hematuria. The remaining 2 patients presented with urinary extravasation after inguinal hernia repair and the Soave procedure, respectively. All patients underwent laparoscopic end-to-end UU. Procedures were performed using either the laparoscopic transperitoneal approach or laparoscopic retroperitoneal approach. All surgeries were performed successfully except for one case that required open surgery because of difficult anastomosis. There were no intraoperative or immediate postoperative complications. The etiology of the midureteral obstruction included congenital midureteral stricture, ureteral polyp, retrocaval ureter, and iatrogenic injury. The mean surgical time was 148.4 min, and postoperative hospital stay was 4.0-9.0 d. Postoperative outcomes were successful in all 13 patients (100%); median follow-up was 19.1 months. CONCLUSION: Laparoscopic UU was found to be feasible and safe for the management of midureteral obstruction in children.

Infectious complications associated with the use of temporary prostatic urethral stents in patients with benign prostatic hyperplasia.

INTRODUCTION: To examine the infectious outcomes after the insertion of the temporary prostatic urethral stent (TPUS) in benign prostatic hyperplasia (BPH) patients. MATERIAL AND METHODS: Between November 2007 and September 2012, ninety TPUS were used in 33 patients with BPH at our institution. All patients had negative urine cultures prior to the first stent insertion. TPUS were sent for cultures at time of removal or exchange. Stents were removed at the time of definite surgical intervention, at 4-6 weeks, or when patients elected another course of treatment. Colonization was defined as asymptomatic positive stent culture. Infection was defined as symptomatic positive stent culture requiring treatment. Infection and colonization rates are reported. Logistic regression was used to examine the predictors of infection at any point. Predictors examined were age, body mass index, history of prostate cancer, diabetes mellitus, hyperlipidemia, coronary artery disease, neurologic disorder, erectile dysfunction and the sequence of stent placement. RESULTS: The majority of the subjects, 72% (24/33) had 1-2 stents, 9.0% (3/33) had 3-4 stents, 6.0% (2/33) had 5-6 stents, and 12% (4/33) of patients had more than 6 stents. From the 69 available culture results, the symptomatic infection rate was 16% (11/69) (95% CI: 8.2%-26.7%). The colonization rate was 58% (40/69) (95% CI: 45.5%-69.7%). None of the predictors examined were identified as a predictor of infection. There was no colonization detected when stents were removed in the first 20 days. CONCLUSION: Infection rates with TPUS in BPH patients are acceptable and early removal may prevent colonization.

Carcinoma arising in enteric diversion or rectal neobladder for bladder exstrophy.

Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.

Comparison of Urologic Complications Between Ureteroneocystostomy and Ureteroureterostomy in Renal Transplant: A Meta-Analysis.

OBJECTIVES: Transplant surgeons use a myriad of ureteral anastomotic techniques in renal transplant. Although the Lich-Gregoir extravesical anastomosis is the most common, ureteroureterostomy also is used. In this meta-analysis, our objective was to compare the complication rates of these 2 techniques as reported in the literature. MATERIALS AND METHODS: A systematic review of the literature revealed 44 articles, 6 of which met our inclusion criteria. Studies were compiled using Review Manager (RevMan version 5.3, Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Forest plots were generated to assess relative risk. A fixed-effects model was used for low heterogeneity, and a random-effects model was used for high heterogeneity. RESULTS: Overall complications were similar for both procedures (relative risk, 1.22; 95% confidence interval, 0.9-1.65), as were rates of urine leak and fistula (relative risk, 0.79; 95% confidence interval, 0.17-3.64) and hematuria (relative risk, 0.24; 95% confidence interval, 0.001-4.84). Stricture, obstruction, and stone formation were more common after ureteroureterostomy (relative risk, 0.63; 95% confidence interval, 0.45-0.88), whereas vesicoureteral reflux (relative risk, 6.82; 95% confidence interval, 1.68-27.61) and urinary tract infection (relative risk, 2.29; 95% confidence interval, 1.3-4.03) were more common after ureteroneocystostomy. CONCLUSIONS: With similar overall complication rates, both procedures can be viewed as being acceptable primary anastomotic techniques. In light of differing individual complication rates and the scarcity of data comparing the 2 methods, no specific recommendation regarding that technique should be used can currently be elucidated. We believe that further prospective studies comparing ureteroneocystostomy and primary ureteroureterostomy may reveal which is superior regarding complication rates.

Complications and quality of life in elderly patients with several comorbidities undergoing cutaneous ureterostomy with single stoma or ileal conduit after radical cystectomy.

OBJECTIVES: To compare peri-operative outcomes and quality of life (QoL) in a series of elderly patients with high comorbidity status who underwent single stoma cutaneous ureterostomy (CU) or ileal conduit (IC) after radical cystectomy (RC). PATIENTS AND METHODS: The clinical records of patients aged >75 years with an American Society of Anesthesiologists (ASA) score >2 who underwent RC at a single institution between March 2009 and March 2014 were retrospectively analysed. After RC, all patients included in the study received an IC urinary diversion or a CU with single stoma urinary diversion. Preoperative clinical characteristics as well as intra- and postoperative outcomes were evaluated and compared between the two groups. In addition, the Bladder Cancer Index (BCI) was used to assess QoL. RESULTS: A total of 70 patients were included in the final comparative analyses. Of these, 35 underwent IC diversion and 35 CU single stoma diversion. The two groups were similar with regard to age, gender, ASA score, type of indication and pathological features. Operating times (P < 0.001), estimated blood loss (P < 0.001), need for intensive care unit stay (P = 0.01), time to drain removal (P < 0.001) and length of hospital stay (P < 0.001) were significantly higher in patients undergoing IC diversion. The number of patients with intra- (P = 0.04) and early postoperative (P = 0.02) complications was also significantly higher among those undergoing IC diversion. Interestingly, the mean BCI scores were overlapping in the two groups. CONCLUSIONS: The present results show that CU with a single stoma can represent a valid alternative to IC in elderly patients with relevant comorbidities, reducing peri-operative complications without a significant impairment of QoL.

Carcinogenesis in rats subjected to a new model ureterosigmoidostomy and treated with L-lysine.

PURPOSE:: To evaluate the effects of L-lysine on the intestinal and urothelial epithelium of rats subjected to ureterosigmoidostomy (new model for surgical carcinogenesis). METHODS:: Forty-two rats, 9 weeks of age, were divided into 6 groups. Animals in groups A, B, C were subjected to ureterosigmoidostomy (US) and treated with L-lysine, celecoxib and H2O, respectively. Groups D, E and F (non-operated controls) received L-lysine, celecoxib and H2O, respectively. The L-lysine dose was 150 mg/kg and that of celecoxib was 20 mg/kg. The colon was analyzed for the presence of aberrant crypt foci (ACF) under a stereomicroscope.The tissue was stained with hematoxylin and eosin and PAS alcian blue. RESULTS:: There were rare ACF, and there was no statistically significant difference between the groups. Histopathologic study of the ureteral epithelium identified moderate to severe urothelial hyperplasia in rats with ureterosigmoidostomy. Transitional hyperplasia in the ureters of animals receiving L-lysine (A) showed an apparent difference compared to the control (C) (P=0.2424). There was no dysplasia or atypia. CONCLUSION:: L-lysine does not promote carcinogenesis of the intestinal and urethelial epithelium of rats subjected to ureterosigmoidostomy at the doses and times studied.

Simultaneous bilateral robotic-assisted laparoscopic procedures in children.

Our main objective is to report the feasibility of performing simultaneous robotic-assisted laparoscopic (RAL) heminephrectomy with contralateral ureteroureterostomy in children with bilateral duplicated systems. Three female children with bilateral congenital renal/ureteral anomalies underwent concurrent RAL simultaneous unilateral partial nephrectomy with ureterectomy and contralateral ureteroureterostomy with redundant ureterectomy using a four/five-port approach. Mean age at repair was 32.9 months (range 7-46 months) and mean weight was 13.7 kg (range 10.4-13.6 kg). The RAL heminephroureterectomy and contralateral ureteroureterostomy were performed via a four-port approach (five ports in one patient), and the patients were repositioned and draped when moving to the other side. Mean operative time was 446 min (range 356-503 min). Mean estimated blood loss was 23.3 cc (range 10-50 cc). Postoperative length of stay for two patients was 2 days and 1 day for one patient (mean = 1.7 days). Mean length of follow-up was 18.3 months (range 7-36 months). No significant intraoperative or postoperative complications occurred for any of the three patients. Two children had no hydronephrosis on postoperative imaging in follow-up, and one child had a small stable, residual pararenal fluid collection on the side of heminephrectomy. Two patients underwent postoperative ureteral stent removal under general anesthesia. In children with bilateral duplicated urinary tract with ureterocele, ectopic ureter, and/or vesicoureteral reflux, laparoscopic repair with robotic assistance can be accomplished safely in a single operative procedure with a short hospital stay.

Impact of the use of bowel for urinary diversion on perioperative complications and 90-day mortality in patients aged 75 years or older.

OBJECTIVE: A potential strategy to decrease the high complication rate of radical cystectomy (RC) in the elderly is to avoid the use of bowel for urinary diversion. The aim of this study was to address this issue in a multicentre study of patients aged ≥ 75 years. PATIENTS AND METHODS: We performed a retrospective, multicentre study of a consecutive series of patients aged ≥ 75 years who underwent RC for muscle-invasive bladder cancer between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. RESULTS: A total of 256 patients (68% men, mean age 79.6 years) were analysed. 204 (80%) patients received a urinary diversion with use of bowel and 52 (20%) a ureterocutaneostomy (UC). Patients with UC were older (82.0 vs. 78.9 years, p < 0.001) and had a higher ASA score (2.6 vs. 2.3, p = 0.007), while the mean Charlson score was lower (4.2 vs. 5.6, p < 0.001). Patients with UC had a shorter operating time (279 vs. 311 min, p = 0.002) and a shorter period in the intensive care unit (0.9 vs. 2.2 days). The overall rate of severe complications graded as Clavien III-V was significantly lower in the UC group (11.5%) as compared to patients receiving bowel for urinary diversion (25.0%) (p = 0.003). Severe (Clavien grade III-V) medical (3.9 vs. 10.3%) and surgical (2.1 vs. 14.1%) complications were all less frequent in the UC group. Inpatient, 30- and 90-day mortality was 5.8, 7.7 and 17.3% in the UC group as compared to 3.9, 5.9 and 6.9% in the bowel cohort, respectively. CONCLUSION: UC following RC is associated with a lower complication rate in geriatric patients. The constantly increasing cohort of geriatric, multimorbid patients requiring cystectomy might justify reconsideration of this form of diversion.

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates.

INTRODUCTION: To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR). MATERIALS AND METHODS: Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement. RESULTS: Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients). In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys. CONCLUSIONS: Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates

Introduction To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR). Materials and Methods Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement. Results Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision ...