Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study.

STUDY OBJECTIVE: To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded. DESIGN: Prospective case series study. SETTING: Tertiary level referral center for endometriosis and minimally invasive gynecology. PATIENTS: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis. INTERVENTIONS: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful. CONCLUSION: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies.

Functional assessment of crossing vessels as etiology of ureteropelvic junction obstruction.

OBJECTIVES: The contribution of crossing vessels to ureteropelvic junction (UPJ) obstruction is controversial. We performed a pilot study on patients undergoing laparoscopic pyeloplasty in whom an intraoperative Whitaker test was performed before and after repositioning a crossing vessel to determine its effect on collecting system drainage. METHODS: From August 2004 to July 2005, 10 patients with UPJ obstruction scheduled to undergo laparoscopic pyeloplasty were prospectively enrolled in this study. Routine laparoscopic access to the renal pelvis was obtained, and a crossing vessel, if present, was identified. Before mobilization of the UPJ or the crossing vessel, an intraoperative Whitaker test was performed using a laparoscopic 22-gauge needle to puncture the renal pelvis and infuse saline at a rate of 10 mL/min. Bladder and renal pelvic pressures were measured simultaneously. After complete mobilization of the UPJ and crossing vessel, if present, the Whitaker test was repeated. Dismembered pyeloplasty was then performed. RESULTS: Of the 10 patients, 6 had crossing vessels and 4 did not. The Whitaker test was successfully performed in all patients. Among those with a crossing vessel, all had a crossing artery, and 67% also had a crossing vein. No significant change was found in the renal pelvic pressure after mobilization of the renal pelvis in patients without crossing vessels. In those with crossing vessels, the mean renal pelvic pressure significantly declined after vessel repositioning (25.6 +/- 4.5 cm H2O to 9.5 +/- 6.6 cm H2O, P = 0.006). CONCLUSIONS: In this pilot study, lower pole crossing vessels directly contributed to UPJ obstruction by causing extrinsic compression.

Safety and efficacy of ureteral access sheaths.

The ureteral access sheath (UAS) was introduced as a means of passing a flexible ureteroscope. Although the device was initially lauded for its ability to facilitate ureteroscopic access, passage was difficult and risked ureteral injury, and the UAS fell out of favor until the development of a new generation of devices that was easier to insert. The UAS should be advanced under fluoroscopy over a stiff guidewire, and the surgeon should ensure copious hydration of all inner and outer surfaces. Use of the UAS is purported to improve irrigant flow and visibility. The UAS can induce transient ureteral ischemia and promote an acute inflammatory response, but it also prevents potentially harmful elevations in intrarenal pressure. Unequivocal data are not yet available to suggest that UAS use during ureteroscopy protects or harms the upper urinary tract. The UAS also has the potential to improve stone-free rates by allowing passive egress or active retrieval of fragments. A large prospective study is needed to unequivocally determine if UAS use is superior in terms of stone-free rates. Cost studies reported to favor UAS use, although a formal cost-effectiveness analysis has not been performed. Further study is needed before routine use of the UAS can be recommended.

Minimally invasive surgery for live kidney donors: techniques and challenges.

Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced post-operative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.

Ureteropelvic junction obstruction: use of helical CT for preoperative assessment--comparison with intraarterial angiography.

PURPOSE: To evaluate helical computed tomography (CT) in the preoperative assessment of crossing arteries in kidneys with ureteropelvic junction (UPJ) obstruction and to compare the results with those obtained by means of angiography. MATERIALS AND METHODS: Forty-one consecutive patients with symptomatic UPJ obstruction in 42 obstructed kidneys underwent renal helical CT and renal intraarterial digital subtraction angiography (DSA; flush aortography and bilateral selective renal injections). The helical CT and DSA images were interpreted in a blinded manner by two readers, and the results were compared. RESULTS: DSA showed 126 renal arteries in the 41 patients; 56% of patients had supernumerary renal arteries. Helical CT depicted 121 (96%) of these 126 renal arteries prospectively. Retrospectively, 124 (98%) renal arteries were visible on CT images. Twelve (29%) of the 42 kidneys with UPJ obstruction had identifiable arteries crossing the UPJ on DSA images. If DSA is used as the standard of reference, CT angiography was 100% sensitive and 96.6% specific for depicting these crossing arteries. CONCLUSION: Renal helical CT seems suitable to replace intraarterial DSA in the preoperative assessment of crossing arteries in kidneys with UPJ obstruction.

Preoperative assessment of ureteropelvic junction obstruction with endoluminal sonography and helical CT.

OBJECTIVE: Our objective was to compare the value of endoluminal sonography with the value of helical CT in the preoperative assessment of crossing vessels in patients with ureteropelvic junction (UPJ) obstruction. SUBJECTS AND METHODS: Thirteen patients with UPJ obstruction underwent contrast-enhanced helical CT with multiplanar reformations and endoluminal sonography. Imaging preceded surgery for UPJ repair. On imaging, vessels were considered significant if greater than or equal to 2 mm in diameter and within 1 cm of the UPJ. RESULTS: Three patients had no crossing vessels revealed by either study. On sonography, another patient had a vessel revealed with a diameter that varied between 1.3 and 2.2 mm; on CT no correlate was detected. The remaining nine patients had vessels revealed by both techniques. On CT, four patients had two vessels revealed and five patients had single vessels revealed for a total of 13 vessels revealed by CT. On sonography, five patients had two vessels revealed and five patients had single vessels revealed. Thus, 15 vessels were revealed by sonography. Both arteries and veins were revealed anterior, posterior, and medial to the UPJ; no lateral vessels were seen. Four patients underwent laparoscopy, during which the absence, presence, and location of vessels were found to correlate with sonography and helical CT. CONCLUSION: Endoluminal sonography and helical CT were similar in revealing crossing vessels in patients with UPJ obstruction.

Experimental assessment of ureteral free autograft.

OBJECTIVE: To establish the sequence of ureteral events under ischemic and desvascularized conditions but without immunologic interference. MATERIALS AND METHODS: Sixty-two rats were divided into four groups. NU group (n 20) control group, normal ureter; SC group (n 15) only surgical control ureterolysis; NIAFG group (n 13) ureter used as non integrated autologous free graft; IAFG group (n 14): ureter used as integrated autologous free graft. Urographic, histologic and histomorphometric studies were performed. RESULTS: We established ureteral changes in the NIAFG and IAFG groups, compared to the control groups (NU, SC). Surgical findings and urographic assessment revealed normal peristalsis with no ectasia in some cases, and no ureteral fistulas or extravasations were found in the IAFG group. Histologic findings showed preservation of the architecture of the three normal layers. Histomorphometric studies showed that ureterolysis caused edema in the lamina propria, while changes in ureter free graft depended on whether the ureter was integrated or not. In the NIAFG group only the urothelial layers showed differences and in the IAFG group the ureteral wall appeared thicker. Histomorphometric studies showed preservation of the normal histologic structures in all cases. CONCLUSIONS: The rat ureter can be used as a free autologous graft and represents an experimental model for immunologic events. We may assume that the necrosis and fibrosis observed in transplanted ureters are secondary to rejection in some cases.

[The information value of rheography and loading tests in the functional assessment of the ureter (experimental research)]. / Informativnost' reografii i nagruzochnykh testov v otsenke funktsii mochetochnika (éksperimental'noe issledovanie).

Functional tests, using electro-ureterography, ureteral rheography, electromanometry and electromagnetic flowmetry in the presence of diuretic and perfusion load tests, were performed at surgery in dogs. Ureteral rheography is shown to be a valuable method for the assessment of ureteral motility (as evidenced by ureteral volume changes), and have certain advantages over other techniques so that it can be used clinically for preoperative functional assessment of ectatic ureters. Load tests are necessary at functional tests of the upper urinary system in order to assess the pattern of ureteral wall contractility and reserves.