Inguinal Herniation of a Transplant Ureter: Lessons Learned From a Case of "Water Over the Bridge".

Inguinal herniation of the transplant ureter is rare, and there is a paucity of reports in the literature. Herniation is usually secondary to implanting a long redundant ureter and may be precipitated by its course over the spermatic cord. Most often, there is loss of the allograft owing to delayed presentation and chronic ureteric obstruction. Here, we report a case of inguinal herniation of a transplant ureter with obstruction and graft dysfunction. A 72-year-old man presented 9 years after deceased-donor kidney transplant, with progressive graft dysfunction and a symptomatic right inguinal hernia. A nephrostogram and subsequent surgery confirmed herniation of a loop of transplant ureter into the inguinal canal with a proximal dilated ureter and hydronephrosis. A long and redundant ureter had been anastomosed "over" the spermatic cord to the bladder during the original operation. The ureter was shortened by excising the distal segment, and the proximal dilated ureter was anastomosed to the bladder passing it "underneath" the spermatic cord. We used a Vicryl (polyglactin 910) mesh to repair the hernia. The graft function improved to baseline levels after the nephrostomy and remained stable after the surgery. This case emphasizes the need to keep the ureter short, and the importance of passing it underneath the spermatic cord before anastomosing to the bladder. Transplant and general surgeons should be aware of such presentations of graft dysfunction with inguinal hernia to avoid delayed diagnosis and graft loss.

Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): experience in 200 tumours.

OBJECTIVES: To evaluate our clinical experience with percutaneous image-guided radiofrequency ablation (RFA) of 200 renal tumours in a large tertiary referral university institution. PATIENTS AND METHODS: Image-guided RFA (ultrasonography or computed tomography [CT]) of 200 renal tumours in 165 patients from June 2004 to 2012 was prospectively evaluated. Institutional Review Board approval was granted. The treatment response and technical success were defined by absence of contrast enhancement within the tumour on contrast enhanced CT or magnetic resonance imaging. Both major and minor complications, glomerular filtration rate (GFR) before and after RFA, the management and outcomes of the complications, as well as oncological outcome were prospectively documented. Multivariate analysis was used to determine variables associated with major complications and also the percentage GFR change after RFA. The overall (OS), 5-year cancer-specific (CSS), local recurrence-free (LRFS) and metastasis-free survival (MFS) rates are presented using the Kaplan-Meier curves. RESULTS: In all, 200 tumours were RF ablated with a mean (range) tumour size of 2.9 (1-5.6) cm and the mean (range) patient age was 67.7 (21-88.6) years with a mean follow-up period of 46.1 months. The primary technical and overall technical success rate was 95.5% and 98.5%, respectively. Two independent predictors of successful RFA in a single sitting were tumour size (<3 cm) and exophytic location in multivariate logistic regression analysis. Major complications included ureteric injury (six patients), calyceal-cutaneous fistula (one), acute tubular necrosis (one) and abscess (two). Two independent predictors of ureteric injury were central location and lower pole position. Within this cohort of patients, only four patients developed significant renal function deterioration i.e. >25% decreased in GFR. In all, 161 (98%) patients of the 165 patients have preservation of renal function. Any change in renal function after RFA was not influenced by tumour factors or solitary kidney status. In our clinical series, this yielded a 5-year OS, CSS, LRFS and MFS rates of 75.8%, 97.9%, 93.5% and 87.7% respectively. CONCLUSIONS: Image-guided RFA is a safe, nephron sparing and effective treatment for small renal cell carcinoma (RCC) tumours with a low rate of recurrence and has good 5-year CSS and MFS rates.

Unenhanced CT for the evaluation of acute ureteric colic: the essential pictorial guide.

Acute ureteric colic is a common emergency, often dealt with by the emergency physician or general practitioner and referred on to the urologist. Unenhanced CT of the kidneys, ureters and bladder (CTKUB) is the 'gold standard' imaging investigation for establishing a diagnosis and guiding management. An appreciation of the CTKUB signs, which support or refute a diagnosis of ureteric colic, is highly valuable to the clinician when making a urological referral, and to the urologist, who must make appropriate management plans. All salient diagnostic and supportive features of ureteric colic are carefully illustrated, as are important radiological mimics, with the objectives of educating and informing the non-radiologist. Ready access to the picture archive and communication system (PACS) allows all specialists involved to interpret the radiological report with the benefit of images. A stone within the ureter may not always be readily apparent. Soft tissue rim sign around a calcific focus is an important indicator of a ureteric stone, whereas a comet tail sign suggests a phlebolith (a calcified venous thrombosis), a radiological mimic of a ureteric stone. Numerous secondary signs of ureteric obstruction may be present including hydronephrosis and perinephric stranding, and can help to confirm the diagnosis. The relative diagnostic weighting of signs is discussed, and a checklist is provided to assist with interpretation. Unexpected alternative radiological diagnoses are also illustrated, which may have significant management consequences necessitating specialist referral.

Acute tubular necrosis following radiofrequency ablation of a renal cell carcinoma.

We described a case of acute tubular necrosis in a patient with a renal cell carcinoma in a solitary kidney following renal RFA.

Protecting the ureter during radiofrequency ablation of renal cell cancer: a pilot study of retrograde pyeloperfusion with cooled dextrose 5% in water.

PURPOSE: To describe early experience with cooled dextrose 5% in water (D5W) solution retrograde pyeloperfusion during radiofrequency (RF) ablation of renal cell carcinoma (RCC) within 1.5 cm of the ureter with respect to feasibility, safety, and incidence of residual/recurrent tumor in proximity to the cooled collecting system. MATERIALS AND METHODS: Between November 2004 and April 2007, 17 patients underwent 19 RF ablation sessions of RCCs within 1.5 cm of the ureter during cooled D5W pyeloperfusion (nine men, eight women; mean tumor size, 3.5 cm; mean age, 73 y; mean distance to ureter, 7 mm). RF ablation was performed with pulsed impedance control current. The records and imaging studies of patients treated with this technique were reviewed for demographics, indication, technique, complications, and tumor recurrence. RESULTS: All 19 RF ablation and ureteral catheter placement procedures were technically successful. No patient developed a ureteral stricture or hydronephrosis during a mean of 14 months of follow-up (range, 4-32 months). Three patients had residual tumor on the first follow-up imaging study, but all three tumors were completely ablated after a second RF ablation session. No complications or deaths occurred. No recurrent tumor was seen anywhere in the treated tumors, and there was complete ablation of the tumor margin in proximity to the collecting system. CONCLUSIONS: RF ablation of RCC within 1.5 cm of the ureter is feasible with cooled D5W retrograde pyeloperfusion and is not associated with reduced efficacy, ureteral injury, or early recurrence.

Infectious complications after percutaneous radiofrequency ablation of renal cell carcinoma in patients with ileal conduit.

Percutaneous renal radiofrequency (RF) ablation is a safe and minimally invasive treatment for renal cell carcinoma. The most common minor complications are pain, self-limiting hematuria, and postablation syndrome. Major complications are rare and include significant hemorrhage and thermal injury to the ureter. Reports of infectious complications after ablation are uncommon, but increased risks in patients with ileal conduits have been reported. The present report describes two patients with ileal conduits who underwent percutaneous renal RF ablation and developed infectious complications (a renal abscess and a calyceal-cutaneous fistula) despite prophylactic antibiotic treatment.

Initial experience with the resonance metallic stent for antegrade ureteric stenting.

BACKGROUND AND PURPOSE: We describe our initial experience with a new metallic ureteric stent which has been designed to provide long-term urinary drainage in patients with malignant ureteric strictures. The aim is to achieve longer primary patency rates than conventional polyurethane ureteric stents, where encrustation and compression by malignant masses limit primary patency. The Resonance metallic double-pigtail ureteric stent (Cook, Ireland) is constructed from coiled wire spirals of a corrosion-resistant alloy designed to minimize tissue in-growth and resist encrustation, and the manufacturer recommends interval stent change at 12 months. METHODS: Seventeen Resonance stents were inserted via an antegrade approach into 15 patients between December 2004 and March 2006. The causes of ureteric obstruction were malignancies of the bladder (n = 4), colon (n = 3), gynecologic (n = 5), and others (n = 3). RESULTS: One patient had the stent changed after 12 months, and 3 patients had their stents changed at 6 months. These stents were draining adequately with minimal encrustation. Four patients are still alive with functioning stents in situ for 2-10 months. Seven patients died with functioning stents in place (follow-up periods of 1 week to 8 months). Three stents failed from the outset due to bulky pelvic malignancy resulting in high intravesical pressure, as occurs with conventional plastic stents. CONCLUSION: Our initial experience with the Resonance metallic ureteric stent indicates that it may provide adequate long-term urinary drainage (up to 12 months) in patients with malignant ureteric obstruction but without significantly bulky pelvic disease. This obviates the need for regular stent changes and would offer significant benefit for these patients with limited life expectancy.

The detour extra-anatomic stent--a permanent solution for benign and malignant ureteric obstruction?

OBJECTIVES: We describe our experience of the Detour extra-anatomic stent (EAS) (Mentor-Porgés, UK) for permanent bypass of complete upper urinary tract obstruction. The self-retaining expanded polytetrafluoroethylene-silicone tube, placed in the kidney using a percutaneous route, is tunnelled under the skin and sutured into the bladder to establish extra-anatomical urinary drainage. METHODS: From April 2002 to November 2005, a total of nine Detour stents were inserted into eight patients; one patient needed bilateral stent insertions. The causes for ureteric obstruction were persistent malignant disease in three and complicated benign disease in five patients. RESULTS: To date, four of five patients with benign disease are alive; one died unexpectedly of metastatic malignancy. The only stent-related complications were infection and haematuria. The two patients with malignancy have subsequently died, but there were no urinary drainage problems for their second and third years of life, respectively. CONCLUSIONS: The preliminary data presented here suggest that the Detour EAS offers a permanent and minimally invasive method to establish internalisation of urinary drainage to bypass complete ureteric obstructions for which conventional stenting has failed, open surgery has been tried and failed or was not considered feasible, and long-term nephrostomy drainage was not favoured.

Radiofrequency ablation of a central renal tumor: protection of the collecting system with a retrograde cold dextrose pyeloperfusion technique.

Renal radiofrequency (RF) ablation therapy is a safe and effective therapy for small renal cell carcinoma. Although the risk of complications is low, the potential for ureteral or calyceal injury does increase in the case of a centrally located lesion. A retrograde cold dextrose pyeloperfusion technique was designed to protect the collecting system in a patient who underwent percutaneous RF ablation of a central tumor of the left kidney.