Predicting negative ureteroscopy for stone disease - Minimizing risk and cost.

INTRODUCTION: Urolithiasis is common worldwide, with ureteric stones being a particular burden. Ureteroscopy (URS) is one of the most useful procedures in treating ureteric stones not passed spontaneously; this procedure has a complication risk of 4%. Negative URS, with described rates up to 15%, represents an avoidable patient risk and use of medical resources. OBJECTIVES: To describe rates and identify predictive factors for negative URS and to define strategies which would minimize patient and financial burden from these unnecessary procedures. MATERIALS AND METHODS: A retrospective cohort study analyzed patients who underwent URS in our Center to treat ureteric stones over a period of 2 years. Patient age, gender, and comorbidities, as well as laboratory and imaging findings, were analyzed. RESULTS: 262 patients underwent URS for ureteric stones. The female population was 50.8% with a mean age of 56.89 years. A total of 78 (29.8%) URS procedures were negative. Univariate analysis showed a higher prevalence of negative URS in female patients, as well as in primary, smaller, and radiolucent stones. At multivariate analysis, a logistic regression model correctly classified 76% of patients, with smaller stone size and radiolucency being significant predictors of negative URS. DISCUSSION AND CONCLUSIONS: Our Center showed a high rate of negative URS, higher than commonly described in the literature. Female patients tend to have an even higher rate, possibly due to unnoticed passage of stones. Patients with small, radiolucent stones showed the highest rates of negative URS.

Urethral lithiasis after phalloplasty.

Female-to-male transsexual patient, 22 years old, with neophallus from radial forearm free flap (phalloplasty in March 2014), history of urethral fistula and urethral stricture 1 year later treated with surgical correction (fistulectomy) and suprapubic urinary diversion. Subsequently, he developed a new urethral stenosis located in the urethral anastomosis. Immediately proximal to the stenosis, there was a urethral dilatation (pseudodiverticulum) with a fibrous septum and several retracted stones. The stones were fragmented, the fibrous septum destroyed and the urethral stricture corrected, all with holmium laser. After 40 months of follow-up the patient shows satisfactory urinary flow with no signs of residual lithiasis or stricture.

Arterioureteral fistula: an unusual clinical case.

Arterioureteral fistulas (AUFs) are abnormal communications between a major artery and the mid to distal ureter. It is a rare but potentially life-threatening condition that is seldom recognised. We present a case of a 66-year-old man who was admitted to the surgical ward owing to infection of an aortic bifemoral bypass graft. During admission, the patient developed persistent haematuria with considerable loss of haemoglobin. He was submitted to urgent surgical exploration of the graft. An ascending pyelography performed at the beginning of the surgery clearly shows a communication between the left ureter and the vascular graft. Open surgical exploration was undertaken, the fistulised section of the ureter resected and an end-to-end ureteroplasty was performed. The vascular graft was removed and the patient later submitted to left supracondylar amputation. Urinary drainage remained intact.

Inguinal hernia containing bladder and ureteroneocystostomy: a rare cause for acute renal graft dysfunction.

A 77-year-old man presented with acute graft dysfunction 25 years after a renal transplant in the left iliac fossa. He also had an asymptomatic left inguinal hernia. Renal ultrasound showed a significant pyelocalicial dilation of the kidney graft and the patient was submitted to a percutaneous nephrostomy. An antegrade nephrostogram was performed, which showed a dilated ureter and the bladder included in the left inguinal hernia that caused the obstructive uropathy. Concomitant retrograde cystography also showed a significant portion of the bladder in the hernia sac. The patient was submitted to inguinal hernia repair, which resolved the obstruction. We present a rare and potentially curable cause of obstructive uropathy in a transplant recipient; it is possible to revert graft dysfunction and prevent graft loss if the condition is recognised early.

[Unclassified sex cord testis tumor]. / Tumor dos Cordões Sexuais Não Classificável do Testículo.

Unclassified sex cord testis tumor is an extremely rare tumor, especially in the adult. It is characterized histologically for a nonspecific combination of testis stromal and epithelial elements, with varying degree of differentiation. Treatment usually consists of radical orchiectomy followed by clinical and imaging surveillance. The available literature about this pathology relies almost exclusively on clinical cases. It's our aim to describe the case of a 37 years old man with an unclassified sex cord testis tumor, the first case described in Portugal, and to review the literature about this issue.

O tumor dos cordões sexuais nÉo classificável do testículo eÌ um tumor extremamente raro, particularmente na idade adulta. Caracteriza-se histologicamente pela conjugaçaÌo inespeciÌfica de elementos estromais e epiteliais do testículo, com grau de diferenciaçÉo variável. A sua abordagem consiste na orquidectomia radical, geralmente realizada antes do diagnóstico, e posterior vigil'ncia clínica e imagioloÌgica. A literatura disponível sobre esta patologia baseia-se quase exclusivamente na descriçÉo de casos clínicos. O nosso objetivo é apresentar o caso de um doente de 37 anos com um tumor dos cordões sexuais nÉo classificável do testículo, o primeiro descrito em Portugal, e fazer uma revisÉo da literatura sobre o tema.

Coagulum pyelolithotomy "revisited" by laparoscopy: technique modification.

OBJECTIVE: Laparoscopic ureteropyeloplasty is a widely accepted treatment option for the obstructed ureteropelvic junction (UPJ). Although it is often a straightforward surgical procedure, there may be technical difficulties in the case of concomitant stone burden, with multiple calicial, small, mobile stones. The authors describe a modification to the classic coagulum pyelolitothomy, using a mixture based on commercially available fibrin sealant, first used in the laparoscopic era. METHODS: During a laparoscopic transperitoneal dismembered ureteropyeloplasty complemented with coagulum pyelolithotomy, the following steps are suggested: (1) Exposure of the UPJ; (2) ureter clamping with a vessel loop 2 cm distal to the UPJ (to allow pelvis filling); (3) transabdominal puncture of the pelvis with an 18-G, 20-cm needle (under laparoscopic vision) and urine aspiration; (4) recording the volume of urine aspirated; (5) preparing an equal volume of fibrin sealant (to avoid overdistention of the pelvis); (6) injecting the sealer protein solution through that needle + 1 mL of methylene blue (color the coagulum and facilitate its identification in the removal procedure); (7) insertion of another needle to inject the thrombin solution; (8) wait 5 minutes to allow coagulum cast formation; (9) circumferential excision of the UPJ; (10) coagulum removal; (11) pelvis plastic reduction (if needed) and ureter spatulation; (12) double-J stent placement; and (13) tension-free anastomosis completion. RESULTS: The procedure results in the extraction of a tenacious coagulum containing more stones than normally anticipated from the x-ray studies. CONCLUSIONS: This technique modification reduces the incidence of incomplete stone removal, when there are small, free stones lying in a large renal pelvis.

Metabolic syndrome and sexual (dys)function.

INTRODUCTION: The general worldwide increase in metabolic syndrome (MS) among most populations may result in more individuals with sexual dysfunction. AIM: To provide an update on clinical and experimental evidence regarding sexual dysfunction in patients with MS from both sexes and treatment modalities. METHODS: A comprehensive literature review was performed using MEDLINE with the MeSH terms and keywords for "metabolic syndrome,""obesity,""female sexual dysfunction,""erectile dysfunction,""androgen deficiency,""weight loss," and "bariatric surgery." MAIN OUTCOME MEASURES: To examine the data relating to sexual function in both men and women with MS, its relationship and the impact of treatment. RESULTS: The MS is strongly correlated with erectile dysfunction, hypogonadism (predictors of future development of MS), and female sexual dysfunction. Few studies have been addressed in the treatment of these dysfunctions in the special setting of MS, other than the observational effects on sexual function of individual risk factors correction. This can be a result of their understudied etiopathogeny. Nonsurgical weight loss has been shown to improve sexual function (with the mainstay on sedentarism prevention), whereas the efficacy of bariatric surgery in this respect, which has been suggested by some preliminary evidence, needs to be further confirmed by adequate clinical trials. CONCLUSION: As the global incidence of MS increases, more individuals may experience sexual dysfunction and a systematic evaluation should be emphasized in this patient population, in order to identify those who are in need of intervention.