Laparoscopic onlay-flap ureteroplasty using cecal appendix.

INTRODUCTION: The management of ureteral strictures longer than 1-2 cm must be treated by major surgery (1, 2). The strictures located at the distal part of the ureter can be managed by a ureteral reimplantation using a psoas hitch or a Boari flap depending on its proximity to the bladder (3). Those located at the proximal ureter can be treated by a pyeloplasty (4). The ureteric strictures in the mid-ureter are the ones that pose a greater challenge for the urologist because a ureteral substitution is needed, either using a segment of the intestine or a buccal mucosa graft (5, 6). Our main objective is to present the management and results at 36 months of a patient with a right mid-ureter stricture. MATERIAL AND METHODS: A 63-year-old male with chronic kidney disease (CKD) and a right single functioning kidney was referred to our department with the diagnosis of a 3 cm stricture in the right mid-ureter. He had a long-term JJ-stent in place but in the last year we had to replace it three times precociously and he even needed the placement of a nephrostomy tube due to the obstruction of the JJ-stent. Accordingly, a permanent resolution was sought and a laparoscopic onlay-flap ureteroplasty using cecal appendix was performed. RESULTS: The first step was to identify the cecal appendix. Then we identified and dissected the ureter. With the ureter dissected, we performed a ureteroscopy to pinpoint the stricture. Once we knew where the stricture was, we proceeded with the ureterotomy and preparation of the cecal appendix. The final step was to perform the ureteroplasty between the ureter and the cecal appendix placing a JJ-stent before the last stitches were done. Total operative time was 190 minutes without any intraoperative complication. The JJ-stent was removed 7 weeks later. The follow-up of the patient was done with regular blood test and ultrasound to rule out deterioration of the CKD and worsening of the residual hydronephrosis. With a follow-up of 36 months, the patient is stent free, he hasn't had any further intervention and neither the CKD nor the hydronephrosis haven't worsened. CONCLUSIONS: Laparoscopic onlay-flap ureteroplasty using cecal appendix is a feasible and well tolerated procedure for patients with right mid-ureter stricture. However, we must bear in mind the difficulty of these cases and they should be performed in expert centers.

Prevalence of distal renal tubular acidosis in patients with calcium phosphate stones.

INTRODUCTION AND PURPOSE: Distal renal tubular acidosis (DRTA) is a metabolic disorder that associates urolithiasis and urinary pH > 6. The prevalence of DRTA in patients with calcium phosphate stones is not well known. The objective is to determine the prevalence of DRTA in patients with calcium phosphate stones and urinary pH above 6 based on the furosemide test. METHODS: A total of 54 patients with calcium phosphate stones and urinary pH above 6.0 were submitted to the furosemide test. The association of DRTA with age, sex, type of stone, stone recurrence, stone bilaterality, 24-h urine biochemistry, and adverse effects of the furosemide test were examined. RESULTS: The furosemide test indicated that 19 of 54 patients (35.2%) had DRTA. The sex ratio was similar in the two groups (p < 0.776). The DRTA group was significantly younger (p < 0.001), and had a higher prevalence of bilateral stones (p < 0.001), a higher prevalence of recurrent stones (p < 0.04), a lower plasma potassium level (p < 0.001), a higher urinary Ca level (p ≤ 0.05), and a lower urinary citrate level (p < 0.001). None of the patients reported adverse effects from the furosemide test. CONCLUSIONS: There was a high prevalence of DTRA in patients with urinary pH above 6 and calcium phosphate stones. Young age, bilateral stones, stone recurrence, hypercalciuria, hypocitraturia, and plasma hypokalemia were associated with DRTA. None of the patients reported adverse effects of the furosemide test.

Multiple renal tumorectomy in a Von Hipple Lindau patient. Combined retro/transperitoneal approach with intracorporeal hypotermia

ABSTRACT Objective & Introduction: To show the feasibility of a combined transperitoneal (TP) and retroperitoneal (RP) laparoscopic approach in a Von Hipple-Lindau (VHL) patient with multiple kidney tumors. VHL is an autosomal dominant inherited syndrome characterized by a high incidence of benign and malignant tumors and cysts in many organs. Renal cell carcinoma is one of the most common and a leading cause of mortality (1). Surgical approach is usually complex because of its multiplicity and the need of maximum kidney function preservation due to the risk of future recurrences (2, 3). Intracorporeal renal hypothermia may be useful in these cases to prevent permanent renal function loss (4). Materials and Methods: A 40 years old male was being monitored for multiple bilateral renal masses. Family history included a VHL syndrome affecting his mother and sister. Past medical history included a VHL syndrome with multiple cerebellar and medular hemangioblastomas, a pancreatic cystoadenoma and bilateral kidney tumors which had significantly grown up during follow-up. The patient was scheduled for laparoscopic multiple partial nephrectomy. A combined TP and RP approach with intracorporeal hypothermia was chosen. Results: A total of six right kidney tumors were removed. Operative time was 240 min. Cold ischemia time was 50 min. Average kidney temperature was 23.7°C. Blood losses were negligible. The patient was discharged after 72 hours. No major changes in serum creatinine were found during the follow-up. Final pathology revealed a clear cell renal cell carcinoma, pT1a, ISUP grade 2 in most of the tumors but one ISUP grade 3. Surgical margins were negative. Conclusions: Combined TP and RP is a feasible alternative for the treatment of multiple renal tumors. It's safe and effective, allowing the use of intracorporeal hypothermia which may improve postoperative renal function. Consistent experience is needed before embarking on this surgery.

[Efficacy and safety of bilateral RIRS for renal lithiasis.] / Eficacia y seguridad de la RIRS bilateral para el tratamiento de litiasis renal.

OBJECTIVES: We present our experience in single-stage bilateral retrograde intrarenal surgery (RIRS), analyzing the stone free rate (SFR), surgical time, hospital stay, pre- and post procedure creatinine, stone composition and complications. METHODS: Between April 2012 and February 2016, 24 RIRS were carried out in 12 patients with bilateral renal stones. Patients were 9 men and 3 women with a median age of 47.5 (range:55),IMC: 23.59 (range: 12.5). RESULTS: Mean number of stones per renal unit was 2.7 (range: 12), mostly located in the renal pelvis (40%), with an average size of 16.08±8.06 mm and an average stone burden of 258.54±242.59 mm². The SFR at 3 months was 83.33%. Average operation time was 75 minutes and median hospital stay was 2 days. Three complications were recorded (25%), all of them minor (Clavien I-II). No major complications were recorded (Clavien III-V). CONCLUSIONS: Single-stage bilateral RIRS is a safe and effective tool for the treatment of patients with bilateral renal stones.

Eficacia y seguridad de la RIRS bilateral para el tratamiento de litiasis renal / Efficacy and safety of bilateral RIRS for renal lithiasis

OBJETIVOS: Presentar nuestra experiencia en cirugía intrarrenal retrógrada (RIRS) bilateral en un mismo acto quirúrgico, analizando la tasa de pacientes libres de litiasis (SFR), el tiempo quirúrgico, la estancia hospitalaria, las complicaciones, las diferencias entre la creatinina pre- y postoperatoria y la composición de los cálculos. MÉTODOS: Entre abril de 2012 y febrero de 2016 se han realizado 24 RIRS en 12 pacientes con litiasis renal bilateral, entre los que se encuentran 9 hombres y 3 mujeres, con mediana de edad de 47,5 (rango: 55), IMC: 23.59 (rango: 12,5). RESULTADOS: El número de cálculos por unidad renal es de 2,7 (rango: 12), localizados preferentemente en la pelvis renal (40%), con un tamaño medio de 16,08±8,06 mm y una carga litiásica media de 258,54±242,59 mm2. El SFR a los 3 meses es de 83,33%. El tiempo operatorio medio ha sido 75 minutos y la estancia hospitalaria mediana de 2 días. Se han registrado 3 complicaciones (25%), todas ellas complicaciones menores (Clavien I-II). No se han registrado complicaciones mayores (Clavien III-V). CONCLUSIONES: La RIRS bilateral en un mismo acto quirúrgico es una herramienta eficaz y segura para el tratamiento de pacientes con litiasis renales bilaterales

OBJECTIVES: We present our experience in single-stage bilateral retrograde intrarenal surgery (RIRS), analyzing the stone free rate (SFR), surgical time, hospital stay, pre- and post procedure creatinine, stone composition and complications. METHODS: Between April 2012 and February 2016, 24 RIRS were carried out in 12 patients with bilateral renal stones. Patients were 9 men and 3 women with a median age of 47.5 (range: 55), IMC: 23.59 (range: 12.5). RESULTS: Mean number of stones per renal unit was 2.7 (range: 12), mostly located in the renal pelvis (40%), with an average size of 16.08±8.06 mm and an average stone burden of 258.54±242.59 mm2. The SFR at 3 months was 83.33%. Average operation time was 75 minutes and median hospital stay was 2 days. Three complications were recorded (25%), all of them minor (Clavien I-II). No major complications were recorded (Clavien III-V). CONCLUSIONS: Single-stage bilateral RIRS is a safe and effective tool for the treatment of patients with bilateral renal stones