An unusual case of ureteric stricture post robotic partial nephrectomy of a renal mass managed by Memokath insertion.

Robotic assisted partial nephrectomy is the gold standard treatment for small renal masses. Ureteric stricture is a rare but serious complication that significantly increase the morbidity and worsens the quality of life for cancer patients. Definitive treatment such as surgical reconstruction or ureteroureterostomy is not always feasible as in patients with significant morbidity or high-risk patients. Other options include ureteric double J stent or nephrostomy tube placement with regular exchange. We present a case of iatrogenic upper ureteric stricture post robotic assisted partial nephrectomy for right renal mass that was discovered on postoperative follow up imaging treated with metallic ureteral stent (Memokath) as reconstructive surgery was difficult due to proximity to the tumor bed. We found that if reconstructive surgery is not feasible, metallic ureteral stents has good durability, better quality of life than ureteric double stents for the management of ureteric stricture.

A new technique for the treatment of ureteric stricture after kidney transplantation.

OBJECTIVE: To evaluate the safety and effectiveness of endoscopic treatments with Allium® metal ureteric stent (AMUS) for ureteric strictures after kidney transplantation (KT). PATIENTS AND METHODS: In a prospective manner, we gathered clinical data from 68 patients who underwent endoscopic treatments with AMUS for ureteric strictures after KT between January 2019 and March 2022. The definition of surgical success was the unobstructed drainage of the AMUS, or in cases where there was AMUS migration, occlusion or encrustation and subsequently removed, there is no worsening of renal hydronephrosis in the patient during the follow-up period. RESULTS: Based on the specific circumstances of the ureteric strictures, three distinct types of surgery were selected for treatment. The overall success rate of endoscopic treatments for ureteric strictures following KT was 90% (61/68) during a follow-up period of 1 year. Surgical complications included haematuria (18%), pain (10%), urinary tract infections (7.4%), and lower urinary tract symptoms (7.4%). The incidences of stent migration, occlusion, and encrustation were 10%, 2.9%, and 1.5%, respectively. Postoperatively, significant improvements were observed in various parameters. At 1 month after surgery, there was a notable decrease in blood creatinine levels (105.5 vs 90.4 mol/L), urea nitrogen levels (6.6 vs 5.4 mmol/L), and hydronephrosis volume (64.4 vs 43.9 mL). Additionally, the serum estimated glomerular filtration rate increased from 49.5 to 64.4 mL/min/1.73 m2. The follow-up results of patients at 1 year after surgery were similar to those observed at 1 month after surgery. CONCLUSIONS: Systemic endoscopic treatments with AMUS were found to be safe and effective for ureteric strictures after KT with short-term follow-ups. This technique offers a novel option for the treatment of post-KT strictures.

British Association of Urological Surgeons Consensus statements on the management of ketamine uropathy.

OBJECTIVES: To provide guidance in the form of consensus statement in the management of ketamine uropathy. METHODS: A literature review of ketamine uropathy was performed. The consensus method was of a modified nominal group technique and has been use in the previous British Association of Urological Surgeons (BAUS) consensus documents and was led by the Female, Neurological and Urodynamic Urology Section of the BAUS. RESULTS: A number of consensus statements detailing the assessment and management of urological complications relate to the recreational use of ketamine (ketamine uropathy) in both elective and emergency urology settings. CONCLUSION: Comprehensive management pathway for ketamine-related urinary tract dysfunction and uropathy has been detailed.

Spontaneous ureteric perforation: A rare complication of tuberculosis.

Genitourinary tuberculosis (GU TB) is a rare condition that has historically been described as a great imitator, owing to its variable and deceptive clinical presentation and course. GU TB may affect any part of the urological system and lead to serious complications such as kidney and ureteric damage. The diagnosis of GU TB requires high index of suspicion especially if complications occur. We describe the first case of spontaneous ureteric perforation secondary to GU TB as spontaneous bladder perforation was previously described.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries.

Background: Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries. Objective: To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries. Design setting and participants: We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B). Outcome measurements and statistical analysis: If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr. Results and limitations: Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up. Conclusions: With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture. Patient summary: The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Cine magnetic resonance urography as a new approach for postoperative evaluation of the reconstructed upper urinary tract: a multicenter study.

PURPOSE: To evaluate the feasibility and usefulness of cine magnetic resonance urography (cine MRU) as a novel postoperative examination after upper urinary tract reconstruction surgery. METHODS: Ninety-six patients underwent cine MRU for postoperative evaluation between August 2015 and August 2020. The morphological observations included regular peristalsis, anastomosis, urine flow signals, and reflux. The quantitative evaluations included luminal diameter, peristaltic amplitude, contraction ratio, peristaltic waves, and ureteric jets. The surgical outcomes were classified as success, gray area, or failure by combining the results of cine MRU, symptoms, and the degree of hydronephrosis. RESULTS: There was no obvious stenosis of the anastomosis in 83 patients (86.46%). Regular peristalsis of the ureter and signals of urination was observed in 85 (88.54%) and 84 patients (87.50%), respectively. In addition, three patients (3.13%) showed urine reflux. The patients in both the success group and the gray area group showed significantly different creatinine levels (success 86.2 ± 22.3 µmol/L vs. failure 110.7 ± 8.2 µmol/L, P = 0.016; gray area 81.0 ± 20.0 µmol/L vs. failure 110.7 ± 8.2 µmol/L, P = 0.009) and estimated glomerular filtration rate (success: 88.5 ± 23.1 mL/min·1.73 m2, failure: 61.6 ± 14.1 mL/min·1.73 m2, P = 0.014; gray area: 94.7 ± 24.6 mL/min·1.73 m2, failure: 61.6 ± 14.1 mL/min·1.73 m2, P = 0.007) compared to those in the failure group. The ipsilateral split renal function was 33.6 ± 15.0, 24.5 ± 13.4, and 20.1 ± 0.4 mL/min in the success, gray area, and failure groups, respectively (P = 0.354). CONCLUSION: Cine MRU demonstrates the morphology and function of the reconstructed upper urinary tract. The results of cine MRU can be used to evaluate the surgical effect, providing guidance for further treatment.

Oral mucosal graft ureteroplasty versus ileal ureteric replacement: a meta-analysis.

OBJECTIVES: To describe outcomes of oral mucosal graft ureteroplasty (OMGU) and ileal ureter replacement (IUR) and determine the relative merits of both procedures. METHODS: Databases (including PubMed, Embase and Cochrane) were interrogated for eligible trials that assessed outcomes of OMGU or IUR from 2000 to 30 July 2022. The variables analysed were reconstruction success rates, stricture length, hospital stays, perioperative complications and long-term complications. RESULTS: A total of 23 single-arm studies were included. The pooled reconstruction success rates for OMGU and IUR were 94.9% (95% confidence interval [CI] 91.0%-97.7%) and 85.8% (95% CI 81.0%-90.0%), respectively. Stricture length of patients in the OMGU and IUR groups were 3.73 (95% CI 3.17-4.28) and 11.55 (95% CI 9.82-13.29) cm, respectively. The maximal stricture length repaired by OMGU was 8 cm. The hospital stays were 5.85 (95% CI 3.88-7.82) and 11.55 (95% CI 6.93-16.17) days in the OMGU and IUR groups, respectively. The incidences of low-grade postoperative complications were 13.6% (95% CI 6.9%-20.3%) and 27.3% (95% CI 19.5%-35.1%), high-grade postoperative complications were 4.6% (95% CI 1.8I-8.5%) and 13.0% (95% CI 9.4%-17.1%), and long-term complications (occurred at > 3months) were 9.0% (95% CI 1.7%-20.0%) and 35.4% (95% CI 25.8%-45.6%) in the OMGU and IUR groups, respectively. CONCLUSION: An OMGU is an effective, minimally invasive, and safe alternative to IUR for the management of long ureteric strictures. OMGU was the preferred treatment for long ureteric strictures, especially obstructed ureter segments of ≤8 cm.

Post-Transplant Ureteric Stricture Managed By Extra-Anatomical Stenting With Modification on the Originally Described Stent Location: A Case Report.

Ureteric strictures are a relatively uncommon complication following renal transplant, which may be managed endoscopically or surgically by repairing the stricture. Extra-anatomical bypass is a useful procedure in complex cases that bypasses the ureter by creating a subcutaneous route, although it is uncommonly used given its rare indication. We report a case of renal transplant ureteric stricture, in which we utilized a modified extra-anatomical stenting technique with a Detour® stent to avoid the fibrotic planes surrounding the lateral aspect of the kidney graft.

A retrospective comparison between laparoscopic and open ureteroneocystostomy for management of benign lower ureteral strictures: An experience in tertiary care centre of Eastern India.

OBJECTIVES: The objective is to discover the etiopathogenesis of benign lower ureteric stricture in Eastern India and compare the outcome of open versus laparoscopic ureteroneocystostomy. MATERIALS AND METHODS: Retrospectively 52 patients who underwent laparoscopic (n = 28) or open ureteroneocystostomy (n = 24) for lower ureteral stricture between January 2018and December 2021 were included. The demography, aetiology, radiologic imaging, intraoperative & postoperative outcomes and follow-up data were collected and analysed. RESULTS: The mean duration of follow up was 14.3 months. Lower ureteric stricture were common in females. The most common cause of the stricture was iatrogenic injury (42%). Other causes were tuberculosis, post-endourological surgery, obstructing mega ureter, endometriosis and idiopathic. Laparoscopic surgery had longer mean operative time (228 vs 171 min), less blood loss (166 vs 246 ml), lower VAS score (6.1 vs 7.22) and less need of post-operative analgesia (1.86 vs 2.36 days). The hospital stay (5.36 vs 6.77 days) and post-operative complications (none vs 3) were also significantly lower in laparoscopic group. Open surgery and laparoscopic surgery had success rate of 100% and 96.6% each. CONCLUSIONS: Iatrogenic injury are the most common cause of ureteric stricture followed by tuberculosis. Laparoscopic approach is a feasible option in treatment of lower ureteric stricture as it offer comparable outcome to open procedure while offering the advantage of a minimal invasive technique. Stricture secondary to iatrogenic injury poses a different challenge due to presence of hard dense fibrosis. This is a complex reconstructive procedure and has a steep learning curve and demands high level of laparoscopic skill.

Polymyalgia rheumatica presenting as sternoclavicular arthritis: a case report.

BACKGROUND: Polymyalgia rheumatica and giant cell arteritis are systemic inflammatory conditions of the elderly. Polymyalgia rheumatica classically presents as a bilateral proximal muscle pain and stiffness syndrome. Biceps tenosynovitis is the commonest pathology in polymyalgia rheumatica. However according to literature, erosive sternoclavicular arthritis is a rare association of polymyalgia rheumatica. Giant cell arteritis is an inflammatory granulomatous arteritis predominantly involving large cerebral arteries. Thus, its classic clinical presentation includes severe headache with scalp tenderness, jaw claudication, and sudden painless loss of vision. Urological manifestations (prostatic vasculitis and epididymo-orchitis) were seldom reported in giant cell arteritis. CASE PRESENTATION: A 53-year-old Sinhalese man presented with progressive right-sided shoulder joint pain and neck pain associated with constitutional symptoms and episodic generalized headache. Examination revealed restricted movements of the right shoulder joint with nontender pulsatile bilateral temporal arteries. Blood testing showed elevated erythrocyte sedimentation rate and C-reactive protein. Color Doppler ultrasound of the superficial temporal artery revealed "halo sign." The temporal artery showed infiltration of mononuclear cells in the arterial media and adventitia. Computed tomography revealed right sternoclavicular arthritis with incidental finding of ureteric stricture. The patient was treated with high-dose oral prednisolone, and good clinical and biochemical response was observed during follow-up. CONCLUSION: Polymyalgia rheumatica-giant cell arteritis may rarely present as erosive sternoclavicular arthritis as the initial manifestation, mimicking many rheumatological conditions. Urological involvement such as ureteric strictures may be rare associations of primary systemic vasculitis. A high degree of suspicion combined with targeted investigations would allow early identification the polymyalgia rheumatica-giant cell arteritis syndrome in the presence of atypical manifestations, leading to improved patient outcomes.

Urological problems in elderly patients of tuberculosis.

Development of tuberculosis is closely linked to poor socioeconomic condition, poor immune functioning and mental health including depression and anxiety. Elderly population becomes an important target group for the disease and deserves special attention. Unique problem with genito urinary tuberculosis (GUTB) in elderly population is the diagnosis. One of the earliest symptoms of GUTB is increased urinary frequency which a large majority in elderly population may already have, owing to their enlarged prostates or an overactive bladder/detrusor over activity mediated centrally or peripherally, which are not uncommon in this group. When left undiagnosed and thereby untreated, GUTB usually leads to irreversible tissue damage and consequences range from abscesses, small capacity urinary bladder to renal failure.

Late Distal Ureteral Stricture in Internal Hemipelvectomy Without Bone Reconstruction: A Case Report.

We report the case of a patient with Ewing sarcoma involving the right pelvis in a 14-year-old girl who had multicycles of neo-adjuvant chemotherapy and preoperative radiation therapy. She underwent an internal hemipelvectomy type I resection, according to Enneking and Dunham's classification without bony reconstruction. There was no intra- and perioperative complication. The patient has good function and needs no gait aids. She can walk with equinus foot compensated for leg shortening 5 centimeters and without a shoe-lift. There is no sign of disease relapse. However, she developed late ureteral stricture at 8-year postoperatively and was successfully treated with a ureteral stent.

Uretero-enteric stricture outcomes: secondary analysis of a randomised controlled trial comparing open versus robot-assisted radical cystectomy.

OBJECTIVES: To analyse the risk of uretero-enteric anastomotic stricture in patients randomised to open (ORC) or robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion. PATIENTS AND METHODS: We included 118 patients randomised to RARC (n = 60) or ORC (n = 58) at a single, high-volume institution from March 2010 to April 2013. Urinary diversion was performed by experienced open surgeons. Stricture was defined as non-malignant obstruction on imaging, corroborated by clinical status, and requiring procedural intervention. The risk of stricture within 1 year was compared between groups using Fisher's exact test. RESULTS: In all, 58 and 60 patients were randomised to RARC and ORC, respectively. We identified five strictures, all in the ORC group. In patients with ≥1 year of follow-up, the increase in risk of stricture from open surgery was 9.3% (95% confidence interval 1.5%, 17%). Of the five strictures, three were managed endoscopically while two required open revision. There was no evidence that perioperative Grade 3-5 complications were associated with development of a stricture (P = 1) and no evidence of a difference in 24-month estimated glomerular filtration rate between arms (P = 0.15). CONCLUSIONS: In this study at a high-volume centre, RARC with extracorporeal urinary diversion achieved excellent ureteric anastomotic outcomes. Purported increased risk of stricture is not a reason to avoid RARC. Future research should examine the impact of different surgical techniques and operator experience on the risk of stricture, especially as more intracorporeal diversions are performed.

Pelvico-Vesicostomy for Horseshoe Kidney With Severe Right Ureteric Stricture and Bilateral Hydronephrosis.

Ureteropelvic junction (UPJ) obstruction is the most common renal anomaly observed in infants with congenital hydronephrosis. The present study presents a five-month-old infant with severe right ureteropelvic obstruction. Anderson-Hynes pyeloplasty intervention significantly improved renal function. The study concludes that early surgical intervention is the definitive treatment for avoiding kidney impairment and its complications.

Surgical and radiological predictive factors for ureteric stricture formation in patients treated with ureteroscopy for ureteric stones.

BACKGROUND: Ureteric stricture is a potential complication of impacted ureteric stones. This study investigates surgical and radiological factors that could predict ureteric stricture formation after ureteroscopic treatment of impacted ureteric stones. MATERIALS AND METHOD: Intraoperative and radiological data for patients who underwent ureteroscopic treatment of ureteric stones impaction over a 5-year period were reviewed retrospectively. Patients who had previous ureteroscopic treatment or strictures were excluded. RESULTS: Between January 2014 and May 2019, 1,340 patients presented as emergency renal colic secondary to ureteric stones. A total of 297 ureteroscopy procedures were performed for impacted calculi. The mean age was 53 years. The stricture rate was 3.3%. Analysis of radiological and surgical factors revealed that the degree of hydronephrosis, residual fragments and intraoperative ureteric injury were significant predictors for stricture formation (p = 0.018, 0.01 and 0.02, OR = 10, 47 and 1776, respectively). None of the other factors significantly predicted ureteric stricture formation. CONCLUSION: Our study found the presence of severe hydronephrosis, residual stone fragments after surgery and intraoperative ureteric injury are significant predictive factors for ureteric stricture formation. The high-risk patients should be monitored with routine postoperative renal ultrasound.

Arteriovenous malformation of ureter presenting without hematuria: An unusual presentation of a rare disease.

Genitourinary tract arteriovenous malformations are extremely rare. Most of the lesions are found either in the kidney or urinary bladder. So far, to the best of our knowledge, only five cases of arteriovenous malformation of the ureter have been reported in the literature. Here, we present, a young male, clinically presented with pain in the left flank with no other significant history. On radiological evaluation found to have left hydroureteronephrosis with stricture of the left distal ureter at the level of iliac vessel crossing. Urine routine, cytology, and cystoscopy were unremarkable. Left retrograde pyelogram showed distal ureteric stricture. Patient underwent excision of left distal ureteric stricture segment and ureteric reimplantation with psoas hitch. Histopathological examination revealed the features of arteriovenous malformation of the left ureter. The patient is asymptomatic and has no recurrence on follow-up until 12 weeks after surgery.

Step-by-step technique for the endoscopic treatment of ureteric stricture.

OBJECTIVE: To outline our step-by-step technique for the endoscopic treatment of ureteric stricture. MATERIALS AND METHODS: Between January 2019 and June 2020, 25 patients with ureteric strictures underwent ureteric bypass and were included in this study. The ureteric bypass surgery included three key steps. First, holmium laser endoureterotomy was used to establish a small channel. Then, balloon dilatation was performed to create a large channel. Finally, an Allium stent was inserted. RESULTS: Over a median follow-up time of 12 months, the success rate of ureteric bypass surgery was 92.0% (23/25). The median operating time was 78 min. The incidence of pain was 16% (4/25), and the incidence of fever was 4.0% (1/25). The preoperative hydronephrosis volume and urea nitrogen levels decreased significantly after surgery. CONCLUSIONS: We performed ureteric bypass for patients with ureteric strictures. This technique was found to be safe and effective over a short follow-up time. For patients who are not suitable for surgical reconstruction, the ureteric bypass technique is a good choice.

Cumulative incidence of ureteroenteric strictures after radical cystectomy in a population-based Swedish cohort.

OBJECTIVE: The incidence of benign ureteroenteric strictures following radical cystectomy (RC) for urinary bladder cancer (UBC) is investigated mainly in single-centre studies from high-volume centres. The aim of this study was to evaluate the cumulative incidence of strictures and risk factors in a population-based cohort. PATIENTS AND METHODS: Data was collected from Bladder Cancer Data Base Sweden (BladderBaSe). The primary endpoint was stricture with intervention. Secondary endpoint included hydronephrosis both with/without intervention. RESULTS: In total, 5,816 patients were registered as having had RC due to UBC between 1997 and 2014. After a median follow-up of 23.5 months (IQR = 9.0-63.1 months; range = 0.0-214.0 months), we found that 515 (8.9%) patients underwent intervention for stricture. Seven hundred and sixty-one (13.1%) patients were diagnosed with hydronephrosis without intervention. The cumulative incidence of strictures with intervention was 19.7% (95% CI = 16.7-23.1%) during the 17 years of follow-up. In the first year, the cumulative incidence of strictures was 5.6% (95% CI = 5.0-6.2%), and in the first 2 years 8.4% (95% CI = 7.6-9.3%). For the secondary endpoint, the cumulative incidence was 30.4% (95% CI = 26.7-33.1%) after 17 years. Only the year of RC was associated with stricture incidence in Cox regression analysis, whereas hospital cystectomy volume, patient age and patient sex were not. CONCLUSION: Ureteroenteric strictures requiring intervention may be more common than previously reported, affecting nearly one fifth of patients who have undergone RC for UBC. The annual incidence was highest in the first 2 years after surgery but the cumulative incidence increased continuously during 17 years of follow-up.

Iatrogenic ureteric stricture post image guided renal cryoablation in a patient with von hippel-lindau syndrome.

A 53-year-old lady is known to have Von Hippel-Lindau syndrome with a long history of previous renal cell carcinomas (RCCs) in both kidneys. She was treated by partial nephrectomy for a right peripheral RCC and subsequently image guided radiofrequency ablation (RFA) of a left central RCC. She developed another de novo RCC adjacent to the right pelvic-ureteric junction (PUJ) 4 years after the initial RFA. Due to the close proximity to the PUJ and visibility of an ice ball with cryoablation (CRYO), the consensus from the MDT was that CRYO would be safer than RFA and she subsequently underwent percutaneous image guided CRYO to treat the small de novo RCC. Unfortunately, during the 1-month imaging follow up, she developed moderate hydronephrosis and a ureteric stricture needing long-term ureteric stent management. This case highlights the risk of ureteric injury caused by the thermal effect of the ice ball during image guided renal CRYO. Therefore, it is vital that all interventional radiologists adopt various manoeuvres to protect the ureter from the ice ball during CRYO in order to avoid the development of latent ureteric stricture.