Intrinsic ureteric obstruction secondary to endometriosis: a rare clinical entity causing obstructive uropathy and renal failure.

Ureteral endometriosis is rare and can be a silent clinical entity, which can potentially lead to serious complications such as obstructive uropathy, sepsis and renal failure. A high clinical suspicion is required especially in childbearing age groups due to non-specific presentation such as renal colic, recurrent urinary tract infection (UTI), renal failure or asymptomatic hydronephrosis.A woman in her 40s presented with febrile UTI and flank pain. She reportedly suffered from recurrent UTIs in the past. Initial workup revealed an infected, obstructed left renal collecting system with gross hydronephrosis and hydroureter to the distal ureter on a significant gynaecological background of severe endometriosis requiring hysterectomy in the past.CT showed chronic obstructive changes and soft tissue nodules within the renal pelvis with no radio-opaque stones. She underwent emergent ureteric stent insertion. Functional imaging demonstrated only 1% contribution of the left kidney with a preserved estimated glomerular filtration rate of 65 mL/min/1.73 m2Endoscopic evaluation of ureters found extensive soft tissue lesions throughout the dilated left collecting system with biopsy-confirmed endometriosis. Subsequently, she underwent laparoscopic nephroureterectomy due to extensive ureteric involvement and chronically obstructed non-functioning kidney. Histopathology demonstrated completely obstructing ureteral endometriosis.Ureteric obstruction secondary to endometriosis can be due to extrinsic or intrinsic disease. In addition to initial assessment with CT urogram MRI may be helpful to evaluate soft tissue thickening. Endoscopic assessment with ureteroscopy and biopsy is required for tissue diagnosis. Surgery is often the treatment of choice, ranging from ureteroureterostomy, ureteroneocystostomy or nephroureterectomy in severe cases.Ureteral endometriosis is a rare clinical entity, clinicians should remain vigilant about common presentations of this rare entity, early diagnosis and prompt treatment is crucial to prevent progression to renal failure.

Localized amyloidosis of the ureter: a case report.

BACKGROUND: Amyloidosis is a collection of disorders characterized by the extracellular deposition of amyloid, a specialized fibrous protein, in diverse tissues, leading to functional impairments. CASE PRESENTATION: A 70-year old Asian-Japanese female was referred to our department for further examination of her left hydronephrosis come from lower ureteral obstruction. Contrast enhanced CT and retrograde pyelo-nephrography revealed left ureteral tumor. Though ureteroscropic biopsy did not show malignant pathological findings, ureteroscopic image suspected malignant disease, thus nephroureterectomy was performed. Pathological findings revealed localized ureteral amyloidosis. Whole body examination including gastro endoscopy and cardio ultrasonography could not reveal amyloidosis except ureter. She was free from recurrence 9 months postoperatively. CONCLUSION: We herein report a rare case of localized ureteral amyloidosis.

Endovascular Treatment Failure of Renal Arteriovenous Malformation due to an Extrarenal Feeding Artery: A Case Report.

Renal arteriovenous malformation (RAVM) is a rare pathology. It may present with heamturia, hypertension, and congestive heart failure. Digital subtraction angiography (DSA) is the standard diagnostic choice, and endovascular embolization is a preferred procedure of management in most cases. The feeding branches of RAVM are reported to originate from renal arteries. In this report, a 43-year-old female with recurrent massive hematuria and left flank pain was described. Renal angiography revealed double renal arteries supplying the left kidney and multiple renal arteriovenous fistula formation around the renal pelvis. Embolization with coils and gelfoam was performed after which her hematuria subsided. One month later, the patient was readmitted to our hospital due to the relapse of massive hematuria following heavy physical activities. DSA found another feeding artery of the RAVM originating from the aorta around the 4th lumbar vertebra. After embolization of this arterial feeder, hematuria settled. There was no recurrence during a 10-month follow-up. To our knowledge, this is the first case of RAVM with an extrarenal feeding artery, and omission of this scenario can lead to treatment failure.

A case of ureteral stenosis due to ureteritis probably associated with rheumatoid arthritis.

Ureteritis associated with the immunological disorder is rarely reported, and most cases in this category are small vessel vasculitis and immunoglobulin G4-related disease. Rheumatoid arthritis (RA)-associated ureteritis is uncommon, and underlying aetiology is unclear. We present a patient with ureteritis who had a medical history of RA and was successfully treated with steroids and immunosuppressant. A 49-year-old woman who had been treated for RA and atopic dermatitis suffered from gross haematuria for 5 successive days. Contrast-enhanced computed tomography (CT) showed right-dominant upper urinary tract dilatation with enhanced thickened wall. The haematuria continued accompanied with intermittent right back and lower abdominal pain, and the following CT image taken after 3 months presented the progression to bilateral hydronephrosis. Ureteral stents were placed, and antibiotic therapy was introduced for obstructive pyelonephritis. Ureterocystoscopy and following biopsy from the upper ureteral tract showed a chronic inflammatory change in the histopathology, and we finally considered the stenosing ureteritis to be caused by immune-mediated mechanism related to RA. After starting steroid therapy with methotrexate, therapeutic response was obtained to remove the stents. In the cases of ureteritis or ureteral stenosis of unknown aetiology with a medical history of immunological disorders, we should consider the underlying immune-activated state and try to test contrast-enhanced CT and histological examination before performing a surgical procedure. After excluding the common causes of ureteritis or ureteral stenosis, these tests would support the appropriate diagnosis.

Double trouble - management of perinephric hematoma and renal vein thrombosis post percutaneous renal biopsy.

BACKGROUND: Performing percutaneous renal biopsy procedures in lupus nephritis (LN) and nephrotic syndrome presents a unique challenge to the nephrologist because of the risk of bleeding from the procedure and the hypercoagulable state in hypoalbuminemia. The management of a patient with venous thrombosis with perinephric hematoma post renal biopsy can be difficult if occurred. CASE PRESENTATION: We are presenting a case of perinephric hematoma following percutaneous renal biopsy in a 23-year-old man with lupus nephritis, nephrotic syndrome, and lower limbs deep vein thrombosis (DVT). The patient developed persistent frank haematuria, flank pain and acute urinary retention post-procedure. We have withheld his oral warfarin three days before the procedure, and no anticoagulation was given subsequently. Initial CT Angiography (CTA) renal showing stable hematoma and no visible evidence of vascular injury. Three weeks later, the patient still has persistent frank haematuria and a repeated CTA renal revealed new bilateral renal vein thrombosis. Considering the high risk of worsening symptomatic venous thrombosis, we gave subcutaneous enoxaparin sodium and restart oral warfarin despite ongoing haematuria. The frank haematuria resolved within two days of anticoagulation with no radiological evidence of worsening of the perinephric hematoma. The follow-up ultrasonography a month later showed resolution of the hematoma and renal vein thrombosis with no adverse effect. CONCLUSION: Our experience, in this case, highlighted the importance of case selection for percutaneous renal biopsy among high-risk patients. Additionally, a prolonged frank haematuria in post-renal biopsy with nephrotic syndrome warranted a reassessment, as a clinical presentation of post-procedure perinephric hematoma and renal vein thrombosis can overlap. We also demonstrated that restarting anticoagulation earlier than four weeks in a patient with renal vein thrombosis and post-renal biopsy perinephric hematoma can be safe in the selective case.

Severe Ureteral Endometriosis Complicated with Hydronephrosis: A Case Report.

BACKGROUND Endometriosis is a disease characterized by endometrial tissue appearing outside the uterus, mainly involving the peritoneum and pelvic organs. Ureteral endometriosis (UE) is rare, typified by deep infiltrating endometriosis involving the ureter and can result in ureteral obstruction, proximal hydroureter, hydronephrosis, and impairment of renal function. Symptoms may be insidious and nonspecific and may lead to a prolonged disease course. We describe a patient with UE complicated by hydronephrosis. CASE REPORT A 42-year-old woman was admitted to the Urology Department with the incidental discovery of right hydronephrosis. After a thorough examination, she underwent right ureteral mass resection and right ureteral stump anastomosis. The pathology report indicated endometriosis. The patient was given 6 doses of gonadotropin-releasing hormone agonist immediately after surgery, followed by an intrauterine levonorgestrel-releasing system. Postoperative follow-up showed that no recurrence was observed in this year. Here, we briefly summarize the epidemiology, pathogenesis, clinical presentation, imaging, treatment, and prognosis of the disease. CONCLUSIONS UE should be listed as one of the differential diagnoses of unexplained hydronephrosis in women of childbearing age, and those with dysmenorrhea should be cognizant of this disease. Active surgical treatment and long-term management should be carried out to obtain better prognosis.

Rate of recurrent hydronephrosis after laparoscopic ureteroneocystostomy for ureteral endometriosis.

STUDY OBJECTIVE: To investigate the short-term outcomes of laparoscopic ureteroneocystostomy in patients with ureteral endometriosis (UE). DESIGN: Retrospective cohort study of consecutive patients who underwent surgery for the ureter endometriosis with hydronephrosis. SETTING: A private hospital that provide primary, secondary and tertiary care. PATIENTS: 30 consecutive patients with UE who underwent laparoscopic ureteroneocystostomy at our institution between May 2008 and April 2020. INTERVENTIONS: Laparoscopic ureteroneocystostomy, if necessary, hysterectomy, salpingo-oophorectomy, cystectomy, partial bladder resection, or partial bowel resection were performed. MEASUREMENTS AND MAIN RESULTS: The most common chief complaint was pelvic pain (40%). Endometriosis affected only the left ureter in 56.7% of patients, only the right ureter in 33.3%, and both ureters in 6.7%. Involvement of the ipsilateral ovary was confirmed in 64.3%. The most frequent location of UE was 1-3 cm above the UVJ (46.7%). A psoas hitch was performed in 7 patients (23.3%), and the Boari flap was used in 9 patients (30%). Hysterectomy was performed in 12 patients (40%), and 6 of them had a concomitant bilateral salpingo-oophorectomy (20%). In addition, 3 patients (10%) underwent partial bowel resection, and 2 patients (6.7%) underwent partial bladder resection. After surgery, 24 of 27 patients (80.0%) were free of sever hydronephrosis after surgery. Hydronephrosis recurred in a single patient (3.3%), but the grade of hydronephrosis improved significantly after surgery (P < 0.001). At 6 months of follow up, 4 patients (13.3%) experienced urinary tract infections and 2 patients (6.7%) reported dysuria. Patients reported a regression of dysmenorrhea symptoms (P < 0.001). CONCLUSION: This study shows that ureteroneocystostomy provides good results in terms of relapses and symptom control in patients with ureteral endometriosis.

Congenital Giant Megaureter in a 16-Year-Old Female Presenting With Abdominal Pain: A Case Report and Review of Literature.

We describe a case of congenital giant megaureter in a 16-year-old female. She presented with a 5-day history of abdominal distention, right flank pain and tenderness. Right pyelonephritis was suspected. Computerized tomography showed a large cystic abdominal mass with no appreciably functioning left kidney causing secondary compression of the contralateral right ureter. A left upper nephroureterectomy was performed, draining over 3.5 L of fluid. Our experience suggests that congenital giant megaureter should be considered in the differential for pediatric patients presenting with a cystic abdominal mass.

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

OBJECTIVE: Systematic placement of a ureteral stent before surgery for posterior deep infiltrating endometriosis (DIE) was previously recommended, but it could increase perioperative complications. We evaluate the role of preoperative ureteral stent in women requiring surgery for ureteral involvement (UI) with large posterior DIE nodules and/or grade I-II hydronephrosis. METHODS: Women undergoing minimally invasive surgery for DIE with UI having posterior nodules >3 cm and/or grade I-II hydronephrosis from 2014 to 2019 were retrospectively included. We progressively changed our strategy from a systematic pre-operative stent insertion (S-PS, up to 2016) to a non-systematic one (NS-PS, from 2016). RESULTS: Eighty-eight women in the S-PS group and 96 in the NS-PS were included. Low urinary tract infections (UTI) were higher in the S-PS group (13.6% vs 2.1%, P = 0.003). Hospital stay was longer in women with S-PS (9.8 ± 5.3 days vs 6.7 ± 2.5 days, P < 0.001). Logistic regression analysis confirmed a significant association between NS-PS and low UTI (adjusted OR 0.20, 95% CI 0.05-0.81, P = 0.024). CONCLUSION: Systematic placement of a ureteral stent before surgery in women requiring surgery does not reduce overall perioperative complication rate, but it is associated with a longer duration of hospitalization and a higher low UTI rate.

Congenital midureteral stenosis in children: a 13-year retrospective study based on data from a large pediatric medical center.

BACKGROUND: Midureteral stenosis is very rare in children and can cause congenital hydronephrosis. We report our experience treating children with congenital midureteral stenosis at our center, focusing on the differences in preoperative diagnosis and treatment compared with other congenital obstructive uropathies. METHODS: We retrospectively reviewed the medical records of 26 children diagnosed with congenital midureteral stenosis at our center between January 2007 and December 2020, such as preoperative examination methods, intraoperative conditions, and postoperative follow-up results. RESULTS: Of the 1625 children treated surgically for ureteral narrowing, only 26 (1.6%) were diagnosed with midureteral stenosis, including 15 infants and 11 children. Eighteen (69.2%) were boys, 13 (50%) were affected on the left side, and 23 (88.5%) had isolated ureteral stenosis. Overall, 13 (50%) of the children presented with prenatal hydronephrosis, and 13 (50%) presented with abdominal pain or a mass. All the children had undergone urinary ultrasound and intravenous urography preoperatively; the diagnostic rate of ultrasound was 92.3%. Only 7 (26.9%) children had undergone pyelography. All the children had undergone surgery. The ureteral stenotic segment was less than 1 cm long in 25 (96.2)% of the children. The mean follow-up duration was 22 months (range: 6-50 months). One child developed anastomotic strictures. Urinary tract obstruction was relieved in the other children without long-term complications. CONCLUSIONS: Congenital midureteral stenosis is rare, accounting for 1.6% of all ureteral obstructions, and its diagnosis is crucial. Urinary ultrasound has a high diagnostic rate and should be the first choice for midureteral stenosis. Retrograde pyelography can be used when the diagnosis is difficult, but routine retrograde pyelography is not recommended. Congenital ureteral stenosis has a relatively short lesion range, largely within 1 cm. The treatment is mainly resection of the stenotic segment and end-to-end ureteral anastomosis, with a good prognosis.

Oncology and complications.

This collection of cases describes some unusual urological tumors and complications related to urological tumors and their treatment. Case 1: A case of uretero-arterial fistula in a patient with long-term ureteral stenting for ureteral oncological stricture and a second case associated to retroperitoneal fibrosis were described. Abdominal CT, pyelography, cystoscopy were useful to show the origin of the bleeding. Angiography is useful for confirming the diagnosis and for subsequent positioning of an endovascular prosthesis which represents a safe approach with reduced post-procedural complications. Case 2: A case of patient who suffered from interstitial pneumonitis during a cycle of intravesical BCG instillations for urothelial cancer. The patient was hospitalized for more than two weeks in a COVID ward for a suspected of COVID-19 pneumonia, but he did not show any evidence of SARS-CoV-2 infection during his hospital stay. Case 3: A case of a young man with a functional urinary bladder paraganglioma who was successfully managed with complete removal of the tumor, leaving the urinary bladder intact. Case 4: A case of a 61 year old male suffering from muscle invasive bladder cancer who was admitted for a radical cystectomy and on the eighth postoperative day developed microangiopathic hemolytic anemia and thrombocytopenia, which clinically defines thrombotic microangiopathy.

A Novel Technique for Management of Simultaneous Fibro-Epithelial Polyp and Blind-Ending Branch in a Duplicated Ureter: A Case Report With 23-year Follow-Up.

Ureteral duplication with a blind-ending branch (BEB) is rare anomaly. The presence of fibro-epithelial polyps in duplicated ureters is also infrequent. Despite the noticeability of endoscopic polypectomy, further recurrence of polyps and persistence of pain increase the probability of further ureteral resection with surgical procedures. In such cases, BEB of duplicated ureter is an excellent reservoir to save the function of the kidney. This is the first case with concomitant presence of fibro-epithelial polyps and BEB in duplicated ureter managed with novel surgical technique of uretero-pelvic junction and BEB branch anastomosis. We followed-up the patient for 23 years.

Supernumerary Kidney Associated With Horseshoe Malformation and Ureteric Stricture With Hydroureteronephrosis - A Rare Case.

Supernumerary kidney is an accessory kidney with its own vasculature, collecting-system and encapsulated parenchyma with about 100 cases reported in the literature. However, there is no report of supernumerary kidney associated with horseshoe malformation with ureteric stricture. We report a rare case of 20 months old female admitted with left-sided abdomen lump and mild abdominal pain. During surgery, supernumerary kidney with horseshoe component with grossly-dilated left-sided pelvicalyceal system and proximal 1-cm of left-ureter, distal to which whole of left-ureter was noncanalized, was seen. Right-ureter was normal. Distal dilated part of left-ureter was anastomosed to bladder-dome after excision of strictured segment of left-ureter with placement of nephrostomy.

Amyloid Deposition of the Bilateral Ureters in a Patient With Chronic Systemic AL Amyloidosis.

Amyloid of the ureter is a rare disease with less than 25 cases reported in the literature. Despite being rare, it remains an important entity as it is typically confused with a primary neoplastic process of the urinary system. We report a case of a 68-year-old male with a history of cutaneous amyloid with late presentation of bilateral ureteral involvement.

A case of flank pain caused by ureteral intussusception accompanied with ureteral polyp.

BACKGROUND: Ureteral intussusception, a rarely reported unique condition, occurs primarily as a complication of ureteric tumours. CASE PRESENTATION: We present a case of ureteral intussusception accompanied with a large ureteral polyp periodically protruding into the bladder cavity occurring in a 56-year-old man who experienced vague flank pain and intermittent haematuria. The patient was successfully treated by ureteroscopic cauterization combined with partial ureterectomy with reanastomosis. CONCLUSIONS: This is the first report that describes polyp-related ureteral intussusception using comprehensive and representative ureteroscopic images and video. Our findings suggest that ureteroscopy is vital for diagnosis. Extensive biopsies through ureteroscopy are less invasive, and make it easier to exclude the presence of ureteral malignancies. Ureteroscopic resection of the whole polyp with its stalk and intussusceptum using Holmium: YAG laser did not seem viable in this case. However, cauterization of partial polyp tissues followed by open surgery for segmental resection of the ureter with reanastomosis is helpful in controlling such patient well-being.

The outcome of kidney transplant from living donors with pelvi-ureteric junction dysfunction.

PURPOSE: To assess the effect of receiving a kidney with PUJ dysfunction on the recipient renal graft function. METHODOLOGY: 198 patients, who underwent renal transplantation from 1st January 2004 to 31st December 2014 in a single Center in the North West of England, were retrospectively reviewed using a computerized database. Split kidney function and the PUJ dysfunction for the donors were assessed using Tc-99 m MAG3 renogram. Each recipient with PUJ dysfunction was matched with a control recipient by age, gender, and number of days after transplantation. Both groups were followed up for 3.5 years post-transplantation. RESULTS: Of the 198 recipients included in the study, 19 recipients received kidneys from donors with PUJ dysfunction. Prevalence of PUJ dysfunction was 9.5% and it was more common in males than females. There was no difference between the case group and the control group in terms of age, gender, and follow-up time post-transplantation. There was also no difference between the case group and the control group in mean creatinine (130 µmol/l and 138 µmol/l respectively, p = 0.305) or the mean eGFR (48.6 ml/min and 47.5 ml/min respectively, p = 0.054) at 3.5 year post-kidney transplantation. CONCLUSION: This study showed that PUJ dysfunction of renal allograft has a negligible effect on graft function over 3.5 years period post-transplantation. A prospective randomized trial is needed to test these findings. In the presence of widened gap between demand and supply in renal transplantation, PUJ dysfunction in potential donors should not preclude them from donation.

Relevance of concurrent hypercalcemia in ureteric sarcoidosis complicated with bladder urothelial carcinoma: a case report.

BACKGROUND: Sarcoidosis is a multisystem inflammatory disorder and can affect any organ; however, ureteric involvement is extremely rare with only four cases reported in the literature to date, all of which were diagnosed with surgical ureteral resection including a nephroureterectomy. This study reports the first case of ureteric sarcoidosis controlled with medical therapy where a differential diagnosis was performed based on the diagnostic clue of hypercalcemia. A definitive diagnosis was established without surgical resection of the ureter. CASE PRESENTATION: A 60-year-old man presented with anorexia and weight loss. Blood tests showed renal dysfunction and hypercalcemia. Computed tomography revealed left hydronephrosis associated with left lower ureteral wall thickening, which showed high signal intensity on diffusion-weighted magnetic resonance imaging. Similarly, we detected a bladder tumor on cystoscopy, and a 2-cm-long stenosis was revealed by retrograde ureterography; therefore, ureteral cancer was suspected. Meanwhile, considering the clinical implication of hypercalcemia, a differential diagnosis of sarcoidosis was established based on elevated levels of sarcoidosis markers. Fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the left lower ureter, skin, and muscles, suggestive of ureteric sarcoidosis with systemic sarcoid nodules. For a definitive diagnosis, transurethral resection of the bladder tumor and ureteroscopic biopsy were performed. Histopathological examination revealed ureteric sarcoidosis with bladder urothelial carcinoma. Following an oral administration of prednisolone, hypercalcemia instantly resolved, the renal function immediately improved, and the left ureteral lesion showed complete resolution with no recurrence. CONCLUSIONS: In this case, the co-occurrence of ureteral lesion with bladder tumor evoked a diagnosis of ureteral cancer. However, considering a case of ureteral lesion complicated with hypercalcemia, assessment for differential diagnosis was performed based on the calcium metabolism and sarcoidosis markers. In cases of suspected ureteric sarcoidosis from the assessment, pathological evaluation with ureteroscopic biopsy should be performed to avoid nephroureterectomy.