Traumatismo renal grado v en paciente con estenosis de la unión pieloureteral no conocida / V grade renal trauma in patient with union pyeloureteral stenosis not known

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Embedded upper end of double J stent at the site of renal pelvis injury following percutaneous nephrolithotomy: a rare complication.

BACKGROUND: Injury of the renal collecting system is a well-known complication of percutaneous nephrolithotomy (PNL). Large injuries may cause excessive bleeding and fluid extravasation and require adequate drainage using several modalities such placement of JJ stents. Herein, we report on two cases in which the upper coil of the JJ stent got buried in the fibrous tissues which formed due to an injury of the collecting system during PNL. CASE PRESENTATION: 40 years old male and 32 years old female underwent standard PNL for partial and total staghorn calculi, respectively. During the procedure in both cases, the renal pelvis was injured. In both cases, JJ stent was used to drain the collecting system. Trial to remove the JJ stent 6 weeks following the procedure failed because the upper coils of the stents were embedded in the fibrous tissues at the perforation site. Laser incision of the fibrous tissues and releasing the upper coil of the stents were performed using percutaneous approach in the first case and flexible ureterorenoscopy (fURS) in the second patient. The procedures were uneventful in both cases. CONCLUSION: This is the first report of embedded JJ stents which got buried by fibrous tissues at the site of collecting system injury that occurred during PNL. To prevent this complication in such cases, we suggest draining the collecting system using nephrostomy tube instead of JJ stent. Alternatively, the upper coil of the stent should be placed away from the injury site.

Delayed Rupture of the Renal Collecting System Secondary to a Traumatic Hemorrhage in the Setting of Suspected Chronic Ureteropelvic Junction Obstruction.

Isolated rupture of the renal pelvis secondary to blunt trauma is rare, though there is increased incidence in the setting of a pre-existing renal abnormality that predisposes the kidney to injury. We report a case of post-traumatic hemorrhage into the renal collecting system leading to delayed rupture of the renal pelvis in the setting of suspected chronic ureteropelvic junction obstruction. This case illustrates the difficulty in diagnosis of acute hemorrhage into the renal collecting system. Special attention should be given to a kidney with a pre-existing abnormality in the setting of trauma to prevent complications. A literature review of hemorrhage into the collecting system along with appropriate imaging and management are discussed.

Ureteral Access Sheath Deployment: How Much Force Is Too Much? Initial Studies with a Novel Ureteral Access Sheath Force Sensor in the Porcine Ureter.

Introduction and Objectives: Ureteral injuries can occur during ureteral access sheath (UAS) deployment. The force exerted during deployment and the amount of force that results in ureteral injury is yet to be accurately quantitated. In this feasibility study, we developed and then tested a novel force-sensing device in our animal laboratory to identify the threshold force that results in a porcine ureteral injury. Methods: With Institutional Animal Care and Use Committee approval, we measured ureteral dilator and UAS deployment force using our proprietary University of California, Irvine Ureteral Access Sheath Force Sensor (UAS-FS). The exerted force was measured during deployment from the moment that the tip of the UAS was passed into the urethral meatus until it reached the renal pelvis; progression of the UAS along the ureter was monitored with fluoroscopy. Ureteroscopic evaluation was performed after deployment of each catheter/sheath ≥8F to assess for ureteral injury using the Postureteroscopic Lesion Scale (PULS). Results: Six juvenile Yorkshire female pigs (12 ureters) were studied. No injuries were detected when the deployment force was <4 Newtons (N), which was the case when the catheter/access sheath was ≤13F. Increasing UAS size >13F resulted in greater peak forces. In five of the pigs, ureters selected for 14F UAS deployment without previous sequential dilation were injured (PULS ≥3) at a mean threshold force of 4.84 N. Serial dilation had a higher threshold for PULS ≥3 at 5.56 N. Overall, injury of PULS ≥3 was routinely noted when the force applied exceeded 8.1 N. Conclusions: The UAS-FS reliably measured forces while deploying a UAS. Significant ureteral injury can routinely be avoided if the applied force is <4.84 N; PULS ≥3 routinely occurred when forces exceeded 8.1 N. Serial dilation may allow safe passage at higher deployment forces, as much as 5.56 N.

Vanin-1 in Renal Pelvic Urine Reflects Kidney Injury in a Rat Model of Hydronephrosis.

Urinary tract obstruction and the subsequent development of hydronephrosis can cause kidney injuries, which results in chronic kidney disease. Although it is important to detect kidney injuries at an early stage, new biomarkers of hydronephrosis have not been identified. In this study, we examined whether vanin-1 could be a potential biomarker for hydronephrosis. Male Sprague-Dawley rats were subjected to unilateral ureteral obstruction (UUO). On day 7 after UUO, when the histopathological renal tubular injuries became obvious, the vanin-1 level in the renal pelvic urine was significantly higher than that in voided urine from sham-operated rats. Furthermore, vanin-1 remained at the same level until day 14. There was no significant difference in the serum vanin-1 level between sham-operated rats and rats with UUO. In the kidney tissue, the mRNA and protein expressions of vanin-1 significantly decreased, whereas there was increased expression of transforming growth factor (TGF)-ß1 and Snail-1, which plays a pivotal role in the pathogenesis of renal fibrosis via epithelial-to-mesenchymal transition (EMT). These results suggest that vanin-1 in the renal pelvic urine is released from the renal tubular cells of UUO rats and reflects renal tubular injuries at an early stage. Urinary vanin-1 may serve as a candidate biomarker of renal tubular injury due to hydronephrosis.

[Bilateral spontaneous renal pelvis rupture during a computed tomography: Report of one case]. / Ruptura pieloureteral espontánea bilateral durante un urotac: Caso clínico.

Spontaneous rupture of the urinary excretory system is a rare condition. It is mainly associated with obstruction of the excretory system and is usually unilateral. We report a 58 years old male who, during the performance of a computed tomography of the urinary system, felt an intense lumbar pain. A bilateral rupture at the level of the fornix was found. The patient had an uneventful evolution thereafter. Fifteen days later a new computed tomography showed indemnity of the urinary excretory system.

Primary Report of Totally Tubeless Percutaneous Nephrolithotomy Despite Pelvi-calyceal Perforations.

PURPOSE: Nephrostomy tube insertion and/or a ureteral stent placement is advised when pelvi-calyceal perforations are encountered during percutaneous nephrolithotomy (PNL) nevertheless totally tubeless PNL is a possible exit strategy in percutaneous renal surgery therefore case series on the short term clinical outcomes of noninvasive management of iatrogenic pelvicalyceal perforations encountered during PNL is presented. PATIENTS AND METHODS: During retrospective analysis of 1271 PNL procedures, 25 incidents of accidental ureteral catheter/ jj stent dislodgement during first 24 post-operative hours were identified in patient who had pelvi calyceal perforations and had no nephrostomy tube (tubeless). Thirteen patients could not be re-stented nor a nephrostomytube could have been placed for them mainly due to patient refusal or comorbid conditions. The main outcome was rate of successful noninvasive management. RESULTS: Eighteen Patients bearing mucosal tears (grade I trauma) or visible peri-pelvic fat (grade II) successfully recovered without need for ureteral stenting or nephrostomy (72.0%). In seven (28.0%) cases of extension of the perforation into the peri-pelvic fat (grade III), either nephrostomy insertion or JJ stenting was needed for resolution of fever and urinoma. The major limitation was the necessity to exclude patients and manage them in the standard fashion according to clinical guidelines. CONCLUSION: Iatrogenic perforations of the collecting system are quite diverse in terms of severity that result in different natural histories and not all might need urinary diversion via nephrostomy or ureteral stenting.Low grade perforations may be successfully managed in totally tubeless fashion nevertheless further prospective investigations seem warranted.

Ruptura pieloureteral espontánea bilateral durante un urotac: caso clínico / Bilateral spontaneous renal pelvis rupture during a computed tomography: report of one case

Spontaneous rupture of the urinary excretory system is a rare condition. It is mainly associated with obstruction of the excretory system and is usually unilateral. We report a 58 years old male who, during the performance of a computed tomography of the urinary system, felt an intense lumbar pain. A bilateral rupture at the level of the fornix was found. The patient had an uneventful evolution thereafter. Fifteen days later a new computed tomography showed indemnity of the urinary excretory system.

La sesión científica que no tuvo lugar / The clinical session that never happened

OBJETIVOS: Una enfermedad da a los clínicos signos que nos permiten el diagnóstico por ocultos que puedan estar, incluso en una momia de hace 3.000 años, gracias a los avances de la medicina y la semejanza con los casos ya conocidos de Litiasis ósea. MÉTODOS: Analizamos en el tiempo las facetas de su localización (vesical, ureteral o renal); el conocimiento se ha ido abriendo paso para permitir hoy una respuesta al enigma de un arcano final. RESULTADOS: La identificación del caso investigado. CONCLUSIONES: Hallamos hoy, 3.000 años después en una momia, la causa más probable de su fallecimiento gracias al cuidado exquisito de su preservación y a la decisión de los científicos de aplicar, entre las técnicas actuales de estudio las menos destructivas con esos restos sabiamente embalsamados

OBJECTIVES: Every illness provides signs that enable diagnosis no matter how hidden they may be, even in a 3.000 years old mummy thanks to the advances in medicine and similarity with other known cases of osseous lithiasis. METHODS: We have analyzed the features of its localization (bladder, ureteral or renal); knowledge got its way to allow today the answer to the final arcane enigma. RESULTS: The identification of the case being investigated. CONCLUSION: Today, in a 3.000 years old mummy, we found the most likely cause of his death thanks to the careful preservation and the scientists decision to select, among the current inspection techniques, those which are less destructive of the wisely embalmed rests

Tissue damage from ultrasonic, pneumatic, and combination lithotripsy.

PURPOSE: To conduct a comparative evaluation of ultrasonic, pneumatic, and dual ultrasonic (DUS) lithotripsy to predict the safety of probes on urinary tract tissue. MATERIALS AND METHODS: The Swiss Lithoclast Ultra (ultrasonic-only [US] and ultrasonic-pneumatic combination [US+P]) and the Gyrus ACMI Cyberwand (DUS) were evaluated. Fresh porcine ureter, bladder, and renal pelvis tissues were used with a hands-free setup to vertically apply 0, 400, or 700 g of force with each probe for a duration of 3 seconds, 5 seconds, or 3 minutes (or until perforation occurred). Data collection included whether perforation occurred and time to perforation. Histological analysis of nonperforated samples was used to compare the anatomical depth to which damage occurred. RESULTS: The total percentage of trials resulting in perforation for all tissue types, contact durations, and forces was found to be 8.5% (10/117) for US, 13.7% (16/117) for US+P, and 26.4% (31/117) for DUS. No perforations occurred with light contact (0 g) of probe force, regardless of tissue type, lithotripsy mode, or contact duration. Overall, the renal pelvis was most resistant to perforation (p=0.0004), while no difference was found between the bladder and ureter tissue (p=0.32). Force beyond 400 g and contact greater than 5 seconds increased risk for damage. CONCLUSIONS: Mode of lithotripsy, tissue type, probe force, and probe-tissue contact duration all significantly impacted the extent of damage and likelihood for perforation to occur. All devices and tissue types provided a reasonable margin of safety for probe-tissue contact times of 3 and 5 seconds with no more than 400 g of force.

Complications in percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is generally considered a safe technique offering the highest stone-free rates after the first treatment as compared to the other minimal invasive lithotripsy techniques. Still, serious complications although rare should be expected following this percutaneous procedure. In this work, the most common and important complications associated with PCNL are being reviewed focusing on the perioperative risk factors, current management, and preventing measures that need to be taken to reduce their incidence. In addition, complication reporting is being criticized given the absence of a universal consensus on PCNL complications description. Complications such as perioperative bleeding, urine leak from nephrocutaneous fistula, pelvicalyceal system injury, and pain are individually graded as complications by various authors and are responsible for a significant variation in the reported overall PCNL complication rate, rendering comparison of morbidity between studies almost impossible. Due to the latter, a universally accepted grading system specialized for the assessment of PCNL-related complications and standardized for each variation of PCNL technique is deemed necessary.

A novel endoscopic treatment for renal arteriopelvic fistula post-percutaneous nephrolithotomy (PCNL).

MAIN FINDINGS: We describe the use of a novel endoscopic approach in the management of unremitting gross hematuria following post-percutaneous nephrolithotomy (PCNL) in a 65-years-old male. This approach proved successful and cost-effective in managing haemorrhage post-PCNL when renal angiography failed to localize the source of bleeding. Case hypothesis: The recommended treatment modality for renal calculi ≥ 2cm is PCNL. It is essential that clinicians are aware of the various complications that can arise from PCNL, including arteriovenous fistula, which is typically managed with renal angio--embolization. The development of a renal arteriopelvic fistula (APF) is an extremely rare complication, and accounts of haemorrhage from renal APF and its treatment have not been well-described in the literature. We successfully hypothesized that the ureteroscopic localization, fulguration, and closure with a fibrin sealant at the site of the arterial bleed results in optimal treatment for this clinical presentation. We report this case in detail. Promising Future Implications: The successful and cost-effective endoscopic approach described here for treatment of post-PCNL renal APF and unremitting gross hematuria ought to be considered as an adjunct to renal angiography and embolization when the source of bleeding cannot be accurately identified using traditional imaging modalities.

A novel endoscopic treatment for renal arteriopelvic fistula post-percutaneous nephrolithotomy (PCNL)

Main findings We describe the use of a novel endoscopic approach in the management of unremitting gross hematuria following post-percutaneous nephrolithotomy (PCNL) in a 65-years-old male. This approach proved successful and cost-effective in managing haemorrhage post-PCNL when renal angiography failed to localize the source of bleeding. Case hypothesis The recommended treatment modality for renal calculi ≥ 2cm is PCNL. It is essential that clinicians are aware of the various complications that can arise from PCNL, including arteriovenous fistula, which is typically managed with renal angio-embolization. The development of a renal arteriopelvic fistula (APF) is an extremely rare complication, and accounts of haemorrhage from renal APF and its treatment have not been well-described in the literature. We successfully hypothesized that the ureteroscopic localization, fulguration, and closure with a fibrin sealant at the site of the arterial bleed results in optimal treatment for this clinical presentation. We report this case in detail. Promising Future Implications The successful and cost-effective endoscopic approach described here for treatment of post-PCNL renal APF and unremitting gross hematuria ought to be considered as an adjunct to renal angiography and embolization when the source of bleeding cannot be accurately identified using traditional imaging modalities. .

[An urinary catheter slipped into the renal pelvis]. / Virtsakatetri luiskahti munuaisaltaaseen.

An elderly woman was referred to hospital because of fever and deterioration of her general condition. Due to urinary retention, the woman had undergone long term catheterization and had a urinary infection for years. In addition, the partial right hip prosthesis was found to be dislocated. While changing the catheter it slipped into the renal pelvis, and the balloon of the catheter was filled at the level of the ureteropelvic junction. The condition, observed in computed tomography scanning, was quickly restored, and the patient managed to avoid complications. Drifting of an urethral catheter into the upper urinary tract is a rare condition, but may lead to significant complications.

Inferior vena cava filter penetration resulting in renal pelvis rupture with urinoma formation.

Inferior vena cava (IVC) filter penetration is common and most often asymptomatic. However, penetration may potentially result in a variety of complications, including aortic trauma and small bowel perforation. Described is a case of IVC filter penetration resulting in renal pelvis perforation with urinoma formation.