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.

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.

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.

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.

Optimal management of distal ureteric strictures following renal transplantation: a systematic review.

Our objective was to define optimal management of distal ureteric strictures following renal transplantation. A systematic review on PubMed identified 34 articles (385 patients). Primary endpoints were success rates and complications of specific primary and secondary treatments (following failure of primary treatment). Among primary treatments (n = 303), the open approach had 85.4% success (95% CI 72.5-93.1) and the endourological approach had 64.3% success (95% CI 58.3-69.9). Among secondary treatments (n = 82), the open approach had 93.1% success (95% CI 77.0-99.2) and the endourological approach had 75.5% success (95% CI 62.3-85.2). The most common primary open treatment was ureteric reimplantation (n = 33, 81.8% success, 95% CI 65.2-91.8). The most common primary endourological treatment was dilation (n = 133, 58.6% success, 95% CI 50.1-66.7). Fourteen complications, including death (4 weeks post-op) and graft loss (12 days post-op), followed endourological treatment. One complication followed open treatment. This is the first systematic review to examine the success rates and complications of specific treatments for distal ureteric strictures following renal transplantation. Our review indicates that open management has higher success rates and fewer complications than endourological management as a primary and secondary treatment for post-transplant distal ureteric strictures. We also outline a post-transplant ureteric stricture evaluation and treatment algorithm.

The risk of ureteric injury associated with hysterectomy: a 10-year retrospective cohort study.

OBJECTIVE: To evaluate the rates of ureteric injury among women undergoing hysterectomy. DESIGN: Retrospective cohort. SETTING: English National Health Service hospitals. POPULATION: Women undergoing hysterectomy in 2001-2010. METHODS: Unadjusted rates of ureteric injury, within 1 year of hysterectomy, calculated by indication and type of procedure. Multivariable logistic regression used to assess the risk of ureteric injury with year of surgery. MAIN OUTCOME MEASURES: Ureteric injury within a year of the hysterectomy. RESULTS: In 2001-2010, 377 073 women underwent hysterectomy, of whom 1792 (0.5%) experienced a ureteric injury. In both benign and malignant groups the rate of injury was higher in 2006-2010 than 2001-2005. After 2006, ureteric injuries were most common for abdominal radical hysterectomy for uterine cancer (10.7%; 95% CI 7.3-15.1%). The proportion of women having a ureteric injury was similar for ovarian and cervical cancer (1.9-4.0% depending on type of procedure). For benign conditions, the rate of injury tended to be lower, typically <1%. Women with endometriosis had the highest risk among this group (1.7% following total abdominal hysterectomy; 95% CI 1.4-2.0%). CONCLUSION: The risk of ureteric injury within 1 year of hysterectomy varied by type of hysterectomy for benign and malignant conditions. The rates of injury have increased between 2001 and 2010. TWEETABLE ABSTRACT: Ten-year study shows ureteric injury rates have increased.

Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients.

OBJECTIVES: To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. PATIENTS AND METHODS: Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. RESULTS: The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intra- or peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient's pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. CONCLUSIONS: Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition.

Ureteric reconstruction for the management of transplant ureteric stricture: a decade of experience from a single centre.

This study was conducted to review the outcomes of patients who had undergone surgical repair of a ureteric stricture following renal transplantation. All patients who developed a ureteric stricture and underwent ureteric reconstruction following renal transplantation, between December 2003 and November 2013, were reviewed. One thousand five hundred and sixty renal transplants were performed during the study period. Forty patients required surgical repair of a ureteric stricture (2.5%, 25 male, median age 48 [14-78]). The median time to stricture was 3 [1-149] months. 19 patients were reconstructed by reimplantation to the bladder, 18 utilized a Boari flap, two were a pre-existing ileal conduit and one was an anastomosis to a native ureter. In one patient, reconstruction was impossible and consequently an extra-anatomic stent was used. Two patients required re-operation for restricture and kinking. Median serum creatinine at 12 months following surgery was 148 [84-508] µmol/l. There was no 90-day mortality. Eleven grafts were lost at the time of this study, a median time of 11 [1-103] months after reconstruction. The incidence of ureteric stricture following renal transplant is low. Surgical reconstruction of the transplant ureter is the optimal treatment and is successful in the majority of patients.

A rare cause of anuria: Bilateral synchronous isolated mid-ureteric tubercular lesions.

A young female presenting with right flank pain, fever, raised creatinine and bilateral hydronephrosis was treated with antibiotics elsewhere, with presumptive diagnosis of bilateral pyelonephritis. She had partial relief in symptoms and her creatinine level showed an improvement. Three months later during evaluation at our center she had anuria, hypertensive crisis and pulmonary edema which were managed with emergency bilateral percutaneous nephrostomies. Cross-sectional imaging and ureteroscopy suggested bilateral synchronous intramural mid-ureteric lesions as underlying pathology. Histopathology of the ureteric segments during laparotomy revealed caseating granulomas suggestive of tuberculosis. This clinical presentation has not been previously described in urinary tuberculosis.

Extra-anatomic stent (EAS) as a salvage procedure for transplant ureteric stricture.

Ureteric stricture is the most common urological complication following renal transplantation. Management often involves endo-urological interventions and open surgery. The definitive treatment is surgical reconstruction to restore continuity. Where this is not possible or contra-indicated and a stent cannot be placed in the ureter, an extra-anatomic stent (EAS) could be used to bypass a complete ureteric obstruction. Using an existing nephrostomy tract, a percutaneous stent is placed in the kidney and is tunneled under the skin into the bladder establishing extra-anatomical urinary drainage. We report the use of a novel EAS system in a patient with transplant ureteric stricture when antegrade stent placement or surgical reconstruction was not possible.

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.

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.

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.

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.

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.

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.

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.

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.