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.

[A Case of Localized Amyloidosis of the Right Ureter Treated Effectively by Occulusive Dressing Technique Therapy Using Dimethyl Sulfoxide : Long-Term Follow-Up of Eight Years].

The patient was a 56-year-old female. She was referred to our department for further examination of right hydronephrosis in 2010. Computed tomography (CT) showed right hydronephrosis, and retrograde pyelography (RP) revealed stenosis of the right lower ureter. Urine cytology was negative. Transurethral biopsy of the right ureter was performed using ureteroscopic cup forceps and the histopathlogical diagnosis was ureteral amyloidosis. A whole-body search was performed, including rectal biopsy, but no evidence of amyloidosis was obtained. She was diagnosed with localized amyloidosis of the right ureter. A ureteral stent was indwelled and the patient was given occulusive dressing technique (ODT) therapy using dimethyl sulfoxide (DMSO) for 1 year. After ODT therapy, right hydronephrosis improved. After a 2-year followup, it worsened. ODT therapy was restarted and continued for 2 years. She consulted our department because of fever and right lumbago in April 2017 after a 4-month interruption of ODT therapy. CT revealed progression of the right hydronephrosis. A ureteral stent was indwelled and ODT therapy was restarted. The right hydronephrosis improved after 1 year. ODT therapy using DMSO was effective for localized ureteral amyloidosis, but periodic follow-up was necessary and ODT therapy was also effective when it recurred after the interruption of treatment.

Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial.

BACKGROUND: Meta-analyses of previous randomised controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, but emphasised the need for high-quality trials with wide inclusion criteria. We aimed to fulfil this need by testing effectiveness of these drugs in a standard clinical care setting. METHODS: For this multicentre, randomised, placebo-controlled trial, we recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned by a remote randomisation system to tamsulosin 400 µg, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (≤5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimisation covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks of randomisation, analysed in a modified intention-to-treat population defined as all eligible patients for whom we had primary outcome data. This trial is registered with the European Clinical Trials Database, EudraCT number 2010-019469-26, and as an International Standard Randomised Controlled Trial, number 69423238. FINDINGS: Between Jan 11, 2011, and Dec 20, 2013, we randomly assigned 1167 participants, 1136 (97%) of whom were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1·3% [95% CI -5·7 to 8·3]; p=0·73) and 304 (80%) of 379 in the nifedipine group (0·5% [-5·6 to 6·5]; p=0·88). No difference was noted between active treatment and placebo (p=0·78), or between tamsulosin and nifedipine (p=0·77). Serious adverse events were reported in three participants in the nifedipine group (one had right loin pain, diarrhoea, and vomiting; one had malaise, headache, and chest pain; and one had severe chest pain, difficulty breathing, and left arm pain) and in one participant in the placebo group (headache, dizziness, lightheadedness, and chronic abdominal pain). INTERPRETATION: Tamsulosin 400 µg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.

A randomized controlled trial comparing alpha blocker (tamsulosin) and anticholinergic (solifenacin) in treatment of ureteral stent-related symptoms.

PURPOSE: To compare the effectiveness of tamsulosin and solifenacin in relieving ureteral stents related symptoms. PATIENTS AND METHODS: A randomized controlled trial was conducted between January 2013 and July 2014. Inclusion criteria were patients aged 20-50 years who underwent temporary unilateral ureteral stent for drainage of calcular upper tract obstruction or after ureteroscopic lithotripsy. Patients with history of lower urinary tract symptoms before stent placement, stents that were fixed after open or laparoscopic procedures, and those who developed complications related to the primary procedure were not included. Eligible patients were randomly assigned to 1 of 3 groups using computer-generated random tables. Patients in group 1 received placebo, patients in group 2 received tamsulosin 0.4 mg once daily, and those in group 3 received solifenacin 5 mg once daily. Ureteral Stent Symptom Questionnaire (USSQ) was answered by all patients 1-2 weeks after stent placement. The primary outcome was the comparison of total score of USSQ between all groups. RESULTS: The study included 131 patients. All baseline characteristics (age, sex, side, indication, length, and duration of stent) were comparable for all groups. Total USSQ score was 61 in solifenacin group, 76 in tamsulosin group, and 83 in control group (P < 0.001). The total USSQ scores and all domains, except sexual index, were significantly better in solifenacin than in tamsulosin group (P < 0.05). CONCLUSION: The use of tamsulosin alone or solifenacin alone in patients with ureteral stents can improve the quality of life by decreasing ureteral stent-related symptoms. Solifenacin was better than tamsulosin. CLINICALTRIAL. GOV IDENTIFIER: NCT01880619.

Combination therapy only shows short-term superiority over monotherapy on ureteral stent-related symptoms - outcome from a randomized controlled trial.

BACKGROUND: Controversy remains on the superiority of combination therapy over monotherapy on ureteral stent-related symptoms (SRSs). We tend to explore if there is a necessity of combination therapy. METHODS: One hundred cases of unilateral upper urinary tract calculi with stent insertion (pre and post flexible ureteroscopy) were randomized into 4 groups, given non-treatment, solifenacin, tamsulosin or combination respectively. Eight times of follow-ups were given after each insertion. RESULTS: SRSs released spontaneously within 4 days after insertion (p = 0.017) but then stay with no further improvement. Benefit of solifenacin on flank pain started showing after day4 (p = 0.002), which was comparable to that of tamsulosin and combination (p = 0.914 vs 0.195). Combination therapy showed superiority over both monotherapy before day4, but after then solifenacin and tamsulosin showed similar effectiveness with the combination therapy on both bladder pain (p = 0.229 vs 0.394) and urgency (p = 0.813 vs 0.974). No improvement on hematuria or frequency was observed in each group. CONCLUSIONS: Combination therapy takes effect faster but shows no supervisory after the first few days compared with monotherapy. TRIAL REGISTRATION: The study protocol was registered on Chinese Clinical Trial Register on April 17th, 2013 (registration number: ChiCTR-TRC-13003148 ).

[Possible Diagnosis of Segmental Ureteritis Due to an IgG4-Related Disease that Improved with Steroid Therapy].

A 70-year-old woman was referred to our department after being diagnosed with right hydronephrosis on the basis of computed tomography (CT). CT and magnetic resonance imaging results indicated circumferential wall thickening in the right middle ureter. A retrograde pyelogram revealed an approximately 20 mm stricture in the right middle ureter, and urine cytology results were pseudo-positive. Ureteroscopy was performed due to suspicion of a malignant tumor of the urinary tract, but no malignant lesions were found. Biopsy results showed only the pathology of nonspecific ureteritis, and a diagnosis could not be made even with immunostaining. The patient's blood IgG4 levels were high (317 mg/dl). Based on the diagnostic criteria, the patient was given a possible diagnosis of an IgG4-related disease and treated by the placement ofa ureteral stent and administration of steroid therapy. After starting treatment, blood IgG4 levels decreased and the imaging findings showed improvement. The ureteral stent was removed in the 12th week, and steroid administration was discontinued in the 14th week. No recurrence has since been noted.

[Ureteral endometriosis treated by hormonal therapy : a case report].

A 40-year-old woman visited our hospital with asymptomatic macroscopic hematuria. A nonpapillary ureteral tumor protruding from the left orifice was identified by cystoscopy. Computed tomography revealed left hydronephrosis due to the ureteral tumor. Transurethral resection for the ureteral tumor was performed and histopathological examination for the specimen revealed intrinsic type ureteral endometriosis. Administration of luteinizing hormone-releasing hormone agonist for 6 months markedly improved the hydronephrosis. The patient received hormonal therapy for 2 years in total. At present, there is no evidence of disease recurrence 6 months after the termination of hormonal therapy. To our knowledge, the present case was the 14th Japanese case with intrinsic type ureteral endometriosis reported in the literature.

[Effect of 3-oxypyridine and succinic acid derivatives on endometrial leucocyte infiltration and lipid peroxidation in recrudescence of inflammatory diseases of the uterus and its appendages].

The effect of domestic 3-oxypyridine and succinic acid derivatives (emoxipin, reamberin and mexidol) included in the complex treatment of recrudescence of inflammatory diseases of the uterus and its appendages, as manifested in endometrial leucocyte infiltration (ELI) compared to lipid peroxidation products concentration in blood serum, was assessed in a short-term, prospective placebo-controlled single-blind randomized trial. It has been found that two-week infusions of emoxipin (single dose, 150 mg), reamberin (single dose, 400 ml), and mexidol (single dose, 300 mg) favor a decrease in ELI and influence ambiguously on lipid peroxidation - antioxidant (LPA) system condition in blood serum of patients. It has been found that 3-oxypyridine derivative (emoxipin) decreases the intensity of ELI, but does not affect LPA system condition. Succinic acid derivative (reamberin) is inferior to emoxipin in the degree of decreasing ELI, but reduces the concentration of the antioxidant protein ceruloplasmin. Mexidol, being 3-oxipyridine and succinic acid derivative simultaneously, exceeds reamberin in decreasing ELI, increases concentration of blood antioxidant components (alpha-tocopherol and ceruloplasmin), and decreases the level of primary isopropanol-soluble products of lipid peroxidation.

First report of idiopathic segmental ureteritis successfully treated by steroid therapy.

We report a case of bilateral idiopathic segmental ureteritis in a 52-year-old woman. The diagnosis was established by imaging studies (magnetic resonance imaging/computed tomography scan), ureteroscopy and biopsies. The left side improved spontaneously, but the right ureteral stricture persisted after 3 months of ureteral stenting. Administration of prednisolone effectively relieved obstruction on the right side after 4 months. This is the first report of idiopathic segmental ureteritis successfully treated by steroid therapy, without invasive open procedures.

Obstructing Nephrolithiasis in an 84-year-old Patient With a Diaphragmatic Herniated Ureter.

Diaphragmatic herniations of the ureter are a rare occurrence overall, with fewer than 10 cases reported. Obstructing nephrolithiasis in the setting of diaphragmatic ureteral herniation has sparsely been documented. Management options to consider include ureteroscopy and laser lithotripsy to alleviate obstruction in herniated ureters. The abnormal path of the ureter and surrounding structures pose unique risks that require careful attention and a high level of operator skill. We present imaging of an 84-year-old woman incidentally found to have right ureteral herniation through the diaphragm with an obstructing 8 mm stone in the right proximal ureter with moderate hydronephrosis.

[PDE5 inhibitors. A new option in the treatment of ureteral colic?]. / PDE-5-Inhibitoren. Ein neuer Therapieansatz in der Behandlung der Harnleiterkolik?

BACKGROUND: PDE5 inhibitors represent the gold standard in the medical therapy of erectile dysfunction (ED). Promising results have been published regarding further urological indications such as treatment of ureteral colic. The aim of the present study was to evaluate the functional effects of the PDE5 inhibitors sildenafil (SIL), vardenafil (VAR), and tadalafil (TAD) on tissue tension and cyclic nucleotide levels of human ureteral smooth muscle segments in vitro. METHODS: Relaxant responses of human ureteral smooth muscle were investigated in vitro using the organ bath technique. Cyclic nucleotides cAMP and cGMP were determined by specific radioimmunoassays. RESULTS: Relaxing effects of ureteral muscle tension were observed in the rank order VAR>SIL>TAD. While only VAR significantly elevated cGMP levels 3.3-fold over control, no increase for cAMP levels was observed. CONCLUSIONS: Our data provide evidence that cGMP is involved in the control of the normal function of the smooth musculature of the human ureter. Our findings suggest the potential of using selective inhibitors of PDE isoenzymes in the treatment of ureteral colic.

[Tamsulosin, oxybutynin or their combination in the treatment of ureteral stent-related symptoms]. / Tamsulosin, oxybutynin or their combination in the treatment of ureteral stent-related symptoms.

BACKGROUND: The aim of this paper is to compare the efficacy of tamsulosin, oxybutynin or their combination for the treatment of symptoms related to double J stent (DJS). METHODS: Randomized clinical non-blinded trial with three arms (tamsulosin, oxybutynin or combination) to assess the improvement of ureteral related symptoms with DJS with the questionnaire of Ureteral Stent Symptom Questionnaire (USSQ) and the adverse effects of treatment. Evaluations were made at 7 and 21 days after the placement of DJS. The maneuvers were compared using Chi squared test, Kruskall-Wallis, ANOVA and Wilcoxon considering a statistically significant p ≤ 0.05. RESULTS: 170 patients with CJJ were evaluated. A perprotocol analysis was performed in 142 patients, 53 received tamsulosin (37.4%), 42 oxybutynin (29.6%) and 47 the combination of both (33%). At 7 and 21 days the improvement was similar in all three arms. Men with tamsulosin and women with oxybutynin had less general symptoms. CONCLUSIONS: Tamsulosin, oxybutynin or its combination similarly improve ureteral stent related symptoms and this improvement becomes more noticeable over time. Men are less symptomatic with tamsulosin and women with oxybutynin.

OBJETIVO: comparar la eficacia de tamsulosina, oxibutinina o su combinación para el tratamiento de los síntomas relacionados con el uso de catéter doble J (CJJ). MÉTODOS: ensayo clínico aleatorizado, no cegado, de tres brazos (tamsulosina, oxibutinina o la combinación), para evaluar la mejoría de los síntomas asociados a CJJ con el cuestionario de síntomas asociados a catéteres ureterales (USSQ) y los efectos adversos del tratamiento. Las evaluaciones se hicieron a los 7 y 21 días de colocado el CJJ. Las maniobras se compararon mediante Chi cuadrada, Kruskall-Wallis, ANOVA y Wilcoxon, considerando estadísticamente significativa una p ≤ 0.05. RESULTADOS: se evaluaron 170 pacientes con CJJ. El análisis se realizó por protocolo con 142 pacientes, 53 recibieron tamsulosina (37.4%), 42 oxibutinina (29.6%) y 47 la combinación de ambos (33%). A los 7 y 21 días la mejoría fue similar en los tres brazos. Los hombres con tamsulosina y las mujeres con oxibutinina tuvieron menos síntomas generales. CONCLUSIONES: la tamsulosina, oxibutinina o su combinación mejoran de manera similar los síntomas por CJJ y esta mejoría se hace más notoria a través del tiempo. Los hombres están menos sintomáticos con tamsulosina y las mujeres con oxibutinina.

PURLs: Kidney stones? It's time to rethink those meds.

Despite being recommended for ureteral stone expulsion, tamsulosin or nifedipine are no more effective than placebo.

Decreased urinary glycosaminoglycan excretion following alfuzosin treatment on ureteral stent-related symptoms: a prospective, randomized, placebo-controlled study.

The objectives of the study were to evaluate changes in ureteral stent-related symptoms and urinary glycosaminoglycan (GAG) excretion after alfuzosin treatment, and to further investigate the relationship between stent-related symptoms and loss of urinary GAGs. Seventy consecutive patients scheduled for unilateral retrograde ureteroscopy with stent placement were recruited. Patients were randomly assigned to treatment with alfuzosin 10 mg/day or placebo for 3 weeks starting on the third postoperative day. The ureteral stent was removed when treatment stopped. International Prostate Symptom Score (IPSS), visual analog scale (VAS) score, and urinary GAG excretion were determined before treatment at 1, 2, and 3 weeks after treatment, and at 3 weeks after stent removal. Fifty-nine patients completed the study. IPSS, VAS score, and urinary GAG excretion were significantly lower in the alfuzosin group, compared with the placebo group, at 1, 2, and 3 weeks after treatment (P < 0.01). In both groups, IPSS, VAS score, and urinary GAG excretion were significantly lower at 3 weeks after stent removal compared with those before stent removal. No significant differences in IPSS, VAS score, or urinary GAG excretion were observed between the two groups at baseline and 3 weeks after stent removal (P > 0.05). Positive correlations were found between urinary GAG excretion (R(2) = 0.65, P < 0.001) and IPSS and between urinary GAG excretion and VAS score (R(2) = 0.33, P < 0.001). Stent placement contributes to loss of urinary GAGs. However, alfuzosin effectively reduces such loss and improves ureteral stent-related symptoms. Loss of urinary GAGs plays a role in these symptoms.

Outcomes of Medical and Surgical Therapy for Entero-urinary Fistulas in Crohn's Disease.

BACKGROUND AND AIMS: The aims of this study were to evaluate the frequency of entero-urinary fistulas in a cohort of Crohn's disease (CD) patients and to analyse the outcomes of medical and surgical therapy. METHODS: This multicentre retrospective study included all CD patients with entero-urinary fistulas diagnosed by the presence of clinical symptoms and confirmed at surgery or by radiological or endoscopic techniques. We evaluated outcomes of medical and surgical therapy. We defined remission as absence of clinical symptoms with a radiological confirmation of fistula closure. Cox regression analysis was performed to evaluate factors predictive of achieving remission without need for surgery. RESULTS: Of 6081 CD patients screened, 97 had entero-urinary fistulas (frequency 1.6%). Seventy-five percent of fistulas occurred in men. After a median follow-up of 91 months, 96% of patients were in sustained remission. Thirty-three patients (35%) received anti-tumour necrosis factor (TNF) therapy. Of these, 45% achieved sustained remission (median follow-up 35 months) without needing surgery. More than 80% of patients required surgery, which induced remission (median follow-up 101 months) in 99% of them. Only the use of anti-TNF agents was associated with an increased rate of remission without need for surgery (hazard ratio 0.23, 95% confidence interval 0.12-0.44; p < 0.001). CONCLUSION: In this large cohort of CD patients, the frequency of entero-urinary fistulas was lower than previously described. More than 80% of patients required surgery, and in all but one of them surgery induced sustained remission. In a selected subgroup of patients, anti-TNF may induce long-term fistula remission and radiographic closure, making it possible to avoid surgery.