Search

Objective: To identify and address factors that may impact a surgeon's performance during endourologic procedures., Methods: A literature review was performed for articles focusing on surgical ergonomics, education, sports and performance psychology., Results: As urologists and trainees have become more comfortable approaching complex pathology endoscopically, there remains an opportunity to refine surgeon-related factors and optimize extrinsic factors to maximize efficiency and provide patients with the highest quality outcomes and safety., Conclusion: Medical centers and training programs should strive to include formal lessons on stress-coping mechanisms, communication, and dedicated ergonomic training, as these all play a role in physician well-being and may lead to improved clinical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of cisplatin-based neoadjuvant chemotherapy (NAC) in patients who underwent nephroureterectomy for high-grade (HG) upper tract urothelial carcinoma (UTUC)., Methods: Retrospective review was conducted of patients with HG UTUC from 2011 to 2017 who underwent nephroureterectomy at 2 institutions. Patients with eGFR >50 mL/min/1.73 m 2 were considered eligible for NAC and were referred for evaluation of NAC prior to nephroureterectomy. Patient demographics, kidney function, clinical and pathologic response rates, and outcomes were analyzed., Results: Of 95 patients with HG UTUC meeting inclusion criteria (mean age 72.3 years, mean preop eGFR 57.0 mL/min/1.73 m 2 ), 61 patients were considered eligible for NAC with eGFR >50 mL/min/1.73 m 2 , of which 25 (41%) received NAC. Of the patients who received NAC, 80% (20/25) of the patients had clinical response on imaging and 80% (20/25) had pathologic response (

Background: Using a selective α-blocker for medical expulsive therapy (MET) is a cost-effective treatment approach widely used for ureteral stones., Objective: To evaluate the efficacy of silodosin, a selective α-1a receptor antagonist, in this setting., Design, Setting, and Participants: This was a multicenter, phase 2 study conducted in adult patients with a unilateral ureteral calculus of 4-10mm. Of 239 patients in the safety population, six discontinued due to adverse events., Intervention: Patients were randomized 1:1 to receive silodosin 8 mg or placebo for up to 4 wk., Outcome Measurements and Statistical Analysis: The primary outcome was spontaneous stone passage, analyzed using logistic regression. Secondary outcomes included time to stone passage, emergency room (ER) visits, hospital admissions, analgesic use, and incidence and severity of pain., Results and Limitations: No significant differences between the silodosin and placebo groups were observed for passage rate of all stones (52% vs 44%, respectively; p=0.2). However, silodosin achieved a significantly greater rate of distal ureter stone passage than placebo (p=0.01). Significant differences were not observed for ER visits, hospital admission, or use of analgesics. The number of patients in the intent-to-treat population was slightly below the calculated sample size (232 vs 240) and sample sizes were not calculated for subgroup analyses., Conclusions: This is among the first prospective, randomized, multi-institutional trials to examine the efficacy of a selective α-1a antagonist as MET in patients with ureteral calculi and did not demonstrate a benefit to the entire ureter. However, silodosin was found to be well tolerated and beneficial in facilitating the passage of distal ureteral stones, warranting additional future studies on distal stone elimination., Patient Summary: In this report, we looked at the efficacy of silodosin for the treatment of ureteral stones. We found that silodosin increased passage of distal ureteral stones., (Published by Elsevier B.V.)

Objective: To characterize the local antimicrobial resistance pattern in patients with obstructing ureteral stones and fever, compare this with our local antibiograms, and guide recommendations for empiric antibiotic regimens., Methods: A retrospective chart review was performed of patients who underwent ureteroscopic intervention for the management of ureteral stones at a neighboring private hospital and a public hospital to identify those patients who had undergone prior decompression for obstructing ureteral stones and fever between 2004 and 2011. Urine culture results were captured to identify uropathogens and sensitivity patterns to antibiotics. These were compared with respective hospital antibiograms., Results: Sixty-five patients were identified, of which 35 had positive urine culture results. More than 25% of the voided urine and upper urinary tract urine cultures differed. Antimicrobial resistance patterns were higher for patients at the public hospital than the hospital antibiogram. The opposite was true at the private hospital. The public hospital demonstrated an overall higher resistance pattern than the private hospital., Conclusion: Antimicrobial resistance makes the selection of empiric antibiotic treatment challenging in patients with obstructive pyelonephritis secondary to ureteral stones. Because of discordance between voided urine cultures and those captured at the time of decompression, it is imperative to obtain both voided urine and urine from the kidney to ensure adequate antibiotic coverage. Local population-specific antimicrobial guidelines that are frequently updated are essential to ensure adequate coverage and treatment of obstructive pyelonephritis, and condition-specific antibiograms would be recommended in the future., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Ectopic ureters are rare congenital mesonephric duct malformations with a higher prevalence in women than men. In women, ectopic ureters are often associated with a duplicated collecting system, whereas in men, ectopic ureters usually drain a single system and are associated with renal dysplasia and obstruction. Presentation and diagnosis generally occurs in the pediatric age group. Herein, we present an unusual case of delayed diagnosis of ectopic insertion of the upper pole ureter in a completely duplicated left kidney causing massive hydroureteronephrosis in an adult man., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To analyze the outcomes of our robotic-assisted pyeloplasty series for primary ureteropelvic junction obstruction (UPJO) and compare them with our series of robotic-assisted pyeloplasty for secondary UPJO. The repair of secondary UPJO can pose additional challenges to surgeons. Robotic assistance could aid in these repairs., Methods: Using an institutional review board-approved database, we reviewed 119 consecutive patients who had undergone robotic-assisted laparoscopic pyeloplasty at our institution during an 8-year period (May 2002 to February 2010). Data were collected in a combined retrospective and prospective manner. The patients were stratified into primary repair and secondary repair for the primary analysis. The patients were also stratified into those with stones and those without stones for the secondary analysis. We compared the demographic, operative, postoperative, and radiographic outcomes. Student's t test and Pearson's chi-square correlation were used for statistical analysis of continuous and categorical variables, respectively., Results: Of the original 119 patients, data were available for 117. Of the 117 patients, 97 had undergone primary pyeloplasty repair and 20 had undergone secondary pyleloplasty repair. Radiographic data were available for 84 patients with primary repair and 17 patients with secondary repair. The radiographic success rate was 96.1% and 94.1%, respectively. No statistically significant differences were found in the patient demographics, operative data, or postoperative or radiographic outcomes for the primary analysis. Additionally, no differences were found in the outcomes for patients with concomitant stone disease., Conclusion: These data represent the largest single-center report of its kind. These data strongly suggest that robotic-assisted laparoscopic pyeloplasty is a safe and durable option for secondary UPJO repair., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To perform a multi-institutional study to characterize CT-detected complications after PNL. Computed tomography (CT) is commonly performed after percutaneous nephrolithotomy (PNL). One benefit of this imaging modality is the detection of procedure-related complications. Presently, the incidence of such complications is not well-defined., Patients and Methods: PNL procedures performed at 5 stone referral centers between July 2007 and June 2008 were reviewed. All patients undergoing CT within 24 hours after surgery were selected for further analysis. All CT studies were reviewed by a staff radiologist., Results: One-hundred ninety-seven patients satisfied the study inclusion criteria. A body mass index >30 was present in 27.5% of patients. Treated stone burden was staghorn in 70 (35.5%), >2 cm in 72 (36.5%), and <2 cm in 55 (28%). Six treated renal units (3%) were ectopic; 45.4% of calculi were predominantly lower pole. Thoracic complications encountered were atelectasis in 88 (44.7%), pleural effusion in 17 (8.6%), pneumothorax in 3 (1.5%), hemothorax in 2 (1%), and hydrothorax in 1 (0.5%). Renal complications were perinephric hematoma in 15 (7.6%), collecting system perforation in 4 (2%), subcapsular hematoma in 3 (1.5%), urinoma in 2 (1%), and pseudoaneurysm in 1 (0.5%). There was 1 trans-splenic nephrostomy without splenic hematoma. No injuries to hollow viscera were detected. Two patients (1%) were found to have ascites., Conclusions: Major post-PNL complications detected by CT are uncommon, and when encountered, they are generally amenable to conservative management., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To present our experience with retrograde ureteral and/or renal access in patients with urinary diversion. Retrograde ureteral access may be indicated for treatment of malignancy, ureteroenteric anastomotic stricture disease, or nephrolithiasis, and, in patients with previous urinary diversion surgery, can be technically challenging., Methods: We retrospectively identified patients undergoing attempted retrograde ureteral access after urinary diversion surgery. The demographic information, diversion type, indication for retrograde access, success or failure of access, and intra- and postoperative complications were recorded., Results: From 2003 to 2008, 21 renal units (15 patients) with previous urinary diversion surgery underwent attempted retrograde ureteral access. The indications for retrograde access included treatment of nephrolithiasis in 5, ureteroenteric anastomotic stricture in 9, upper tract filling defects in 3, positive cytology findings in 1, and known upper tract malignancy in 3. We made 28 retrograde access attempts. Of these, 21 (75%) were successful. The success rate for each type of urinary diversion was 90% (9/10) for orthotopic neobladders, 73% (11/15) for ileal conduits, and 33% (1/3) for Indiana pouches. All 6 attempts to access the renal units for ureteroscopic management of suspected upper tract malignancy were successful. The access attempts were less successful in 5 of 10 patients (50%) with anastomotic stricture disease. No complications were reported., Conclusions: Retrograde access in patients with urinary diversion is feasible and safe. The risk of failed access is increased in patients with ureteral anastomotic stricture. The diagnosis and/or treatment of upper tract urothelial carcinoma and stone disease can be readily performed with retrograde ureteroscopic techniques.

Objectives: To investigate and compare practice patterns regarding malignant extrinsic ureteral obstruction among urologists (GU) and oncologists (ONC)., Methods: We invited members of the American Urological Association and the American Society of Clinical Oncologists to participate in a web-based survey. Participants gave recommendations in clinical scenarios, as well as opinions regarding use of ureteral stents and nephrostomy tubes (PCN)., Results: The survey was randomly sent to 1500 GU and 1500 ONC, of whom 226 (15%) and 191 (12.4%) responded, respectively. The groups significantly varied in treatment preferences in all clinical scenarios. Regarding stent failure, ONC preferred PCN (79% versus GU 62%); GU (18% versus 5%) next preferred stent manipulation (eg, increase stent size, dual stents) (P <0.0001). The greatest risk of stents per GU was decreased quality of life (65% versus 13%), whereas ONC were most concerned about infection (43% versus 3%) (P <0.0001). The greatest risk of PCN per GU was dislodgement (48% versus 18%), whereas ONC were most concerned about infection (40% versus 8%) (P <0.0001)., Conclusions: Practice patterns vary significantly between GU and ONC in the treatment of malignant extrinsic ureteral obstruction. Further investigation and collaboration are necessary to determine which interventions are best for these patients and how to ensure consistency in their care.

Objectives: Ureteral obstruction is a common finding in retroperitoneal fibrosis (RPF). The management of ureteral obstruction in patients with RPF is challenging and controversial. To our knowledge we are the first to report on laparoscopic ureterolysis (LU) and robotic ureterolysis (RU) for the management of RPF to determine feasibility and success., Methods: We reviewed the charts of all patients who have undergone laparoscopic ureterolysis with or without robotic assistance at our institution., Results: Between 2001 and 2006, one surgical team performed laparoscopic ureterolysis with or without robotic assistance on 15 renal units in 10 patients. Mean age was 50.9 years (range, 28 to 71 years). Eight patients presented with back pain and all 15 renal units had radiographic evidence of obstruction. Five patients underwent LU, and 5 underwent RU. Mean operative times for bilateral and unilateral LU were 509.0 and 110 minutes, and the mean estimated blood loss was 362.5 and 50 mL. Mean operative times for bilateral and unilateral RU were 390 and 220.5 minutes, and the mean estimated blood loss was 25 and 35.5 mL. With a mean follow-up of 15.6 months, 90% of all patients were asymptomatic and 86.7% renal units had no signs of obstruction on imaging., Conclusions: Laparoscopic ureterolysis with or without robotics may be performed with minimal perioperative morbidity and provides excellent success rates for relief of symptoms and obstruction in RPF. RU appears to have better short-term outcomes and is now our technique of choice.

Introduction: Ureterocalicostomy is a well-established treatment option for patients with recurrent ureteropelvic junction obstruction or proximal ureteral stricture refractory to endoscopic management in the setting of diminutive or intrarenal pelvis or significant peripelvic fibrosis. We report a case of robotic-assisted laparoscopic ureterocalicostomy using the da Vinci robotic system in a patient with proximal ureteral stricture refractory to endoscopic management., Technical Considerations: All techniques described to date for ureterocalicostomy have been either open or purely laparoscopic. We report a case of robotic-assisted laparoscopic ureterocalicostomy in a patient with refractory proximal ureteral stricture secondary to multiple interventions for stones. We used laparoscopy for the initial dissection and exposure and robotic techniques for lower pole amputation and ureterocaliceal anastomosis. Intraoperative nephroscopy was also performed through the lower pole calix. The patient had resolution of the obstruction at 10 weeks postoperatively with the stent out and radiographic confirmation of excretion and drainage., Conclusions: Robotic-assisted laparoscopic ureterocalicostomy is a feasible alternative to open or laparoscopic techniques for treating refractory proximal ureteral stricture or ureteropelvic junction obstruction. To our knowledge, this is the first described case of robotic-assisted laparoscopic ureterocalicostomy with intraoperative nephroscopy.

Objectives: To report our contemporary experience with ureterocalicostomy to determine whether the indications or results have changed in modern practice. Ureterocalicostomy is a well-established treatment for patients with complicated ureteropelvic junction (UPJ) obstruction and other forms of proximal ureteral obstruction. Although both retrograde and antegrade endourologic interventions have become accepted forms of management, the success rates do not approach those of open or even laparoscopic interventions, potentially leading to a greater number of patients with treatment failure and the need for more complicated reconstruction., Methods: Between July 1991 and February 2004, 11 patients (4 women and 7 men), aged 19 to 68 years (mean 38), underwent open surgical ureterocalicostomy. The indications for surgery were primary UPJ obstruction in 4, failed cutting balloon incision for UPJ obstruction in 3, proximal ureteral stricture after ureteroscopic stone removal in 2, and obliterated UPJ after percutaneous nephrolithotomy and failed antegrade endopyelotomy in 1 patient each., Results: Hospitalization ranged from 4 to 7 days (mean 5.1). No patient experienced a significant perioperative complication. With follow-up ranging from 5 to 32 months (mean 10.1), relief of obstruction was evident in all patients as documented by intravenous urography or nuclear renography. Furthermore, differential function on the involved side improved from a mean of 54.6% preoperatively to 60.1% postoperatively (P <0.05)., Conclusions: The spectrum of indications for ureterocalicostomy has changed, although excellent results can still be achieved. Although laparoscopic approaches are currently being evaluated, most patients currently undergoing this reconstructive procedure still require open operative intervention.

We describe 2 cases of spurious quartz-containing calculi; the first patient-driven and the second iatrogenic. An iatrogenic etiology can occur after the use of holmium:yttrium-aluminum-garnet laser energy because the fiber tip is composed of quartz. To make the diagnosis of a spurious stone, a high degree of suspicion is essential. A quartz stone should prompt the diagnosis of a factitious disorder in the absence of the appropriate surgical history. Psychological counseling and/or referral to a pain management clinic should be considered in such cases.

Renal vein thrombosis typically occurs in the setting of nephrotic syndrome, tumor thrombus, primary retroperitoneal processes with vein compression, oral contraceptive use, steroid therapy, transplanted kidney, or trauma. Trauma-induced renal vein thrombosis usually presents in combination with renal arterial or parenchymal injury. We report a case of isolated renal vein thrombosis secondary to blunt abdominal and flank trauma. The diagnosis was made with computed tomography, which revealed a filling defect in the affected renal vein and persistent nephrogram on delayed images. In general, conservative management is the preferred treatment approach with anticoagulation.

Objectives: To review our contemporary experience with ileal ureter reconstruction. Despite advancements in surgical technology and technical expertise, ureteral injuries continue to occur. These injuries can be extensive, and ileal ureter reconstruction may be necessary., Methods: A total of 18 ileal ureter substitutions were performed in 16 adults (10 men and 6 women) by a single surgeon during a 6-year period. The mean patient age was 49.4 years (range 25 to 72). The mean follow-up was 18.6 months (range 7 to 59). All ileal ureter substitutions were performed in an isoperistaltic, refluxing fashion. Follow-up included clinical evaluation, nuclear renography, intravenous urography, and serum chemistry testing., Results: Postoperative nuclear renography demonstrated no relative loss of function of the affected renal unit and no evidence of functional obstruction. An unobstructed state was also confirmed with intravenous urography. No statistically significant metabolic changes were found in any patient, as assessed by serum chemistry testing. None of the patients had evidence of new stone formation. Two patients developed an isolated, symptomatic urinary tract infection during follow-up, and one has had recurrent urinary tract infections, a problem that was present preoperatively., Conclusions: Ileal ureter substitution remains an effective treatment for patients with complex ureteral strictures or injuries. Stone activity does not appear to increase, and metabolic sequelae are uncommon in properly selected patients.