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Introduction: Idiopathic retroperitoneal fibrosis is a known cause of obstructive uropathy. Ureterolysis is done when medical management fails or the presentation is at an advanced stage. Conventionally ureterolysis without omental wrap has been considered incomplete. Our Institute has experience of laparoscopic or robotic ureterolysis with intraperitonealization of the ureter alone and no other adjunctive procedure. This study retrospectively assesses the result of the procedure with patients presenting with varying severity of disease., Methods: From 2008, all patients who underwent laparoscopic or robotic ureterolysis were analyzed retrospectively for pre-operative management, operative findings, and post operative outcomes., Results: We operated and released nine renal units in seven patients. Two of the nine cases were performed robotically completely and the rest was performed by laparoscopic approach. Median follow up was 60 months. All patients documented resolution of symptoms. The mean post-operative creatinine at 1 year was significantly decreased to 1.47 ± 0.49 mg/dl in comparison to preoperative creatinine ( p  < 0.05). The postoperative mean ESR decreased significantly from a preoperative value of 58.2 ± 19.41 mm to 15.8 ± 17.23. The nuclear scan revealed unobstructed drainage and radiological imaging revealed resolution of hydronephrosis and fibrosis in all. The mean GFR on the nuclear scan after 3 and 12 months of surgery was 36.3 ± 4.33 and 40 ± 3.77, respectively. Thus, there was significant increase noted in GFR at 3 and 12 months in comparison to preoperative GFR ( p  < 0.05)., Conclusion: Laparoscopic/robotic ureterolysis with intraperitonealization alone is secure and durable procedure for idiopathic retroperitoneal fibrosis needing surgical release.

Objectives: To compare the surgical outcomes of open and laparoscopic ureterolysis procedures in patients requiring surgical treatment for ureteral obstruction caused by retroperitoneal fibrosis (RPF). Materials: This study was designed retrospectively. The clinical records of patients who underwent ureterolysis between January 2005 and April 2019 because of ureteral obstruction caused by RPF were examined. According to the type of surgery, the patients were divided into two groups as Group 1 (open ureterolysis) and Group 2 (laparoscopic ureterolysis). Demographic features, preoperative-postoperative renal functions, duration of follow-up with ureteral stents, and perioperative-postoperative complications were examined. The requirement of ureteral stent placement during the follow-up period was accepted as unsuccessful ureterolysis. Results: Ureterolysis was performed in 13 patients and 23 renal units. Eleven of these patients were men and two were women. The median age of the patients was 54 (44-68) years. There were six patients and 12 renal units in Group 1 and seven patients and 11 renal units in Group 2. Postoperatively, a total of four patients (30%) had minor complications (Clavien-Dindo 1-2) and one patient had a major complication (Clavien-Dindo 3a). Ureterolysis was determined to be effective in 21 of the renal units (91%) [11/12 (92%) in Group 1 vs 10/11 (91%) in Group 2]. No statistically significant difference was found between the groups in terms of the success and complication rates ( p  = 1 and p  = 0.529, respectively). Postoperative hospitalization length and recovery time to return to normal preoperative activities were significantly shorter in Group 2 than in Group 1 ( p  = 0.011 and p  = 0.041, respectively). Conclusions: The success and complication rates were similar between the open and laparoscopic methods for ureterolysis. Laparoscopic approach was advantageous over open approach in terms of postoperative hospitalization length and recovery time to return to normal preoperative activities.

Objective: To characterize the timing and effectiveness of medical management in resolving stent-dependent ureteral compression secondary to idiopathic retroperitoneal fibrosis (RPF), the long-term relevant outcomes, and the side effects of treatment., Methods: A retrospective review of RPF patients diagnosed from 2002-2018 was performed. Patients with hydronephrosis due to ureteral involvement that were managed with medication and with temporary stenting as needed, but without initial ureterolysis, were included. Patient demographics and RPF management details were obtained, including the following subsequent events: ureterolysis, nephrectomy, recurrent upper tract obstruction, and medication side effects., Results: Fifty-two patients met inclusion criteria. Resolution of ureteral obstruction with medical management and temporary renal drainage as needed occurred in 36 (69%) patients with a median stent duration of 16 months, and median clinical and radiographic follow up of 4.2 and 3.3 years, respectively. Recurrent obstruction after a stent-free period occurred in 9 (18%) patients. Ureterolysis was performed in 8 (15%) patients at a median of 2.2 years for medication intolerance, lack of radiographic response to medication, or persisting pain. Potential medication side effects occurred in 6 (12%) patients., Conclusions: Medical management supported successful resolution of ureteral obstruction in 69% of patients without the need for ureterolysis after temporary renal drainage using stents, with rare incidence of worsening renal dysfunction or medication side effect. To date, this is the largest reported series of systematically managed RPF patients with obstructive uropathy receiving initial medical therapy and serves to counsel patients and advise urologists and nephrologists of the expected course and advantages and disadvantages of medical versus surgical management., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To report our experience with ureterolysis for the management of retroperitoneal fibrosis., Methods: The data of 25 patients who underwent ureterolysis due to primary retroperitoneal fibrosis between 2002 and 2017 were reviewed retrospectively. Initial symptoms, laterality, renal function status (initial/final), operation complications and serum creatinine levels (diagnosis/preoperative/6 months, 12 months postoperatively) were recorded. After surgery, patients were followed up by ultrasonography and serum creatinine levels. Patients with impaired results underwent furosemide renogram and/or late phase of computed tomography. Factors affecting final serum creatinine levels were evaluated. The χ 2 -test was used for nominal data among groups. The level of statistical significance was set as P < 0.05., Results: A total of 19 patients (76%) were operated bilaterally. The mean follow-up period was 46.2 ± 9.2 months. Among 44 operated renal units, non-functioning kidney developed in seven (15.9%). A total of 34 renal units (77.3%) did not require any additional surgical intervention, and two underwent balloon dilatation (4.5%), one (2.25%) followed with double J stent changes. Two patients developed end-stage renal disease secondary to bilateral unresolved obstruction. High final serum creatinine levels developed in eight (32%) patients without dialysis. Eight patients (32%) were treated with immunosuppressive therapy for systemic recurrence. There was a significant relationship between preoperative serum creatinine levels with final serum creatinine levels (P = 0.005). There was no statistically significant relationship between diagnosis serum creatinine levels with final serum creatinine levels and postoperative dialysis requirement (P = 0.79 and P = 0.817, respectively)., Conclusions: Ureterolysis provides acceptable success with low complication rates in patients with retroperitoneal fibrosis. Preoperative high-serum creatinine levels can be considered as a risk factor for long-term renal impairment and these patients should be followed closely., (© 2021 The Japanese Urological Association.)

Objective: To investigate the clinical features and outcome of hydronephrosis induced by retroperitoneal fibrosis (RPF), and to evaluate the effect of corticosteroid based therapy combined with surgical intervention of ureteral obstruction., Methods: A total of 17 RPF patients with hydronephrosis hospitalized in Peking University International Hospital from May 2016 to December 2019 were analyzed retrospectively., Results: The median age was 56 (53, 65) years, the male to female ratio was 2.4 : 1, and the disease duration was 4.00 (0.83, 8.00) months. The initial symptoms included back pain (9 cases), abdominal pain (6 cases), oliguria (2 cases) and lower limb edema (3 cases). Eight patients presented left hydronephrosis, 1 right hydronephrosis and 8 bilateral hydronephrosis. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both elevated in 13 patients (76.5%, n =17). Immunoglobin (Ig) G4 increased in 5 cases (29.4%, n =17). IgG, IgE and IgA increased in 4 cases (30.8%, n =13), 4 cases (30.8%, n =13) and 1 case (7.7%, n =13), respectively. Among 12 patients who underwent biopsy, 3 patients were diagnosed with IgG4-relate disease. The level of IgG4 in the tissues varied, 6 cases expressed less than 10 per high power field (HPF) or no expression (50.0%). Only 2 cases expressed 10-30/HPF (16.7%), and 4 cases revealed more than 30/HPF (33.3%). Among the 17 patients with ureteral obstruction, no urinary drainage procedure was needed in 4 patients who had mild ureteral obstruction, whereas, ureteral stenting was carried out in the other 13 cases before drug treatment. Time was too short to evaluate the effect of urinary drainage procedures in 4 patients. For the rest, ureterolysis had to be performed in 3 cases after failed ureteral stent insertion. Successful drain removal was accomplished in all of these 9 patients and the mean time to drain removal was (6.7±3.0) months. In addition, 10 patients had complete medical records after an average follow-up time of 5 (3-13) months. Levels of ESR, CRP, IgG4, IgG, IgE, IgA were 54.0 (36.3, 98.5) mm/h, 26.8 (8.7, 53.0) mg/L, 1.34 (0.55, 3.36) g/L, 16.3 (13.0, 21.1) g/L, 40.5 (31.4, 203.0) IU/mL, 2.51 (1.82, 3.25) g/L at baseline, which all decreased predominantly after treatment. ESR, CRP, IgG4, IgG, IgE and IgA dropped by 38.5 (23.5, 54.3) mm/h ( P < 0.01), 23.0 (5.5, 52.0) mg/L ( P < 0.05), 0.92 (0.40, 2.85) g/L ( P < 0.01), 6.5 (1.7, 9.1) g/L ( P < 0.05), 23.7 (4.8, 162.0) IU/mL ( P < 0.05) and 0.77 (0.32, 1.26) g/L ( P < 0.05), respectively. Size of mass measured by CT/MRI imaging became smaller significantly and hydronephrosis relieved., Conclusion: Onset of RPF is insidious and lack of specific initial symptoms. Corticosteroid based therapy combined with surgical intervention of relieving obstruction is effective.

Retroperitoneal fibrosis is a rare cause of renal dysfunction, typically presenting with obstructive uropathy (sometimes with extra-renal manifestations). Given its insidious and subtle presentation, reaching the diagnosis can be challenging. We report the case of a 65-year-old female presenting with a 6-month history of unexplained constitutional symptoms, weight loss and mild renal impairment. Abdominal imaging revealed bilateral ureteric obstruction due to retroperitoneal fibrosis and so she underwent urgent ureteric stent insertion. Subsequent treatment with oral corticosteroids led to resolution of her symptoms and regression of the retroperitoneal mass., Competing Interests: No conflict of interests declared

Retroperitoneal fibrosis is an inflammatory process which may cause acute renal failure. In patients who admitted to emergency services with obstructive uropathy, retroperitoneal fibrosis should be considered in the differential diagnosis. We present our ten cases who admitted to emergency department with obstructive acute renal failure related to retroperitoneal fibrosis.

Objective: To determine the outcomes of open ureterolysis in a contemporary cohort of patients presenting with ureteric obstruction secondary to retroperitoneal fibrosis (RPF)., Patients and Methods: We conducted a prospective analysis of 50 patients undergoing open ureterolysis and omental wrap between January 2012 and January 2016 in a single centre, managed by a multi-disciplinary RPF team. Patients had a minimum follow-up of 1 year. Indications were: nephrostomy-dependent drainage (n = 5); stent failure as evidenced by persistent hydronephrosis (n = 20); severe stent symptoms (n = 22); and patient choice/pre-emptive (n = 3). Outcome measures were stent-free rate; change in renal function post-ureterolysis; operating variables (operating time, blood loss, complications, length of hospital stay); and need for further intervention., Results: Of the 50 patients, 48 (96%) were stent-free at 3 months and 47/50 (94%) were stent-free at 12 months. The median (interquartile range [IQR]) changes in glomerular filtration rate, according to these indication groups, at 1 year were: overall +6 (-4 to +22)% (P < 0.05); stent failure +25 (+5 to +27)% (P < 0.001); stent symptoms +0 (-17 to +6)% (P = 0.834); nephrostomy-dependent drainage -10 (-19 to -2)% (P = 0.731); and pre-emptive 0 (0 to +8)% (P = 0.5). A total of 11/50 patients (22%) underwent additional procedures: nephrectomy, n = 7; uretero-ureterostomy, n = 1; aneurysm repair, n = 1; 1 Boari flap, n = 1; and ureteric re-implant, n = 1. Serious complications (Clavien III or IV) occurred in 12% of patients. The median (IQR) blood loss was 390 (20-1,200) mL and the median (IQR) length of hospital stay was 8 (3-21) days., Conclusions: This study suggests that for patients with ureteric obstruction caused by RPF, contemporary ureterolysis performed by a high-volume specialist team can successfully render patients stent- or nephrostomy-free without compromising renal function. The results suggest that ureterolysis should be considered in all patients who present with ureteric obstruction caused by RPF that does not respond quickly to standard treatment., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To evaluate the long-term renal function outcome of management of retroperitoneal fibrosis (RPF)-induced ureteral obstruction., Methods: Thirty-six patients with idiopathic RPF-induced ureteral obstruction were classified according to the management type into two groups, group A; managed by indwelling JJ stent and group B managed by ureterolysis and omental wrapping (UOR). The primary outcome was to define the long-term outcome of management on RF. It was evaluated by changes in serum creatinine and estimated GFR (eGFR) using Modification of Diet in Renal Disease equation where 20% changes in eGFR is considered significant. The second outcome is to compare the outcomes between both groups., Results: After 27.5 (1-124) months, median (range) follow-up, median (range) serum creatinine increased significantly from 1.5 (0.8-8.1) to 1.6 (1-12.1) mg/dl (p value =0.04) and eGFR showed non-statistical significant reduction from 43 (5-110) to 41 (5-88) ml/min/1.73 m 2 (p value =0.3). Eight (22.2%), 12 (34.4%) and 16 (44.4%) patients showed stable, increased and decreased eGFR. Group A showed statistically significant increased serum creatinine and insignificant decreased eGFR (p value =0.04 and 0.09), while group B showed statistically insignificant changes in serum creatinine and eGFR (p value =0.5 and 0.9). In group B, nine (21.4%) renal units are still harboring JJ stents., Conclusion: For idiopathic RPF, UOR avoided indwelling ureteral stents in 78.6% of renal units with apparent better long-term renal function outcome.

Objective: The present report aimed to present a unique case of idiopathic retroperitoneal fibrosis (RPF) presenting features of unilateral ureteral and sigmoid colon obstruction. RPF is a rare disorder with unclear etiology., Case Report: A 43-year-old female had a 10-day history of lower right abdominal and lumbar pain. Gynecological examination, ultrasound, and computed tomography (CT) were all suggestive of right ovarian tumor. An enhanced CT showed right-sided hydronephrosis. The patient was diagnosed as having ovarian cancer. Ten days after hospitalization, a right intraureteral stent with a double-J catheter was inserted. Upon exploring the abdomen, unyielding RPF was encountered. A partial sigmoidectomy and colostomy were performed. Postoperative pathological results suggested idiopathic RPF. She received steroid treatments., Conclusion: RPF is a rare disease that can be misdiagnosed. Our understanding about its presentation has to be improved and it should be considered as a differential diagnosis for patients presenting with abdominal diseases.

Idiopathic Retroperitoneal fibrosis is a rare clinical condition recently identified as an autoimmune process related to Immunoglobulin G4 (IgG4) deposition. Herein we report a case of a 46 year old male presenting with 4 months history of backache, fever, flank pain and leg swelling for 2 weeks. Investigations revealed acute kidney injury diagnosed as a result of bilateral ureteric obstruction. This was later confirmed to be retroperitoneal fibrosis on CT scan and biopsy. Histopathology was consistent with IgG4 related disease. Treatment with immunosuppressive agents showed reduction in the fibrosis and normalization of the kidney functions. We discuss the IgG4 related retroperitoneal fibrosis in detail along with its varied presentations.

The purpose of the study was to present the symptoms, diagnostic methods, and treatment in retroperitoneal fibrosis (RPF). We present a case of a 53-year-old woman admitted to the hospital due to low back and abdominal pain complaints lasting a year. Ultrasonography revealed a myoma located along the right bank of the uterus. Six months after myoma enucleation, the patient underwent relaparotomy due to intensifying pain. The surgery revealed the presence of highly vascularized tissue; ureteral structure and topography of the right retroperitoneal were abolished, and anatomical borders were obliterated. Ureteral right catheter was placed, retroperitoneal adhesions were released and tissue fragments were collected from the retroperitoneal space for intraoperative histopathological examination. The result of histopathological examination indicated the presence of eosinophiia, adult fibroblasts proliferation, lymphocyte and plasmocyte infiltration, which confirmed the diagnosis of RPF. Corticosteroid therapy, which was applied during the postoperative period, minimized the pain.

Background/aim: Retroperitoneal fibrosis (RPF) repre sents a chronic pathological process characterized by fibro sis which entraps and compresses the ureters and the grea blood vessels in the retroperitoneal space. A specific form of RPF is idiopathic RPF, an uncommon collagen vasculaj disease of unclear etiology. The series of 15 patients whicl underwent open surgical repair due to idiopathic RPF is presented herein., Methods: From 1989 to 2012, 11 male and 4 female patients underwent surgery due to primar RPF. The ureters were entrapped unilaterally (7 patients), or bilaterally (8 patients). Major symptoms included low bacl pain due to hydronephrosis (9 patients), uremia (4 patients) and urinary tract infection (2 patients). The diagnosis was based on intravenous urography (IVU), retrograde uretero pyelography and computed tomography (CT)., Results: Surgical procedures included intraperitoneal ureteral dis placement (8 patients) and ureteral wrapping with omental flap (6 patients). One patient underwent bilateral uretera stenotic segments resection and oblique ureterography, followed by wrapping with omental flap. Pathological examination confirmed primary RPF in all patients. The meat operative time was 3.5 h (range 2.5-4.5 h). The average in trahospital stay was 21 days (range 16-26 days). The meat follow up was 32 months (6-46 months). During the follow up, 12 patients had improvement on IVU., Conclusion: Early recognition of signs and symptoms of RPF is of the utmost importance for the outcome. Surgical procedures including ureteral wrapping with omental flap, or intraperi toneal ureteral displacement, usually represent definitive treatment.

Introduction: Ureteral obstruction due to extrinsic compression is associated with significant morbidity and mortality. Management options for this condition include renal drainage with percutaneous nephrostomy (PCN) or internal ureteral stent placement. A significant portion of patients will have disease progression leading to internal stent obstruction which is almost uniformly managed with PCN. We evaluated a novel, wire-reinforced internal ureteral stent as an alternative to PCN in those patients who fail initial internal ureteral stent placement., Materials and Methods: A retrospective chart review was performed to identify patients with extrinsic ureteral obstruction that failed conventional plastic internal ureteral stent placement and ultimately underwent placement of wire-reinforced internal ureteral stents (Scaffold) at the University of Michigan Health System between 2006-2011. Outcomes assessed included time to Scaffold stent failure and failure free time with Scaffold stent in place., Results: A total of 8 patients were identified with extrinsic ureteral obstruction that failed initial conventional ureteral stenting and had a Scaffold stent placed. Scaffold stents ultimately failed in 3 out of 8 patients. Mean time to Scaffold stent failure was 197 days (range 20-536). In the remaining 5 patients, mean failure-free time with Scaffold stents in place was 277 days (range 18-774)., Conclusion: Scaffold stent placement is a viable alternative to PCN in those patients with extrinsic ureteral obstruction who fail conventional internal ureteral stent placement.

Aims and Background: Neuroendocrine tumors are uncommon clinical entities and only a few cases of the co-occurrence of neuroendocrine tumors and retroperitoneal fibrosis have been described in the literature., Methods and Study Design: We report the promising results achieved in a case of neuroendocrine tumor complicated by retroperitoneal fibrosis causing right ureteral obstruction treated with long-acting release octreotide and tamoxifen., Results and Conclusions: The treatment resulted in a complete response without toxicity.

Ileal ureter is a suitable treatment option for patients with long ureteral strictures. Minimally invasive techniques have been shown to be as safe as open technique and superior in terms of postoperative recovery. We report the first case of laparoscopic totally intracorporeal replacement of ureter using whole-mount ileum in a patient with right-sided long ureteral stricture. The operative time was 150 minutes, and there were no complications. We have demonstrated the safety and feasibility of laparoscopic intracorporeal ileal ureter with possible advantage of shorter operative time compared with the robotic-assisted technique reported recently.

Objective: To confirm the efficacy of using Seprafilm® (Genzyme Corp., Cambridge, MA, USA) for wrapping the ureter to treat the ureteric stenosis caused by retroperitoneal fibrosis (RPF)., Patients and Methods: Between August 2010 and September 2012, 11 ureters in eight patients with RPF (seven males and one female, mean age 65 years) were treated. The mean (range) length of the narrow segment of the ureter was 30 (10-90) mm. During surgery, after having been released from adhesive tissue, the stenotic segment of the ureter was wrapped with Seprafilm to isolate it from the surrounding tissue. A radiographic follow-up was performed every 6 months using computed tomography, i.v. pyelography and/or (99m) Tc-mercapto-acetylglycyl-glycyl-glycine ((99m) Tc-MAG3) renal scintigraphy., Results: For the unilateral operations, the mean estimated blood loss was 39 mL, and the mean operating time was 154 min. All ureters were isolated from the fibrotic tissue and wrapped with Seprafilm successfully without major complications. During the mean follow-up period of 17 months, no ureteric restenoses were observed in the affected sides, but new stenosis occurred in the contralateral side of the ureter in one patient., Conclusions: Although the follow-up period is still limited, we believe that the use of Seprafilm has the potential to become an effective option in the treatment of ureteric stenosis caused by RPF, when the omentum cannot be used. To establish the relative advantages of using Seprafilm over performing a standard omental wrap, further experimentation will be required to compare the two techniques., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: To investigate the efficacy and complications of urinary drainage procedures in patients with idiopathic retroperitoneal fibrosis complicated by ureteral obstruction., Methods: A retrospective study of 30 idiopathic retroperitoneal fibrosis patients involving 44 obstructed urinary units who underwent urinary drainage from January 2002 through April 2010 was carried out. Data of all diagnostic procedures, blood and urine cultures, and hospital admissions were collected and analyzed., Results: In 12 of 44 (27%) cases, percutaneous nephrostomy was carried out at the first step. Attempted ureteral stenting at the first step was successful in 25 of 32 (79%) cases, of which 20 (80%) cases could be managed successfully by ureteral stenting alone throughout the study period. Successful prolonged urinary drainage with percutaneous nephrostomy alone was accomplished in 10 cases, three at the first step and seven at the second step after failed intraureteral stent insertion or after unsuccessful maintenance of urinary drainage with an intraureteral stent. A total of 21 urinary tract infection episodes occurred in 11 patients. The incidence and accumulated incidence of acute pyelonephritis was 0.062 episodes/100 person-days and 30%, respectively. The incidence and accumulated incidence of urosepsis was 0.015 episodes/100 person-days and 6.6%, respectively. The overall number of complications did not differ between external and internal urinary drainage procedures (percutaneous nephrostomy, 21% vs intraureteral stent, 17.9%; P = 0.79)., Conclusion: Both intraureteral stent and percutaneous nephrostomy placement are a safe way to relieve urinary obstruction in idiopathic retroperitoneal fibrosis patients, and they have comparable complication rates. Over time, the need for using both management options in the same patient might be required. Hence, these techniques should be regarded as complementary., (© 2013 The Japanese Urological Association.)

Chronic periaortitis is an inflammatory and fibrosing disease presenting as periaortal fibrosis and formation of aortic aneurysms which are mostly localized in the retroperitoneum and occasionally in the mediastinum. Inflammatory vasculitic involvement of large vessels is also possible. In addition to symptoms of systemic inflammation, mechanical complications also occur whereby obstruction of the ureter is the most frequent. The diagnosis is made by contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) and if the findings are atypical the diagnosis should be confirmed by biopsy. After exclusion of a secondary genesis, in which case therapy of the underlying illness would be necessary, idiopathic chronic periaortitis can be treated with steroids. In cases of refractory and relapsing courses the administration of further immunosuppressive medication can be necessary. Duration of therapy, dosage and indications for immunosuppressive medication are currently unclear and have to be defined in further randomized controlled trials with larger cohorts. If complications occur, interventional or operative treatment can be necessary; in cases of hydronephrosis the placement of double-J-stents is usually sufficient.

Retroperitoneal fibrosis (RPF) is a rarely occurring disease process characterized by the development of fibrous plaques that encase retroperitoneal organs and major vessels. The most common sequelae is obstructive uropathy secondary to ureteral compression. Ureterolysis with intraperitoneal transposition and omental wrapping has historically been a popularized means to relieve ureteral obstruction. We present the case of a 47-year-old man with bilateral hydronephrosis secondary to RPF. Due to insufficient length of omentum, we report the first documented use of SurgiWrap to wrap the ureters to minimize the future possibility of recurrent/continued fibrosis, compression, and ureteral obstruction.

A 65-year-old man presenting with apparent acute coronary syndrome was found to have an acute kidney injury. A CT scan of the abdomen revealed bilateral hydronephrosis secondary to retroperitoneal fibrosis, and an unruptured infrarenal abdominal aortic aneurysm Medical management with corticosteroids relieved the ureteric obstruction and renal function started to normalise within 72 h.

Objectives: To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis., Methods: One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed., Results: One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50 mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200 mL in LU and 30 mL in RU., Conclusions: Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery.

Inflammatory aneurysms of thoracic aorta are rare. Of all the aneurysms, only 5-10% are inflammatory in nature and are almost exclusively confined to the infrarenal segment of the aorta. We hereby present a patient with a large inflammatory aneurysm involving the thoracic aorta in association with mediastinal fibrosis and idiopathic retroperitoneal fibrosis.

A 9-month-old cat was presented for routine vaccination before rehoming. Physical examination revealed a palpable mass in the cranial abdomen. The right kidney was severely enlarged (6cmx4cm) on plain abdominal radiographs, and failed to opacify normally during intravenous urography. Ultrasonography demonstrated a hydronephrotic right kidney. During exploratory coeliotomy, a retroperitoneal mass was identified, adherent to the caudal edge of the right kidney, enveloping the ureter and blocking urine outflow. The ureter caudal to the mass was of normal size. Right ureteronephrectomy was performed; the mass was subsequently freed from adhesions to the caudal vena cava and sublumbar muscles and excised. Histopathological examination revealed the mass to be composed of both normal and necrotic adipose tissue and fibrous tissue surrounding the ureter and a thrombosed, recanalised vessel. This appearance was consistent with an area of infarction and fibrosis with obstruction of the ureter. The cat was clinically well 3 months postoperatively.

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.

Background/aims: Retroperitoneal fibrosis (RPF) is a chronic inflammatory disorder causing obstructive nephropathy and renal failure. We reviewed our management of this condition., Method: All patients with RPF treated at a single center over a 15-year period were identified. A full review of notes and computer records was undertaken., Results: Data was available on 27 patients, 3 of which were excluded from later analysis. Diagnosis was based on clinical history and cross-sectional imaging. Retroperitoneal biopsy was undertaken in 3 patients. 96% had significant renal impairment at presentation with a mean serum creatinine of 688 micromol/l. 46% required emergency hemodialysis. All patients were treated with a combination of ureteric stents and/or steroids with an excellent clinical response. The mean best creatinine reached by the cohort was 136 micromol/l, and renal function remained stable in the long term. No patients required chronic dialysis. Ureteric stents were removed within 12 months and low-dose steroids were continued for a mean of 34 months. Recurrent disease was observed in 25% of patients, who all responded well to further steroid therapy. Mean duration of follow-up was 76 months., Conclusions: RPF is very effectively treated by a combination of ureteric stents and steroids, with excellent long-term results using this approach. Continued follow-up is advised because of the possibility of recurrent disease., (Copyright 2008 S. Karger AG, Basel.)

Retroperitoneal fibrosis (RPF) is a rare condition of unclear etiology. It can cause ureteral obstruction. We present the unique case of a 54 years old female, who initially presented with spontaneous perforation of the cecum. Upon exploring the abdomen, the classical glistening white, unyielding retroperitoneal fibrosis was encountered. A right hemicolectomy was performed. Subsequently, the patient presented with bilateral ureteral obstruction, and later on with small bowel obstruction. Ureteral obstruction was treated with stents, and small bowel obstruction was treated with bypass. To our knowledge no case of idiopathic RPF presenting with features of both bilateral ureteral and small bowel obstruction has been reported in the literature.

Background and Purpose: We describe our technique for laparoscopic ureterolysis for idiopathic retroperitoneal fibrosis. Various options for tissue interposition are discussed, including management of bilateral disease., Patients and Methods: Patients found to have retroperitoneal fibrosis were offered laparoscopic ureterolysis with the option of treatment with anti-inflammatory medications preoperatively. The obstructed renal collecting system was decompressed preopeatively with a nephrostomy tube or Double-J stent to stabilize renal function. A four-port transperitoneal approach was used. Patients with bilateral obstruction were offered bilateral ureterolysis in the same operative session., Results: Case 1 was a 57-year-old man with right-ureteral obstruction in a solitary kidney, the left kidney having been lost to retroperitoneal fibrosis. The patient had right laparoscopic ureterolysis with omental interposition. Case 2 was a 45-year-old man with left-flank pain and left-sided hydronephrosis. He underwent laparoscopic ureterolysis with an omental wrap through a mesenteric window. Case 3 was a 56-year-old woman with a retroperitoneal mass causing bilateral hydronephrosis. The patient had left laparoscopic ureterolysis with omental interposition through a mesenteric window. In the same sitting, the patient was repositioned for right laparoscopic ureterolysis with interposition of a peritoneal flap., Conclusions: The treatment of retroperitoneal fibrosis can be performed in a safe and effective manner through the laparoscopic approach. Interposition of omentum or peritoneum can be accomplished laparoscopically. Moreover, bilateral disease can be managed in a single session using this approach.

Objectives: To describe a novel technique and assess an initial series of hand-assisted laparoscopic ureterolysis for the treatment of retroperitoneal fibrosis., Methods: Five patients (3 women and 2 men, mean age 56.4 years) with ureteral obstruction secondary to retroperitoneal fibrosis underwent bilateral hand-assisted laparoscopic ureterolysis with biopsy. These patients had undergone an imaging evaluation with excretory urography, computed tomography, furosemide washout nucleotide scan, and/or magnetic resonance imaging. All had ureteral stents placed before or at surgery. A periumbilical hand port, bilateral 10-mm perirectal camera ports, and bilateral 5-mm or 10-mm working ports were placed. The ureters were completely mobilized and placed intraperitoneally. The patient demographic, operative, and early and late postoperative data were collected., Results: The average operating room time was 259 minutes (range 215 to 300), and the estimated blood loss was 80 mL (range 50 to 200). The mean hospital stay was 4.20 days (range 3 to 5). One minor intraoperative ureteral injury and no postoperative complications occurred. The mean analgesic requirement was 45.6 mg morphine sulfate (range 20 to 88). Three patients also received 120 mg of parenteral ketorolac. All indwelling ureteral stents were removed by 2 to 4 weeks postoperatively. At 22.4 months (range 12 to 29) postoperatively, 90% of the renal units were unobstructed., Conclusions: Hand-assisted laparoscopic ureterolysis is an effective minimally invasive technique with less morbidity than open ureterolysis. It offers a shorter operative time and is less technically challenging than conventional laparoscopy. It is our preferred surgical approach for obstructive retroperitoneal fibrosis.

Ureteral obstruction caused by extrinsic compression by a malignancy generally can be overcome initially with a ureteral stent. However, the long-term failure rate is high, usually necessitating placement of a nephrostomy tube. Herein, we present the initial case, in this country, of intractable ureteral obstruction managed successfully with the newly developed all-metal Resonance stent (Cook Ireland Ltd., Limerick, Ireland) constructed of MP35N alloy, a composite of nonmagnetic nickel-cobalt-chromium-molybdenum. The patient is a 64-year-old woman with metastatic breast cancer causing retroperitoneal fibrosis and ureteral obstruction diagnosed laparoscopically. The obstruction failed to respond to placement of a single 7F double-J stent and then of two 6F double-J stents in the left ureter. As a last resort, in order to avoid nephrostomy-tube placement, the 6F metal stent was placed; this provided unobstructed flow of urine, as documented on a subsequent Whitaker test and, most recently, on a renal scan, 4 months after initial stent placement.

Erdheim-Chester disease (ECD) is a rare, progressive, non-Langerhans cell histiocytosis that portends a poor prognosis. Misdiagnosis is common until adequate tissue analysis reveals the infiltrative histiocytic process. The disease process affects various organ systems, and effective treatment options are limited. Knowledge of the constellation of signs and symptoms associated with ECD is important to avoid misdiagnosis. We describe a patient who underwent laparoscopic bilateral ureterolysis and laparoscopic biopsy for presumed retroperitoneal fibrosis confirmed previously by percutaneous needle biopsy findings. The final pathologic diagnosis based on laparoscopic biopsy results was ECD. As evidenced by this case, ureterolysis offers little benefit to patients with ECD.

Ureteral obstruction due to idiopathic retroperitoneal fibrosis is a rare but severe clinical problem. The open approaches, as well as surgical techniques used to prevent stenosis recurrence, are described. Ureterolysis remains the procedure to relieve ureteral obstruction. The ureter is dissected and freed from the fibrotic process, and then separated to prevent the recurrence of the stenosis. Recently, the development of Laparoscopic urology has allowed for minimal invasive treatment of many urological problems. We present our technique of ureterolysis for extrinsic ureteral obstruction. Advantages and complications of each method are considered and indications are proposed.

We report a case of ureteral obstruction due to retroperitoneal fibrosis secondary to a solitary left internal iliac aneurysm. It has been reported that as a cause of ureteral obstruction, an internal iliac aneurysm without aortic and/or common iliac aneurysms is very rare. In the present case, magnetic resonance imaging was a useful modality to diagnose retroperitoneal fibrosis secondary to an internal iliac aneurysm as a direct cause of ureteral obstruction.

We report an unusual but catastrophic complication of 'haemo peritoneum' noted following an uneventual insertion of ureteric stent. Its management was primarily affected by the presence of a significant coexisting pathology. This case highlights two important points: (1) recognizing the most rare but real possibility of major intra peritoneal haemorrhage following simple stenting of the ureter (2) the importance of checking that the guide wire has been correctly preloaded in the spool before its placement up the ureter as inserting the wrong (nonfloppy) end may have serious implications.

Retroperitoneal fibrosis has been described as a rare occurrence during the course of inflammatory bowel disease, mainly Crohn's disease. This is the third report on retroperitoneal fibrosis occurring during the course of ulcerative colitis. A 62-year-old male patient with a 5-year history of ulcerative colitis developed stenosis of the left ureter due to retroperitoneal fibrosis. Treatment consisted in surgically releasing the ureter from the mass and steroids. During a 2.5-year follow-up, renal function was stable and ulcerative colitis in remission. Important aspects of this case are the moderate course of ulcerative colitis, ultrasound confirmation of normal kidney structure before manifestation of fibrosis, hypertension diagnosed four years before retroperitoneal fibrosis, a non-functioning kidney at diagnosis, and reduction of retroperitoneal mass after steroid treatment. Retroperitoneal fibrosis, although a rare disease entity should be considered when a patient with ulcerative colitis develops otherwise unexplained renal insufficiency.

Inflammatory abdominal aortic aneurysms are known to be associated with retroperitoneal fibrosis and ureteral complications. We report a case of an inflammatory aneurysm that produced bilateral ureteral envelopment and obstructive renal failure. Incidence, pathogenesis and clinical onset of this kind of aneurysms and management of the ureteral complications are reviewed.

Objectives: We present the results of treatment by laparoscopy of two patients with retroperitoneal fibrosis and review the literature since 1992, when the first case of this disease that was treated using laparoscopy was published. We also discuss the contemporary alternatives of clinical treatment with corticosteroids and tamoxifen., Case Report: Two female patients, one with idiopathic retroperitoneal fibrosis, and other with retroperitoneal fibrosis associated with Riedel's thyroiditis, were treated using laparoscopic surgery. Both cases had bilateral pelvic ureteral obstruction and were treated using the same technique: transperitoneal laparoscopy, medial mobilization of both colons, liberation of both ureters from the fibrosis, and intraperitonealisation of the ureters. Double-J catheters were inserted before the operations and removed 3 weeks after the procedures. The first patient underwent intraperitonealisation of both ureters in a single procedure. The other had 2 different surgical procedures because of technical difficulties during the first operation. Both patients were followed for more than 1 year and recovered completely from the renal insufficiency. One of them still has occasional vague lumbar pain. There were no abnormalities in the intravenous pyelography in either case., Conclusions: Surgical correction of retroperitoneal fibrosis, when indicated, should be attempted using laparoscopy. If possible, bilateral ureterolysis and intraperitonealisation of both ureters should be performed in the same operation.

The chief complications of retroperitoneal fibrosis RPF in the ureteric compression ab extrinseco by fibrotic tissue. In the period 1994 to 1999, we treated two cases of idiopathic RPF: the first case a 49 years aged man, presented a left hydronefrosis and bilateral ureteral displacement to the midline. RMN showed widespreads fibrotic tissue in the retroperitoneal space. At operation, the histological findings was that of aspecific fibrositis. The surgical procedure was ureterolysis and lateralization of both ureters with the aid of a wrapping with a pedicled omental graft. The patient was also treated with metilprednisolon, 8 mg-die, for altogether twelve months, Now he is asymptomatic. The second case, a man aged 60, had a compression of both ureter by fibrotic tissue down to the pelvic tract; the histologic picture was the same of that of the first case. A difficult ureterolysis was carried on, plus an omentoplasty and a left ureteral reimplantation to the bladder. Medical treatment followed, following the above scheme. Seven months after surgery the patient is well. This experience of ours urological complications of RPF is confirmatory of the importance of a sound surgical approach and of a tight follow up as well as a sustained corticosteroid therapy in order to prevent relapse.

We have evaluated 21 patients, ranging in age from 44 to 71 years (mean: 55 years), who presented to our department with the radiologic characteristics of retroperitoneal fibrosis. Ureterolysis was performed in all cases. Intraperitoneal placement of the ureter was performed in 9, and placement of the ureter in a lateral extraperitoneal position in 12 cases. We found no difference in the postoperative course and radiological and clinical improvement to favour the first or the second method, and therefore we consider the intraperitoneal approach as an unnecessary manoeuvre.

We report the incidental finding at surgery for retroperitoneal fibrosis of a carcinoid tumour causing complete right ureteric obstruction. Retroperitoneal fibrosis is an uncommon inflammatory disease that leads to extensive fibrosis throughout the retroperitoneum. It can occur at any age, peak incidence being in patients between 40 and 60 years of age. Carcinoid tumours arise from enterochromaffin or amine precursor uptake and decarboxylation cells that occur in gastrointestinal tract. Carcinoid tumours are an uncommon clinical entity and incidence varies with gender and age. No association between retroperitoneal fibrosis and carcinoid tumour has been previously reported in the English literature, although one case has been reported in a French journal.

In five patients with chronic intractable ureteral obstruction, a fine-bore nephrostomy tube was placed in a subcutaneous tunnel to drain the kidney without an external appliance. Good quality of life was achieved for 6 months to 2 years. When conventional intraluminal stents cannot be used, consideration should be given to subcutaneous diversion rather than long-term nephrostomy tubes.

Retroperitoneal fibrosis is a rare disease, typically with an insidious clinical course. It is thought that this disease process is perhaps an exaggerated reaction to an inciting inflammatory event. In this study, a case of retroperitoneal fibrosis is reported, in which the patient presented with typical symptoms of retroperitoneal fibrosis, along with some atypical vasculitic symptomatology. Retroperitoneal fibrosis is a disease process with an unknown etiology, which has been observed to be associated with a number of different possible inciting factors. Two factors that have been documented in the literature as being associated with retroperitoneal fibrosis include the use of beta-blocking agents, and connective tissue disease processes such as systemic lupus erythematosus. The patient discussed was using beta-blocker medication and also had signs and symptoms suggestive of a lupus syndrome. There are no reported cases of the combined association of beta-blocker usage, lupus, and retroperitoneal fibrosis.