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Background: To compare various lower pole pelvicalyceal anatomical factors of stone bearing kidney with contralateral normal kidneys and determine whether these factors predispose to stone formation in one kidney., Methods: A descriptive study was done with Computed Tomography of 54 patients with solitary lower pole calculus in one kidney and normal contralateral kidney were included. Various lower pole pelvicalyceal anatomical factors like infundibulopelvic angle, infundibular width, infundibular length and calyceopelvic height of both stone bearing and contralateral kidneys were measured and compared for any differences Results: The mean infundibular width was 5.4±1.9mm on stone bearing kidneys and 5.2±2.05mm on contralateral normal kidneys. The mean infundibular length was 18.9±4.4mm on stone bearing kidneys and 18.8±3.9mm on contralateral normal kidneys. The mean infundibulopelvic angle was 47.9±10.8° on stone bearing kidneys and 47.6±11.2° on contralateral kidneys. The mean calyceopelvic height was 15.7±4.6mm on stone bearing kidneys and 15.5±3.9mm (range 7.5to 23.1mm) on contralateral kidneys. There were no statistically significant differences between stone bearing and contralateral normal kidneys in respect to these pelvicalyceal anatomical factors., Conclusions: In this study, we found no significant difference in lower pole pelvicalyceal anatomical factors between stone bearing kidneys and contralateral normal kidneys and therefore these factors do not seem to have significant role in stone formation in one kidney compared with the other.

Calyceal diverticula (CD) are relatively uncommon urologic conditions that generally follow an asymptomatic course and rarely require medical intervention. CD are thought to have a congenital origin due to abnormalities during the process of ureteral bud formation. Clinically and radiologically, they can mimic multiple neoplastic and non-neoplastic renal processes, with potentially relevant differences in the management of these patients. Symptoms are usually associated with the presence of stones, obstruction to the drainage of the diverticulum, large size, or secondary infection. In chronic cases, surgery might become necessary, creating an opportunity to examine the histopathological characteristics of this condition. Although these are benign in the majority of patients, some rare instances of malignancy arising from the CD have been reported. In this series, we addressed the clinical, radiological, and histopathological findings of CD., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Renal calyx diverticulum refers to a cystic lesion covered with the transitional epithelium in the renal parenchyma. Although there is no clear evidence that calyx diverticulum can cause hypertension, there exists a close association between the two, and there are few related reports. Herein, we reported the case of a child with renal calyx diverticulum complicated with hypertension and summarized the diagnosis and treatment., Case Presentation: Physical examination of the patient, an 11-year-old child, revealed a left renal cyst with hypertension (155/116 mmHg). There were no related symptoms. Routine urine and blood biochemical examinations showed no abnormalities. Imaging revealed left renal cyst compression causing the hypertension. She underwent renal cyst fluid aspiration and injection of a sclerosing agent into the capsule, but her blood pressure increased again 3 days postoperatively. Color Doppler ultrasonography showed that the size of the left renal cyst was the same as that preoperatively. To further confirm the diagnosis, cystoscopic retrograde ureteropyelography was performed to confirm the diagnosis of renal calyx diverticulum. Subsequently, renal calyceal diverticulum resection and calyx neck enlargement were performed. The operation went smoothly and the blood pressure returned to normal postoperatively. No abnormalities were noted at the 7-month postoperative follow-up., Conclusion: There exists an association between renal calyx diverticulum and hypertension. Therefore, hypertension can be considered a surgical indication for renal calyx diverticulum. Moreover, renal calyceal diverticulum in children can be easily misdiagnosed as a renal cyst. Therefore, it is important to be vigilant to prevent a series of complications, such as postoperative urine leakage, in such cases., (© 2021. The Author(s).)

This study was conducted to evaluate preoperative risk factors for development of complications of percutaneous nephrolithotomy (PCNL). All consecutive patients aged ≥ 16 years who underwent PCNL during 2015 were retrospectively reviewed. Non-contrast CT (NCCT) was performed for all patients to evaluate stone complexity. The technique of PCNL was the same for all patients. Intra-operative and postoperative complications were recorded and classified based on modified Clavien system. The differences in preoperative data (patients, renal and stone characteristics including Guy's and STONE scores) between complicated and uncomplicated cases were compared using univariate and multivariate statistical analyses for detection of independent risk factors. The study included 1178 patients (61% were males). Mean age was 50 ± 12 years, and mean BMI was 30.7 ± 5.7 kg/m 2 . Complicated group included 166 patients (14.1%). Independent risk factors on multivariate analysis were infected preoperative urine culture (RR: 2.098, P 0.001, 95%CI: 1.380-3.189), largest stones diameter 30 mm or more (RR: 2.481, P > 0.001, 95%CI: 1.697-3.627) and number of calyces affected by the stones (RR: 2.431, P 0.002, 95%CI: 1.400-4.222 for affection of two calyces and RR: 2.778, P 0.005, 95%CI: 1.357-5.684 for affection of three calyces). While two scoring systems (Guy's and STONE) were not predictive of complications after PCNL, preoperative risk factors were infected preoperative urine culture, distribution of the stones or stone branches in two or three calyceal groups and stone size 30 mm or more.

Objective: To investigate the impact of a mobile application (app) displaying a visualization of the internal anatomy of the pelvicalyceal systemPCS and of kidney stones on patient understanding of their affected kidney anatomy and their upcoming percutaneous nephrolithotripsy (PCNL)., Materials and Methods: One-hundred patients who required PCNL were included in this study, and all patients were nonrandomly distributed into 2 groups: counseled using only 3D-reconstructed computed tomography (CT) images (group 1) or using only the "InsKid" app (group 2). Patient data were obtained from CT scans as Digital Imaging and Communications in Medicine format and converted into stereolithography (STL) format. All patients completed the questionnaire after counseling, and the results were compared between groups., Results: Patients from group 2 better understood the anatomy of their affected kidney by 53%; awareness regarding their stone location was better by 32%; the steps of planned surgery, as well as possible complications, were more transparent for patients using the app by 24% and 56%, respectively. The number of patients who were dissatisfied with the mobile counseling dropped by 70%. The average duration of consultation with the 3D reconstruction of CT images was 10.9 ± 0.6 min, while counseling using our program reliably led to a reduction in this duration (7.3 ± 0.5 min)., Conclusion: The InsKid app is a freely available, easy-to-use educational software that improves patient counseling without considerable financial expense or long waiting periods for use., (Copyright © 2020 Elsevier Inc. All rights reserved.)

To examine different locations and laser settings' effects on the efficiency of the "popcorn" method of laser lithotripsy, which consists of placing the laser in a group of small stones and firing continuously to break them into smaller particles. Pre-fragmented BegoStones were created between 2 and 4 mm to mimic typical popcorning conditions. A 0.5 g collection of fragments was placed into 3D-printed models (a spherical calyx and ellipsoid pelvis model) and a 200-µm laser fiber was positioned above the stones. The laser was fired for 2 min with irrigation, with 5 trials at each setting: 0.2 J/50 Hz, 0.5 J/20 Hz, 0.5 J/40 Hz, 1 J/20 Hz, 0.2 J/80 Hz, 0.5 J/80 Hz. After drying, fragmentation efficiency was determined by calculating the mass of stones reduced to sub-2 mm particles. Statistical analysis was performed with ANOVA and Student's t test. The trials within the calyx model were significantly more efficient compared to the pelvis (0.19 vs 0.15 g, p = 0.01). When comparing laser settings, there was a difference between groups by one-way ANOVA [F(5,54) = 8.503, p = 5.47 × 10 -6 ]. Post hoc tests showed a power setting of 0.5 J/80 Hz was significantly more efficient than low-power settings 0.2 J/50 Hz and 0.5 J/20 Hz (p < 0.05). Additionally, 0.2 J/50 Hz was significantly less efficient than 0.5 J/40 Hz, 1 J/20 Hz, and 0.2 J/80 Hz. Popcorning is most efficient in smaller spaces; we recommend displacement of stones into a calyx before popcorning. No difference was seen between high-power settings, although 0.5 J/40 Hz and 0.5 J/80 Hz performed best, suggesting that moderate energy popcorning methods with at least 0.5 J per pulse are most efficient.

The objectives of the study are to compare the safety and efficacy of "all-seeing needle" optical puncture system micro-percutaneous nephrolithotomy (micro-PCNL) and flexible ureterorenoscopy (FURS) for the treatment of lower calyceal stones of ≤ 2 cm and to determine the advantages and disadvantages of each. 116 patients in total with lower calyceal stones of ≤ 2 cm were randomly divided into two equal groups, "all-seeing needle" optical puncture system micro-PCNL and FURS. In both groups, holmium laser was utilized for lithotripsy. The perioperative parameters were compared between the two groups. Compared to the "all-seeing needle" micro-PCNL group, the mean operative time was significantly longer in the FURS group (P = 0.000). However, there was no significant difference between the two groups with respect to mean hemoglobin reduction (P = 0.087), complications (P = 0.731) and LOS (P = 0.856). The overall SFR of the "all-seeing needle" micro-PCNL group and FURS group was 84.5% (49/58) and 79.3% (46/58), respectively, without any significant difference between the groups (P = 0.469). For treating lower calyceal stones of ≤ 2 cm, the "all-seeing needle" micro-PCNL group had shorter operative time than FURS, while no significant differences between the two groups with respect to mean hemoglobin reduction, complications, LOS and SFR were found.

Background: Calyceal diverticula outpouchings that occur rarely in the upper collecting system of the kidney and is often difficult to detect. In this study, we present two cases of calyceal diverticula and discuss their clinical characteristics and radiologic features., Patients and Methods: In the presented two cases, we applied several imaging examinations, including delayed intravenous pyelography, retrograde pyelography and axial computerized tomographic (CT) scanning of the kidneys with and without contrast. Serum creatinine levels in fluid withdrawn from the diverticula were found to be significantly higher than the simultaneous serum creatinine levels. Intravenous injection of methylene blue through a ureteral catheter was also aided in the diagnosis. Calyceal diverticulum neck dilatation was performed through a percutaneous nephroscope.ResultsThe two cases were diagnosed preoperatively and the operation was successful performed. The nephrostomy tube was removed seven days after surgery without complications. CT scans of the kidney after six months showed that the size of the calyceal diverticulum of two patients were considerably smaller than pre-surgery. There were no reports of pain in the lumbar region or other discomfort., Comments: Diagnosis of calyceal diverticulum mainly depend on a variety of imaging examinations, including the delayed intravenous pyelography, retrograde pyelography, and kidney CT plain scan plus enhanced scan. If the patient cannot be diagnosed by above methods, cyst fluid can be aspirated percutaneously to measure the preoperative creatinine level. If it is significantly higher than the serum creatinine level, the cyst fluid is considered urine, which can assist in the diagnosis of calyceal diverticulum. A ureteral catheter should also be inserted before operation namely, intravenous injection of methylene blue through a ureteral catheter is helpful for diagnosis. The choice of surgical treatment is based on the size and location of calyceal diverticulum and clinical manifestations.

Objective: To present our novel surgical technique, ileocalicostomy ureteral substitution, for the management of long upper ureteral strictures in patients without a dilated extra-renal pelvis., Materials and Methods: Two patients were identified with long, complex proximal ureteral strictures who were treated with our novel surgical technique by a single surgeon at a single institution. Perioperative data for these two patients are presented along with a detailed description of the surgical technique., Results: Ileocalicostomy ureteral substitution was successfully performed in two cases. The total operative time for these cases was 436 minutes and 246 minutes, with estimated blood loss of 300 mL and 200 mL. Length of stay for the two patients was 8 days and 6 days, respectively. There were no major (Clavien-Dindo Classification ≥ grade 3) complications. Both patients are entirely free of urinary tubes with unobstructed kidneys since reconstruction., Conclusion: Ileocalicostomy ureteral substitution is a feasible reconstructive option for select patients. To our knowledge this report is the initial experience in the literature presented., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones., Materials and Methods: We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test., Results: Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m 2 , p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement., Conclusions: Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: In the first-in-human trial of ultrasonic propulsion, subjects passed collections of residual stone fragments repositioned with a C5-2 probe. Here, effectiveness and safety in moving multiple fragments are compared between the C5-2 and a custom (SC-50) probe that produces a longer focal beam and burst duration., Materials and Methods: Effectiveness was quantified by the number of stones expelled from a calyx phantom consisting of a 30-mm deep, water-filled well in a block of tissue mimicking material. Each probe was positioned below the phantom to move stones against gravity. Single propulsion bursts of 50 ms or 3 s duration were applied to three separate targets: 10 fragments of 2 different sizes (1-2 and 2-3 mm) and a single 4 × 7 mm human stone. Safety studies consisted of porcine kidneys exposed to an extreme dose of 10-minute burst duration, including a 7-day survival study and acute studies with surgically implanted stones., Results: Although successful in the clinical trial, the shorter focal beam and maximum 50 ms burst duration of the C5-2 probe moved stones, but did not expel any stones from the phantom's 30-mm deep calyx. The results were similar with the SC-50 probe under the same 50 ms burst duration. Longer (3 s) bursts available with the SC-50 probe expelled all stones at both 4.5 and 9.5 cm "skin-to-stone" depths with lower probe heating compared to the C5-2. No abnormal behavior, urine chemistry, serum chemistry, or histological findings were observed within the kidney or surrounding tissues for the 10 min burst duration used in the animal studies., Conclusions: A longer focal beam and burst duration improved expulsion of a stone and multiple stone fragments from a phantom over a broad range of clinically relevant penetration depths and did not cause kidney injury in animal studies.

Introduction: Traditional techniques for obtaining percutaneous renal access utilize continuous fluoroscopy. In an attempt to minimize radiation exposure, we describe a novel laser direct alignment radiation reduction technique (DARRT) for percutaneous access and test it in a bench-top model., Methods: In this randomized-controlled bench-top study, 20 medical personnel obtained renal accesses using both the conventional bullseye technique and the laser DARRT. The primary endpoint was total fluoroscopy time. Secondary endpoints included insertion time, puncture attempts, course corrections, and subjective procedural difficulty. In the laser DARRT, fluoroscopy was used with the C-arm positioned with the laser beam at a 30° angle. The access needle and hub were aligned with the laser beam. Effective caliceal puncture was confirmed with fluoroscopy and direct vision. The Paired samples Wilcoxon signed rank test was used for statistical analysis with significance at p < 0.05., Results: A total of 120 needle placements were recorded. Fluoroscopy time for needle access using the laser DARRT was significantly lower than the bullseye technique in all groups as follows: attendings (7.09 vs 18.51 seconds; p < 0.001), residents (6.55 vs 13.93 seconds; p = 0.001), and medical students (6.69 vs 20.22 seconds; p < 0.001). Students rated the laser DARRT easier to use (2.56 vs 4.89; p < 0.001). No difference was seen in total access time, puncture attempts, or course corrections between techniques., Conclusion: The laser DARRT reduced fluoroscopy time by 63%, compared with the conventional bullseye technique. The least experienced users found the laser DARRT significantly easier to learn. This novel technique is promising and merits additional testing in animal and human models.

Results of treatment of 276 patients, suffering the lower renalis calyx (LRC) calculi, hav' ing size (1.14 ± 0.35) сm, were analyzed. Depending on acuteness of іnfundibulo— pelvic angle (ІPA) the examined persons were divided on groups with blunt (n=118) and acute (n=158) IPA; 8 аnatomic parameters of the LRC were in total determined. There was established, that еxtracorporal shock—wave lithotripsy, in accordance to the cal' culated index of a LRC calculis elimination, is expedient to apply in a bigger ІPA, lesser іnfundibulo—lumbar angle, lesser length of the LRC neck; transcutaneous nephrolithotripsy is effective not depending from a calculi dimensions, length of the LRC neck, value of ІPA and infundibulo—lumbar angle.

Purpose: To evaluate LithoVue, the new single-use digital flexible ureteroscope, in a human cadaveric model and compare it with a nondisposable fiber optic and digital flexible ureteroscopes., Materials and Methods: LithoVue, a conventional fiber optic, and digital flexible ureteroscopes were each tested in four renal units of recently deceased female cadavers by three surgeons. The following parameters were analyzed: accessibility to the kidney and navigation of the entire collecting system with and without ureteral access sheath (UAS), lower pole access measuring the deflection of the ureteroscope with the working channel empty, and with inside two different baskets and laser fibers. A subjective evaluation of maneuverability and visibility was assessed by each surgeon at the end of every procedure., Results: Kidney access into the Renal unit 1 was not possible without UAS for all ureteroscopes because of noncompliant ureter at the level of sacroiliac joint. The reusable digital ureteroscope was unable to reach one calix of the lower pole and one calix of the upper pole (Renal units 2 and 3) without UAS placement. Lower pole access with baskets and laser fibers was possible for each ureteroscope after UAS placement. No statistically significant differences were detected in angle deflection between ureteroscopes. The digital ureteroscope was preferred for visibility in all procedures: LithoVue for maneuverability in six procedures, fiber optic in five procedures, and the digital ureteroscope in one procedure., Conclusions: LithoVue seems to be comparable with conventional ureteroscopes in terms of visibility and manipulation into the collecting system in fresh human cadavers. Further studies in humans are needed to determine the clinical value of this new instrument.

Introduction: This study assesses the differences in the presentations, complications and metabolic abnormalities of children with renal calyceal microlithiasis (RCM) and overt urolithiasis in different pediatric ages., Materials and Methods: A total of 465 children with urolithiasis were investigated retrospectively. Patients were categorized based on their ages to infancy, early childhood, middle childhood and adolescence. When the hyperechogenic spots on ultrasound imaging were <3 mm, they were considered RCM, and if they were ≥3 mm, they were considered overt urolithiasis., Results: Metabolic abnormalities were detected in 71%; hyperuricosuria in infants, hyperoxaluria in younger children and hypocitraturia in older children were the most common metabolic abnormalities. Hypercalciuria was the only metabolic abnormality that was significantly associated with overt urolithiasis in all pediatric ages (OR 2.25, 95% CI 1.21-4.19). The clinical presentations were not significantly different between RCM and overt urolithiasis; however, complications such as urinary tract infection was significantly higher with overt urolithiasis in infancy (p = 0.01), early childhood (p = 0.02), middle childhood (p = 0.007) and adolescence (p = 0.01). Also, growth retardation was significantly higher with overt urolithiasis in infancy and early childhood (p = 0.02)., Conclusions: Most children with urolithiasis have underlying urinary metabolic abnormalities that differ according to the child's age. Despite these differences, hypercalciuria is significantly associated with overt urolithiasis in all pediatric ages. Clinical and laboratory features cannot differentiate RCM and overt urolithiasis; however, complications are significantly higher with overt urolithiasis., (© 2015 S. Karger AG, Basel.)

Introduction: This paper attempts to verify the anatomical veracity of the belief that in order to enter into a posterior calyx one must aim for the medial calyx during a percutaneous nephrolithotomy (PCNL)., Methods: Volume rendered and maximum intensity projection reconstructions of normal pelvicalyceal systems were assessed in various rotational planes. An experienced urologist decided the appropriate access for PCNL in the upper, interpole and lower calyx on each side. The selected calyx was then viewed on anteroposterior sections to decide whether they were projecting laterally or medially., Results: Of the 508 calyces studied, the posterior calyx was projecting laterally in 72% and medially in 28%. In the upper calyx, the posterior calyx was projecting laterally in a majority of cases, 94% on the right and 89% on the left. In the right lower calyx, the posterior calyx was pointing laterally in 86%, whereas the distribution on the left was 64%., Conclusion: Our results refute the belief that the medial calyx is always synonymous with the lateral calyx., (© 2016 S. Karger AG, Basel.)

Background and Objectives: Standard clinical assessments do not predict surgical intervention in patients with a moderate degree of upper tract hydronephrosis. This study investigated whether combined measures of renal calyceal dilation and anteroposterior diameter (APD) of the renal pelvis at the first postnatal ultrasound better predict surgical intervention beyond standard assessments of the APD or Society of Fetal Urology (SFU) grading system., Design, Setting, Participants, & Measurements: A retrospective cohort of 348 children with antenatal hydronephrosis followed from 2003 to 2013 were studied. Using Cox regression, the risk for surgery by APD, SFU, and combined grading on the basis of the first postnatal ultrasound was calculated. The predictive capability of each grading system for surgery was determined by calculating the positive likelihood ratio (LR+)., Results: The combination of APD≥6-9 mm and diffuse caliectasis had a hazard ratio (HR) of 19.5 (95% confidence interval [95% CI], 3.94 to 96.9) versus 0.59 (95% CI, 0.05 to 6.53) for APD≥6-9 mm alone and a similar risk of 8.9 for SFU grade 3 (95% CI, 3.84 to 20.9). The combination of APD≥9-15 mm and diffuse caliectasis had an HR of 18.7 (95% CI, 4.36 to 80.4) versus 1.75 (95% CI, 0.29 to 10.5) for APD≥9-15 mm alone. The LR+ for surgery for diffuse caliectasis and APD≥6-9 mm was higher than for APD≥6-9 mm alone (HR=2.62; 95% CI, 0.87 to 7.94 versus HR=0.04; 95% CI, 0.01 to 0.32) and was higher for APD≥9-15 mm and diffuse caliectasis than APD≥9-15 mm alone (HR=2.0; 95% CI, 1.15 to 3.45 versus HR=0.14; 95% CI, 0.04 to 0.43). Both combined groups of moderate hydronephrosis (APD≥6-9 mm or ≥9-15 mm with diffuse caliectasis) had only slightly higher LR+ than SFU grade 3 (HR=1.89; 95% CI, 1.17 to 3.05)., Conclusions: These results suggest a grading system combining APD and diffuse caliectasis distinguishes those children with moderate degrees of upper tract hydronephrosis that are at higher risk of surgery., (Copyright © 2015 by the American Society of Nephrology.)

Background: In 2010, Health Canada, the equivalent to the FDA, reported that the risk of uterine perforation caused by levonorgestrel intrauterine device (IUD) is very serious, warning that its use had increased the number of uterine perforation., Clinical Case: A 33 years old patient in who was placed three years before a levonorgestrel IUD; She presented evolution of 10 days with pain in hypogastric and both flanks and chronic constipation of two years; in exploration: moderate abdominal distention, IUD strings were not visible in uterine cervix. With translocated IUD diagnosis, a tomography was performed, finding IUD in abdominal cavity and ureter pyelocalyceal bilateral ectasia; preoperative plasma concentration of levonorgestrel 5.1 nmol/L, leukocytosis of 11,000 cells/mm3, and 20-30 erythrocytes in urine exam. Laparoscopic resection of omentum attached to IUD translocated was performed. One month after surgery plasma levonorgestrel in 0.3 nmol/L, normal urinalysis and hematic cytometry and resolution of the urinary tract ectasia., Conclusions: devices translocated with levonorgestrel, must be removed because the inflammatory reaction caused and the perforation of hollow viscera likelihood, with possibility to produce digestive tract and urinary tract ectasia by its pharmacologic action on smooth muscle.

Purpose: We aimed to evaluate iatrogenic renal arterial lesions, including pseudoaneurysm, arteriovenous fistula, and arteriocaliceal fistula, their management by endovascular embolization, and the clinical results., Methods: Fifty-five patients (forty males, fifteen females) with a median age of 40 years (range, 8-85 years), who underwent endovascular embolization of iatrogenic renal arterial lesions between March 2003 and December 2013 were included in this retrospective study. Types of iatrogenic lesions and details of embolization procedures were reported. Estimated glomerular filtration rate (eGFR), renal function tests, hemoglobin, and hematocrit levels before and after embolization were recorded and compared., Results: Median follow-up was 24 months. We identified 53 pseudoaneurysms, 30 arteriovenous fistulas, and 11 arteriocaliceal fistulas in 55 patients, after percutaneous nephrolithotomy (n=26), renal biopsy (n=21), nephrostomy (n=3), renal surgery (n=3), and extracorporeal shock wave lithotripsy (n=2). Median number of pseudoaneurysms was 1 (range, 1-4) with a median size of 7 mm (range, 1.5-35 mm). Fifty-one patients underwent coil embolization. Median number of coils was 5 (range, 2-21) and median renal parenchymal loss was 5% (range, 1%-50%). There were no significant differences between pre- and postoperative eGFR and serum parameters., Conclusion: Iatrogenic renal arterial lesion can be a life threatening condition. Superselective coil embolization is a safe, minimally invasive treatment option with minimal renal parenchymal loss and without significant change in renal function.

Purpose: To determine the renal arterial hemodynamic changes induced by obstructive uropathy using Doppler ultrasonography., Materials and Methods: 60 adult subjects with suspected obstructive uropathy and 60 asymptomatic apparently healthy controls with normal renal ultrasound features were evaluated. B-mode sonography of the kidneys and spectral Doppler examination of the renal interlobar arteries of all the participants were performed. The mean resistive indices (mRI) of both interlobar arteries were obtained and compared to that of the controls. The mRI of bilaterally obstructed kidneys were also compared with the mRI of unilaterally obstructed kidneys., Results: The mRI of the right and left kidneys of subjects were 0.72±0.04 and 0.69±0.06 while those of the controls were 0.64±0.04 and 0.63±0.03 respectively. The mRI for the grades of caliectasis increased from grade I (0.72±0.03) to grade II (0.73±0.03) and grade III (0.73±0.02) but fell within the most severe levels of obstruction (0.69±0.07). There was no statistically significant relationship between the grades of caliectasis and unilateral or bilateral obstruction for both kidneys. The results show a sensitivity and specificity of 86.7% and 90% respectively when mRI≥0.7 was used to determine presence of obstruction., Conclusion: Renal duplex sonography is highly sensitive and specific for diagnosis of obstructive uropathy. Increased resistive index of the obstructed kidney may be a useful diagnostic tool in situations where intravenous urography cannot be done or is contraindicated.

Candiduria may be a marker of serious fungal infections such as pyelonephritis. With the exception of fluconazole and flucytosine, antifungals drugs are not excreted into the urine as active drugs, making the management of infection due to fluconazole-resistant Candida difficult. We report a case of recurrent Candida parapsilosis candiduria in a kidney transplant recipient suffering from chronic ureteral obstruction requiring permanent ureteral catheterization (double-J stent). Attempts to remove the stent led to pyelonephritis episodes during which only Candida was isolated from the urine. Following several courses of azole-based therapy, the causative agent became resistant to fluconazole. Clinical and mycological cure were obtained combining irrigations of caspofungin through a percutaneous calicostomy catheter and oral flucytosine. This strategy may represent an interesting therapeutic alternative in case of fluconazole-resistant symptomatic candiduria., (Copyright © 2015. Published by Elsevier Masson SAS.)

Purpose: To evaluate the effect of stone localization on the success and complication rates of the percutaneous nephrolithotomy (PNL) procedure., Materials and Methods: Five hundred seventy-eight PNL procedures that were performed in our clinic were retrospectively evaluated. The patients were divided into seven groups according to the localization of the renal stones as: group 1, patients having stones only in the upper calyx; group 2, patients having stones only in the pelvis; group 3, patients having stones only in the lower calyx; group 4, patients having partial staghorn stones; group 5, patients having multiple calyx stones; group 6, patients having stones in both the pelvis and lower calyx and group 7, patients having complete staghorn stones. The first three groups were defined as simple stones, and the other four groups were defined as complex stones., Results: The mean stone clearance rate was 77% in simple stones and 53% in complex stones (P = .005). The complication rate was significantly higher only in the group with complex staghorn stones at a rate of 19.5% (P = .006). The difference between preoperative and postoperative hematocrit concentrations was the least in the group that had stones in the pelvis and this value was statistically significantly lower than the patients with complex staghorn stones (P = .027). The mean duration of the operation and the number of ports was higher in patients with complex stones., Conclusion: The localization of stone affects the success and complication rates of the operation.&nbsp;

Background: Improvement in ultrasound imaging has led to the identification of subtle non-structural markers during the 18 - 20 week fetal anomaly scan, such as echogenic bowel, mild cerebral ventriculomegaly, renal pelvicalyceal dilatation, and nuchal thickening. These markers are estimated to occur in between 0.6% and 4.3% of pregnancies. Their clinical significance, for pregnancy outcomes or childhood morbidity, is largely unknown. The aim of this study is to estimate the prevalence of seven markers in the general obstetric population and establish a cohort of children for longer terms follow-up to assess the clinical significance of these markers., Methods/design: All women receiving antenatal care within six of seven Welsh Health Boards who had an 18 to 20 week ultrasound scan in Welsh NHS Trusts between July 2008 and March 2011 were eligible for inclusion. Data were collected on seven markers (echogenic bowel, cerebral ventriculomegaly, renal pelvicalyceal dilatation, nuchal thickening, cardiac echogenic foci, choroid plexus cysts, and short femur) at the time of 18 - 20 week fetal anomaly scan. Ultrasound records were linked to routinely collected data on pregnancy outcomes (work completed during 2012 and 2013). Images were stored and reviewed by an expert panel.The prevalence of each marker (reported and validated) will be estimated. A projected sample size of 23,000 will allow the prevalence of each marker to be estimated with the following precision: a marker with 0.50% prevalence to within 0.10%; a marker with 1.00% prevalence to within 0.13%; and a marker with 4.50% prevalence to within 0.27%. The relative risk of major congenital abnormalities, stillbirths, pre-term birth and small for gestational age, given the presence of a validated marker, will be reported., Discussion: This is a large, prospective study designed to estimate the prevalence of markers in a population-based cohort of pregnant women and to investigate associations with adverse pregnancy outcomes. The study will also establish a cohort of children that can be followed-up to explore associations between specific markers and longer-term health and social outcomes.

Renal angiomyolipomas are benign neoplasms composed of varying amounts of adipose tissue, smooth muscles and blood vessels. They typically contain macroscopic fat, which is seen as negative attenuation on computed tomography. Calcification and scarring is rarely seen in renal angiomyolipomas. We report the case of a 40-year-old man who was found to have a renal angiomyolipoma with a central stellate scar and focal calcification. The lesion was initially misdiagnosed as a calyceal calculus.

Although lower urinary tract dysfunction (LUTD) in patients with cerebral palsy (CP) has been previously documented by clinical observations and urodynamic tests, its correlation with upper urinary tract deterioration (UUTD) has not been demonstrated. This paper documents symptoms and urodynamic findings of LUTD and their relationship with UUTD in 33 children with CP. By sonography, 4 of these children were found to have UUTD. Age was found to correlate with UUTD, but gender difference and mental or motor functions did not. When comparing urinary symptoms with UUTD, incontinence (n = 31) did not correlate, but on the other hand symptoms of detrusor sphincter dyssynergia (interrupted voiding, urinary retention, hesitancy; n = 5) and culture proven febrile urinary tract infections (n = 4) did. Abnormal urodynamics findings were not diagnostic. We conclude that, apart from incontinence, dysfunctional voiding symptoms and febrile urinary tract infections are valuable indicators of UUTD., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: Laparoscopic surgery is following a natural course as it decreases surgical aggression on the abdominal wall without undermining the curative and functional results. Although it is still being developed, single port surgery has meant an advance in this sense., Material and Methods: We present the first single port laparoscopic pyelolithectomy surgery in horseshoe kidney, using conventional rigid instruments. The case of an 18-year old patient with BMI of 19 in whom the imaging tests (urogram and computed tomography) showed a horseshoe kidney with left coralliform lithiasis and discrete calyceal ectasia is presented. The lithiasis was extracted using umbilical access with single port device and conventional rigid instruments., Results: The surgery was performed without complications. Surgery time was 110 minutes and bleeding 50 cc. On incision of the urinary system, there was purulent urine extravasation that conditioned fever of 38 °C in the post-operatory period. During the intervention, a double J stent was placed via percutaneous approach. The patient was discharged on the third day of hospitalization., Conclusion: Single port laparoscopic access for pyelolithectomy surgery in horseshoe kidney is a reasonable alterative. The use of conventional rigid instruments facilitates the performance of this surgery with good triangulation, without conflict regarding hands and safety for the patient., (Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.)

Objectives: We present the management with partial nephrectomy and interposition of the greater omentum in case of urinary fistulas in renal allograft., Material and Method: We present a patient with necrosis at the inferior pole of the renal graft that affected calyceal system but with pyeloureteral vascularization preserved. The patient's condition was satisfactorily managed with a partial nephrectomy of the necrotic renal segment and primary suturing of the collecting system with interposition of the greater omentum. We reviewed the cases published to date of partial nephrectomy in renal allograft, and examined their outcomes by analyzing the patient presentation, diagnostic tools, and surgical techniques used., Results: There are few cases in the current literature that describe conservative surgical management of urinary fistulas caused by segmental necrosis after renal transplantation. Surgical approach using partial nephrectomy in these cases produces favorable outcomes in our experience and reported cases., Conclusions: Despite its obvious surgical complexity, this nephron-sparing management is feasible and should be implemented in cases where the prior renal function and the quantity of healthy parenchyma indicate a favorable subsequent evolution for the renal graft., (Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.)

A 22-year-old girl who had a background of reflux nephropathy and urinary tact infection presented during the night with renal angle pain and vomiting. She was treated on the emergency department (ED) pyelonephritis protocol and admitted to the short stay ward. When reviewed the next morning she was aymptomatic and feeling better. It seemed likely that she would be discharged but an ED ultrasound showed right-sided hydronephrosis and some fluid between the liver and the right kidney. CT examination confirmed the suspicion of renal tract obstruction and ruptured calyx. An 8 mm calculus was found to be the cause of the pathology. Urgent urological review was organised and the system formally decompressed with a J-J stent inserted cystoscopically later that day.

Objective: To determine the effect of antenatally detected caliectasis on the postnatal surgical intervention rate., Methods: From 2006 to 2010, 56 patients with an anteroposterior diameter (APD) of 7-20 mm on the prenatal ultrasound scan performed in the third trimester of pregnancy were included in the present study. In these 56 patients, other anomalies (vesicoureteral reflux, posterior urethral valves, duplex system, megaureter) were excluded, and the postnatal clinical and radiologic follow-up data were available. The mean follow-up was 12.82 ± 10.72 months. These 56 patients were divided into 2 groups: those with (n = 32) and without (n = 24) caliectasis. In the caliectasis group, the mean follow-up was 13.6 ± 12.09 months and was 11.7 ± 8.70 months in the group without caliectasis. The statistical correlation between the postnatal operation rates and the presence of caliectasis (APD range 7-20 mm in third trimester) was investigated using the chi-square test., Results: In the study group (n = 56) with an APD range of 7-20 mm in the third trimester, postnatal surgical treatment (pyeloplasty) was performed in 12 (37.5%) and 3 (12.5%) of the children with and without caliectasis, respectively (P = .037). The risk of postnatal surgical treatment increased threefold in patients with an APD of 7-20 mm and a diagnosis of caliectasis (relative risk 3.0, 95% confidence interval 1.07-8.40)., Conclusion: In our study, the presence of concomitant caliectasis within the APD range of 7-20 mm on the third trimester ultrasound scan increased the risk of surgical treatment threefold. During prenatal counseling, the presence of caliectasis requires more rigorous follow-up., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: This report describes a partial nephrectomy with a minimally invasive approach, carried out laparoscopically as a treatment for a hydrocalicosis caused by a congenital infundibular stenosis., Clinical Case: The patient presented a clinical background of one year of evolution, manifested as recurrent urinary tract infections caused by urine accumulation in the adjacent collecting tubules which were compressed by the superior hydrocalicosis. This procedure was made using a transperitoneal access, making a superior pole resection of the right kidney and respecting the adrenal gland., Conclusions: In our opinion, to widen the usage of the laparoscopic surgery in urology can benefit patients to reduce post-surgery complications and hospitalization time, with a more comfortable recovery.

Background and Purpose: Caliceal diverticula are rare renal anomalies present in approximately 0.6% of the population. They are associated with calculi in 50% of cases. Therapeutic options include several minimally invasive techniques. We report a retrospective review of outcomes and complications from our series of patients who were treated with a percutaneous approach., Patients and Methods: A database of outcomes related to percutaneous nephrolithotomy (PCNL) has been maintained at our institution since 1992. Data on all patients with caliceal diverticular stones who underwent PCNL during a 17-year period from 1992 to 2009 were reviewed retrospectively. Our preferred approach to PCNL in these patients is to puncture directly into the diverticulum and to try to advance a guidewire through the infundibular neck. In cases where the caliceal neck could not be intubated, we performed a transdiverticular approach with creation of a neoinfundibulum as a salvage procedure. We evaluated the two techniques with regard to stone-free rates and early postoperative complications., Results: Seventy-six procedures were performed. The mean age was 43 years (range 17-72 y). The mean stone area was 583 mm(2). The surgical approach was direct puncture in 47, transdiverticular in 20, retrograde in 8, and unknown in 1 patient. Eight patients underwent lining fulguration. The average duration of surgery was 75 minutes (23-169 min) with an average hospital stay of 4.7 days. There were a total of 23 complications, of which 11 necessitated additional intervention. The overall stone-free rates were 77% and 89% for direct puncture and transdiverticular approaches, respectively., Conclusions: The percutaneous management of caliceal diverticular calculi is highly effective and can be accomplished with low morbidity.

Background and Purpose: The use of bipolar electrocautery has proven advantages over monopolar energy during transurethral surgery by limiting hyponatremia and its clinical sequelae. Percutaneous ablation of caliceal diverticula and parapelvic renal cysts has been shown to be an effective surgical approach for the management of these conditions when clinically indicated. We present single center results of percutaneous ablation of renal cysts and caliceal diverticula using a bipolar energy technique and compare the results with a cohort of patients undergoing the procedure using monopolar energy., Patients and Methods: Between July 2006 and June 2010, 30 patients with caliceal diverticula and renal cysts underwent percutaneous ablation using the bipolar resection system with saline irrigation (group 1). This group was compared with a cohort of 19 patients who underwent traditional ablation using a standard resectoscope, monopolar energy, and glycine irrigation (group 2). We evaluated operative times, change in hematocrit and serum sodium levels from preoperative levels, complication rates, as well as symptomatic and radiographic success rates., Results: The mean operative times were 87 minutes and 63 minutes for groups 1 and 2, respectively (P = 0.07). The mean percent decrease in hematocrit was 3.27 ± 1.93 in group 1 and 3.82 ± 2.09 in group 2 (P = 0.16), and the mean decrease in serum sodium level was -0.21 ± 2.24 mEq/L in group 1 and 3.78 ± 2.18 mEq/L in group 2 (P < 0.001). There were no intraoperative complications. One patient needed ureteral stent placement for persistent urine leak. All patients with symptomatic renal cysts reported resolution of their discomfort, with radiographic success confirmed in 89% in group 1 and 79% in group 2 (P = 0.41)., Conclusions: Percutaneous ablation of caliceal diverticula and renal cysts using a bipolar resection system is feasible and appears to have efficacy similar to that of the monopolar system. In addition, use of isotonic saline as the irrigation medium appears to reduce the risk of postoperative hyponatremia.

Background and Purpose: Three small diameter (<1.5F) stone baskets have recently been introduced. Our objective was to evaluate the stone capture rate of these baskets in an in vitro ureteral model and an in vitro caliceal model using novice, resident, and expert operators., Materials and Methods: Sacred Heart Medical Halo™ (1.5F), Cook N-Circle(®) Nitinol Tipless Stone Extractor (1.5F), and Boston Scientific OptiFlex(®) (1.3F) stone baskets were tested in an in vitro ureteral and a caliceal model by three novices, three residents, and three experts. The caliceal model consisted of a 7-cm length of 10-mm O.D. plastic tubing with a convex base. Each operator was timed during removal of a 3-mm calculus from each model with three repetitions for each basket. Data were analyzed by analysis of variance single factor tests and t tests assuming unequal variances., Results: In the ureteral model, the Halo had the fastest average rate of stone extraction for experts and novices (0:02 ± 0:01 and 0:08 ± 0:04 min, respectively), as well as the overall fastest average stone extraction rate (0:08 ± 0:06 min). No statistical significant differences in extraction times between baskets were identified in the resident group. In the novice group, the Halo stone extraction rate was significantly faster than the OptiFlex (P=0.029). In the expert group, the OptiFlex had statistically significant slower average extraction rates compared with the Halo (P=0.005) and the N-Circle (P=0.017). In the caliceal model, no statistically significant differences were noted., Conclusion: While no significant differences were noted in extraction times for the caliceal model, the extraction times for the ureteral model were slowest with the OptiFlex basket. Other variables important in selection of the appropriate basket include operator preference, clinical setting, and cost.

Unusual imaging features of urothelial cancer of the renal pelvicaliceal system can be challenging for any radiologist. These manifestations include noncalcified and calcified focal infiltrative parenchymal masses, incidentally detected tumors in a hydronephrotic kidney due to ureteropelvic junction obstruction, transpelvic infiltrating solid masses extending through the retroperitoneum, and tumors primarily invading the perirenal fat. Less common manifestations include massive papillary frond-like projections within a large hydronephrotic sac, large multiloculated cystic masses with thick and irregular septa, tumors invading the renal vein, and paraaortic lymph node metastases as the only sign of an undetectable primary tumor of the renal collecting system. Radiologists should be aware that an eccentric, focal, infiltrative pelvicaliceal carcinoma that causes distortion of the renal contour may simulate renal cell carcinoma; when calcified, such a pelvicaliceal carcinoma may simulate chronic inflammatory renal disease. The radiologist should also be aware of the importance of a meticulous sonographic evaluation of a hydronephrotic kidney, particularly in older patients, to avoid missing a urothelial cancer. When a nonfunctioning and enlarged kidney is present, radiologists should always consider infiltrative hydronephrotic urothelial carcinoma as a diagnostic possibility. Familiarity with unusual imaging features of urothelial cancer of the renal pelvicaliceal system may facilitate making the correct diagnosis, thus enabling adequate therapeutic management., (© RSNA, 2010.)

Background and Purpose: Excluded calices refer to a single calix or multiple calices that are completely isolated from the collecting system. The etiology is a result of infection, malignancy, or inflammation that is secondary to endoscopic renal surgery. We report our experience with the endoscopic management of excluded calices., Patients and Methods: We retrospectively reviewed the data for our patients with a diagnosis of excluded calices. Patients were treated with various endoscopic techniques, all necessitating the formation of a neoinfundibulum. Patients were evaluated for symptomatic and radiographic evidence of resolution., Results: Eight patients were found to have excluded calices. Seven patients had a history of urolithiasis and previous endoscopic renal surgery. One patient had undergone a laparoscopic partial nephrectomy with a postoperative urinary fistula. Six of eight patients were treated with a percutaneous approach followed by laser incision, balloon dilatation, or nephroureteral stent placement. Two objective failures occurred. One patient received re-treatment and has not demonstrated persistence or recurrence since the second procedure. No complications occurred as a result of endoscopic management., Conclusion: Excluded calices commonly result from inflammation from previous renal surgery. Goals of management include relief of obstruction, management of stones, and regaining continuity with the remaining collecting system. Successful treatment with endoscopic management involves creation of a neoinfundibulum and placement of a temporary ureteral stent.

Removing small stones, fragments and debris, clots, or clusters of small stones can be bothersome and time consuming. We perform a technique to sweep out fragments from the kidney during percutaneous nephrolithotomy using suction. The nephroscope is used as a vacuum cleaner by adapting the suction tube to the nephroscope operating channel. The fragments are quickly aspirated through the nephroscope working channel under direct vision. This technique gives the best opportunities to render a patient stone-free from even the fine sand debris.

Background: Tubeless percutaneous nephrolithotomy is defined as PCNL without postoperative nephrostomy tubes. It is reported to reduce postoperative pain, hospital stay and recovery time. To date the procedure has been reserved for selected patients., Objectives: To assess our initial experience in extending the implementation of tubeless PCNL without preoperative patient selection., Methods: All consecutive PCNLs performed during 2004-2008 were evaluated. Tubeless PCNL was performed when residual stones, bleeding and extravasation were excluded intraoperatively. Staghorn stones, stone burden, supracostal and multiple accesses, anatomic anomalies, solitary kidneys and operative time were not considered contraindications. We analyzed the clinical data and the choice of tubeless PCNL over time., Results: Of 281 PCNLs performed during the study period 200 (71%) were tubeless. The patients' average age was 53 years (range 28-82 years), the stone burden was 924 mm2 (400-3150 mm2), operative time was 99 minutes (45-210 min), complication rate was 14% and immediate stone-free rate 91%. There were 81 conversions to standard PCNL (29%) due to expected second-look (n = 47, 58%), impression of bleeding (n = 21,26%), suspected hydrothorax (n = 7, 9%) and extravasation (n = 6, 7%). The transfusion rate was 1%. The median hospital stay was 1 day (1-15 days) and recovery time 7 days (5-20 days). The rate of implementing the tubeless procedure increased steadily along time from 46% to 83% (P = 0.0001)., Conclusions: Tubeless PCNL can be safely and effectively performed based on intraoperative decisions, without preoperative contraindications. They are easily accommodated by experienced endourologists and provide real advantages.

Purpose: To evaluate the indications for, and the effects of, the management of renal caliceal calculi with deflectable tip rigid ureteroscopy., Patients and Methods: We designed a new deflectable tip rigid ureteroscope, and 175 patients with renal caliceal calculi received deflectable tip rigid ureteroscopic lithotripsy with a holmium laser., Results: From December 2003 to December 2007, the procedure was successfully performed in all patients with a mean operative time of 28 minutes (range 19-45 min). The mean size of renal caliceal stones was 1.3 cm (range 0.8-2.4 cm). Seventeen patients had concurrent proximal ureteral calculi. The mean lithotripsy time was 11 minutes (range 5-22 min), and the mean discharge time was 3 days after operation. The overall stone-free rate at the 1-month follow-up was 83%., Conclusion: Ureteroscopic lithotripsy with the novel deflectable tip rigid ureteroscope is a safe procedure and combines the advantages of rigid and flexible ureteroscopy, especially for renal caliceal calculi of relatively small size.

Abstract Percutaneous nephrolithotomy is now the gold standard for treatment of large renal stones. In this article, we describe the indications for use of antegrade flexible nephroscopy during percutaneous nephrolithotomy, as well as for treatment of infundibular stenosis. We also discuss various new technologies to help in these endeavors, including digital cystoscopes and ureteroscopes and our preferred baskets, as well as our particular techniques for improving stone-free rates. The treatment of infundibular stenosis through percutaneous access is also reviewed.

Keratinizing desquamative squamous metaplasia (KDSM), also known as leukoplakia or cholesteatoma, of the genitourinary tract is a rare condition that is difficult to differentiate from a malignant process without surgical intervention. We present a case of KDSM of the upper urinary tract that was managed via percutaneous endoscopic approach. Although KDSM is a benign lesion, there are rare reports of it occurring concurrently with squamous-cell carcinoma; however, no direct causal relationship has been identified. This case demonstrates the ease with which KDSM can be removed by peeling it away from the underlying parenchyma; however, surgical intervention may not be necessary in the asymptomatic patient after evaluation has ruled out malignancy. Regardless of how KDSM is managed, follow-up is important because these lesions are known to recur.