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Upper tract urothelial carcinoma (UTUC) accounts for 5–10% of urothelial cancers and is associated with high morbidity and mortality. Increasing incidence of UTUC has been observed since the 1970's, alongside the evolution of advance imaging techniques, precision biopsy equipment, and risk stratification models. The high morbidity of radical nephroureterectomy (RNU) which is still the gold-standard treatment for high-risk UTUC, has driven the development of kidney-sparing surgery alternatives for low-risk UTUC. Now, several treatment approaches have outcomes comparable to RNU for low-risk UTUC and guidelines are recommending kidney-sparing surgery for favorable low-risk disease. The main categories of kidney-sparing surgery include segmental ureterectomy, endoscopic ablation, chemoablation, and vascular-targeted phototherapy. These treatments are highly nuanced making them difficult to compare, but for most cases of favorable low-grade disease, we recommend endoscopic laser ablation with optional adjuvant intracavitary therapy. Adverse events associated with kidney-sparing surgery include ureteral stricture, bleeding requiring transfusion, and bladder recurrence of UTUC. Limitations of kidney-sparing surgery include appropriate tissue sampling (contributing to under-grading and under-staging), higher rates of ipsilateral recurrence, and potential for grade and stage progression. Collectively, these may subsequently necessitate RNU. Here, we review the technical variations and evidence behind kidney-sparing therapies as well as their practicality in the real world. [ABSTRACT FROM AUTHOR]

Background: The urinary tract is one of the most frequently involved organs in advanced non-urologic pelvic malignances. Extensive resection of ureteric organs is mandatory during a curative surgery. Urinary reconstruction after partial ureterectomy, the most challenging situation, is associated with a higher incidence of complication than cystectomy, especially when performed with laparoscopy. Furthermore, to date, no generally accepted strategy for urinary reconstruction after extensive tumor resection with partial ureterectomy has been established. Methods: The study identified and scrutinized intraoperative videos and clinical records of patients with locally advanced or recurrent pelvic malignancies who underwent segmental ureterectomy during en bloc resection of advanced tumors between February 2020 and February 2024. Results: The study enrolled nine patients, including four cases managed by ureteroureteral anastomosis, two cases managed by ureteroneocystomy, two cases managed by Boari flap reconstruction, and one case managed by ileal interposition. In all nine cases, R0 margins were obtained, and no case needed conversion to laparotomy. No clinical evidence of postoperative urinary leakage was identified. The median follow-up period was 14 months (range, 5–19 months). In three of the nine cases, recurrence was identified, at the 3rd, 18th, and 19th month follow-up evaluations, respectively. One patient died of systemic metastasis. Conclusions: Laparoscopic ureteric reconstruction is feasible for patients who undergo segmental ureterectomy during extensive surgery for locally advanced or recurrent pelvic malignancies. A low anastomotic leakage rate and favorable postoperative renal function could be achieved in this study when anastomosis was performed laparoscopically. [ABSTRACT FROM AUTHOR]

Primary neoplasms of the ureter, although rare, usually present as malignant and epithelial neoformations, with urothelial carcinoma being one of the most common. Complete luminal interruption of the ureter leads to progressive dilation of the upper urinary tract causing renal conditions such as hydronephrosis, pyelonephritis, renal parenchymal injury, and loss of renal function. The aim of this report is to describe a surgical case of neoplastic ureteral resection caused by low-grade urothelial carcinoma. It is concluded that although rare, urothelial carcinoma should be one of the differential diagnoses for ureteral obstruction and when it is only located in this region, the prognosis is favorable and surgery for tumor removal is a satisfactory treatment for this neoplasm. [ABSTRACT FROM AUTHOR]

Comprehensive analyses including both metachronous and synchronous metastatic upper tract urothelial carcinoma are limited. In this retrospective cohort study, we evaluated oncologic outcomes and costs associated with management of metastatic upper tract disease using the SEER-Medicare database and evaluated quality of care in this space using a novel and easily applied metric. Less than half of patients met quality care criteria. Those that did meet criteria experienced longer overall survival at marginally increased costs. Background: Population-based studies evaluating outcomes for metastatic upper tract urothelial carcinoma (mUTUC) are sparse and rarely capture both patients with de novo (synchronous) metastases and those who progress to metastatic disease (metachronous). Herein we evaluated the outcomes and costs associated with synchronous and metachronous mUTUC, utilizing a novel Methodology. Additionally, we created a guideline-based quality score to improve care in this space. Patients and Methods: We identified all patients with mUTUC aged 66 years and older included in the SEER-Medicare linked database between 2004 and 2012. Achievement of 3 quality cr iter ia was assessed: (1) cancer-specific survival (CSS) > 12 months; (2) receipt of systemic therapy; (3) receipt of hospice/palliative care. Total healthcare and out-of-pocket costs were evaluated. Regression analyses were performed to assess characteristics associated with quality criteria and total healthcare costs. Results: Of the 1223 patients identified, at least one quality cr iter ion was met in just 40.2% and only 54 patients (4.4%) received palliative care. In multivariable analysis, patients with synchronous mUTUC (OR:0.55, 95%CI:0.41-0.72), and at least 3 comorbidities (OR:0.68, 95%CI:0.47-0.98) were less likely to achieve at least 1 quality cr iter ion. Meeting at least 1 quality cr iter ion was associated with increased costs ($94,677, 95%CI:87,702-101,652 versus $63,575, 95%CI:59,598-67,552). Conclusions: Less than half of patients with mUTUC met at least 1 quality cr iter ion. Quality score achievement was associated with a modest increase in total healthcare spending. These findings not only provide guidance for future study of rare diseases using secondary data, but also highlight inadequacies in the current management of mUTUC. [ABSTRACT FROM AUTHOR]

Simple Summary: Minimally invasive radical nephroureterectomy is gaining momentum among upper tract urothelial carcinoma management by offering oncological radicality and less surgical morbidity. Long-term oncological outcomes suggest that it is a safe and effective treatment option for upper tract urothelial cancer. The gold standard treatment for non-metastatic upper tract urothelial cancer (UTUC) is represented by radical nephroureterectomy (RNU). The choice of surgical technique in performing UTUC surgery continues to depend on several factors, including the location and extent of the tumor, the patient's overall health, and very importantly, the surgeon's skill, experience, and preference. Although open and laparoscopic approaches are well-established treatments, evidence regarding robot-assisted radical nephroureterectomy (RANU) is growing. Aim of our study was to perform a critical review on the evidence of the last 5 years regarding surgical techniques and outcomes of minimally invasive RNU, mostly focusing on RANU. Reported oncological and function outcomes suggest that minimally invasive RNU is safe and effective, showing similar survival rates compared to the open approach. [ABSTRACT FROM AUTHOR]

Abstract Background Ipsilateral synchronous renal and ureteric tumor is uncommon. Nephron sparing surgery is the standard for small renal masses. Ureteric tumors can be selectively managed with nephron sparing surgery, especially in renal dysfunction. This case report details the management of double malignancy by nephron sparing surgery with robot-assisted approach. Case report A 63-year-old gentleman with diabetes presented with history of intermittent gross hematuria for 2 weeks. He was clinically normal. On evaluation, he had grade 4 renal dysfunction (Se. creatinine 4.5 mg%) with mild proteinuria. Magnetic resonance imaging revealed right renal upper polar Bosniak III lesion and right hydroureteronephrosis due to 2 cm ureteric tumor near the vessel crossing. Renogram showed overall GFR of 22 ml/min with 31% (6 ml/min) contribution from the right side. He underwent robot-assisted right partial nephrectomy with distal ureterectomy and Boari flap ureteric reimplantation. Histopathology revealed margins free T2 clear cell carcinoma (kidney) and high-grade T3 transitional cell carcinoma (ureter). His nadir creatinine at 1 year follow-up was 3.3 mg% and no recurrence on MRI, cystoscopy, and ureteroscopy at 1 year. Conclusion Minimally invasive nephron sparing surgery is feasible and reasonable option with satisfactory oncological control even in ipsilateral synchronous renal and ureteric tumors in selected patients with renal dysfunction.

Simple Summary: Although upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy in Western countries, recurrence and distant metastasis are common even after definitive surgery. Many prognostic factors have been identified from previous studies, allowing clinicians to better stratify risk to select patients for perioperative systemic therapy; however, the applicability of adjuvant chemotherapy for patients with stage II UTUC after radical surgery remains unclear. In this study, we found that patients with primary tumor location at ureter or renal pelvis plus synchronous ureter had more frequent disease relapse and worse long-term oncological outcomes than other patients. Male sex, older age, history of previous bladder cancer, and positive surgical margins remain important unfavorable prognostic factors for recurrence and survival. Additional treatment and closer surveillance in patients with these negative prognostic factors are warranted despite complete pathological removal of the tumor. Background: Oncologic outcomes for pT2N0M0 upper tract urothelial carcinoma (UTUC) after nephroureterectomy are not well defined, with most previous studies focused on a heterogeneous population. Therefore, we aimed to investigate the clinical determinants of extraurinary tract recurrence and survival after radical surgery in patients with localized UTUC. Methods: We retrospectively identified 476 patients with pT2N0M0 UTUC who underwent radical nephroureterectomy or ureterectomy between October 2002 and March 2022. To evaluate the prognostic impact, patients were divided into renal pelvic, ureteral, and both-region (renal pelvis plus synchronous ureter) groups based on tumor location. The outcomes included recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Associations were evaluated using multivariable Cox regression analyses for prognostic factors and Kaplan–Meier analyses for survival curves. Results: The renal pelvic, ureteral, and both-region groups consisted of 151 (31.7%), 314 (66.0%), and 11 (2.3%) patients, respectively. Kaplan–Meier analyses comparing the three tumor types showed significant differences in 5-year RFS (83.6% vs. 73.6% vs. 52.5%, p = 0.013), CSS (88.6% vs. 80.7% vs. 51.0%, p = 0.011), and OS (83.4% vs. 70.1% vs. 45.6%, p = 0.002). Multivariable analyses showed that age >60 years, previous bladder cancer history, ureteral involvement (ureteral and both-regional groups), and positive surgical margins were significant negative prognostic factors for the studied outcomes. Conclusions: Patients with pT2 UTUC and presence of ureteral involvement had more frequent disease relapse. Subsequent adjuvant therapy regimens and close follow-up in patients with negative prognostic factors are warranted despite complete pathological removal of the tumor. [ABSTRACT FROM AUTHOR]

Myeloid sarcoma (MS) is an extramedullary tumor mass causing proliferation of mature or immature blast cells of one or more myeloid lineages. Involvement of the genitourinary tract is rare. We present a case of MS of the ureteral wall. A 74-year-old man was evaluated for left hydronephrosis and ipsilateral low back pain. A computed tomography scan showed a nodular formation in the pelvic ureter. Urinary cytology revealed cellular atypia, so ureteroscopy was performed showing a distal ureteral mass. The histological examination of the biopsy revealed to be malignant neoplasm. The patient underwent left laparoscopic nephroureterectomy with bladder cuff excision. Microscopic histological examination revealed a tumor compatible with MS. A postoperative positron emission tomography revealed residual hypercaptation of the bladder, pelvic muscle and iliac nodes, so the patient started chemotherapy. A multidisciplinary approach was required, taking into account the patient's age, the already poor renal function and the location of the neoplasm. [ABSTRACT FROM AUTHOR]

Background: Ipsilateral synchronous renal and ureteric tumor is uncommon. Nephron sparing surgery is the standard for small renal masses. Ureteric tumors can be selectively managed with nephron sparing surgery, especially in renal dysfunction. This case report details the management of double malignancy by nephron sparing surgery with robot-assisted approach. Case report: A 63-year-old gentleman with diabetes presented with history of intermittent gross hematuria for 2 weeks. He was clinically normal. On evaluation, he had grade 4 renal dysfunction (Se. creatinine 4.5 mg%) with mild proteinuria. Magnetic resonance imaging revealed right renal upper polar Bosniak III lesion and right hydroureteronephrosis due to 2 cm ureteric tumor near the vessel crossing. Renogram showed overall GFR of 22 ml/min with 31% (6 ml/min) contribution from the right side. He underwent robot-assisted right partial nephrectomy with distal ureterectomy and Boari flap ureteric reimplantation. Histopathology revealed margins free T2 clear cell carcinoma (kidney) and high-grade T3 transitional cell carcinoma (ureter). His nadir creatinine at 1 year follow-up was 3.3 mg% and no recurrence on MRI, cystoscopy, and ureteroscopy at 1 year. Conclusion: Minimally invasive nephron sparing surgery is feasible and reasonable option with satisfactory oncological control even in ipsilateral synchronous renal and ureteric tumors in selected patients with renal dysfunction. [ABSTRACT FROM AUTHOR]

Introduction and Importance: Ureteric stump syndrome [USS] is a series of febrile recurrent lower abdominal pain, urinary tract infections, and hematuria that sometimes present with empyema as a rare complication. The ureteric stump is left after ureteric re-implantation due to an impacted stone at the Vesical-ureteric junction [VUJ], or after nephrectomy of a non-functional kidney due to a distal stone; the ureteral stump forms a source of infection to the urinary bladder, in addition to long-term obstructive stones left at the ureteric stamp. This usually cause chronic irritation of the mucosa and potentially change to metaplasia, dysplasia and malignancy. On a standard protocol, in upper urinary tract, transition cell carcinoma [TCC], because of its multifocality, nephrectomy is performed along with ureterectomy to the level cuff of the urinary bladder en block resection, but not in the case of a non-functional kidney where the proximal ureterectomy is performed, and a potential ureteric stump is left in a patient, whom later on presents with recurrent febrile lower urinary tract symptoms. It is important to exclude ureteric stump syndrome after nephrectomy or ureteric re-implantation. The need for surveillance of the ureteric stump is of paramount important., Case Presentation: A patient aged 66 yrs., female presented with right flank pain for one year, colick in nature, radiating to the lower abdomen and genitalia and was associated with nausea and vomiting. The patient was yet experiencing a recurrence of lower abdominal pain and repeatedly being diagnosed with recurrent urinary tract infection for the past 6 months after ureteric re-implantation. Several blood tests showed leukocytosis and urine culture revealed Pseudomonas, and the patient was given antibiotics. Symptoms resolved after the administration of antibiotics, and after a while symptoms subsequently recurred again. The patient was then scheduled for retrograde ureteroscopy of the native ureter and uretero-renoscopy (URS) of the neo-ureterocystostomy (neo-reimplanted ureter). Intraoperative findings were an impacted distal ureterolithisias of the native ureter, with debris that was subsequently fragmented with rigid uretero-renoscopy [URS] and contact lithotripsy. The re-implanted ureter was surveyed and found to have good patency., Clinical Discussion: Recurrent febrile urinary tract symptoms, hematuria, and lower abdominal pain are associated with ureteric stump syndrome in a patient after nephrectomy and proximal ureterectomy post-ureteric re-implantation due to distal ureterolithiasis. A potential risk factor for our patient was an infected stone which was impacted at VUJ, that led to stasis of urine that was trapped due to obstruction. Radiological investigations that can be used to diagnose ureteric stamp syndrome include retrograde ureterography, cystography, and CT IVU, which reveal the thickening of the ureteral stamp wall and enhancement and, if it contains calculi, hyperdense foci in the plain phase. Complications such as psoas muscle abscess or the fistulization of ureteric stamps to the uterus. Management options for ureteric stump syndrome include surgical excision of the ureteric stump or a laparoscopy approach for distal ureterectomy; others can also include transurethral fulguration of the empyema ureteric stump. The URS is either flexible or rigid., Conclusion: Complete resection of the ureteric stamp due to stones at the VUJ is of paramount importance, especially when a foreign body is left in situ, because of the potential for infections, termed ureteric stump syndrome. It is important to exclude ureteric stump syndrome after nephrectomy or ureteric re-implantation. Surveillance of the ureteric stump is of paramount important., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Leiomyomas of the genitourinary tract are rare and their manifestation in the ureter is even rarer. To our knowledge, only 14 cases of leiomyoma of the ureter have been reported worldwide since 1955, therefore this case will be 15th. Case presentation: We present a rare case of primary leiomyoma of the right ureter. Ureteroscopy did not show any abnormal findings in the ureteral mucosa. The primary leiomyoma was resected with distal ureterectomy and partial cystectomy that was followed with ureteroneocystostomy due to extraluminal mass that caused hydronephrosis and back pain. Conclusion: Although rare, we believe that leiomyoma should be considered in the differential diagnoses of well-circumscribed ureteral masses and kidney-sparing surgery should be performed. [ABSTRACT FROM AUTHOR]

Aspergillosis is a vicious fungal infection that can develop in immunosuppressed patients. The presence of aspergillosis in the ureter or elsewhere in the genito-urinary tract is highly uncommon and rarely reported in the literature. Here, we present a 54-year-old gentleman, with uncontrolled diabetes, who presented with urosepsis. Right hydronephrosis and ureteric stricture with urinary extravasation were seen on imaging. Right percutaneous nephrostomy was done, with drainage and analysis of the pus revealing the growth of Aspergillus fumigatus species. On open exploration, a ureteric abscess cavity, which was adherent to the duodenum, was drained and uretero-ureterostomy along with feeding jejunostomy was performed. Histopathological examination and special staining confirmed the growth of aspergillosis. The patient was treated with antifungal agents and responded well with an uneventful post-operative recovery., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jambunathan et al.)

A duplicated collecting system is a common congenital anomaly of the urinary tract. However, late symptomatic presentation in adulthood is uncommon. We report the first case of left heminephrectomy, ureterectomy and radical prostatectomy using the da Vinci SP (single port) surgical system in a 64-year-old patient with localized prostate cancer and duplicated system with ectopic ureteral insertion into the prostatic urethra. The procedure was completed without technical difficulties or intraoperative adverse events. We demonstrate that the da Vinci SP robot allows for efficient performance of concomitant surgeries on the kidney and prostate without the limitations reported with single site surgeries.

Introduction: Ureteral reimplantation is indicated for patients with congenital distal ureteral strictures, for iatrogenic intraoperative distal ureteral injuries, and for those who require distal ureterectomy for transitional cell carcinoma. Methods: Using the da Vinci system from Intuitive, we demonstrate distal ureterectomy with reimplantation. Both a refluxing extravesical reimplant and nonrefluxing extravesical reimplant are shown. We also demonstrate modifications, including psoas hitch and Boari flap. Results: Robotic ureteral reimplantation with psoas hitch and Boari flap are demonstrated in a reproducible manner. Additional topics covered include the delineation of diseased ureter vs healthy ureter, the applications of indocyanine green, and the use of interoperative ureteral stents. Conclusions: Robotic ureteral reimplantation is safe and feasible when performed with proper technique. Ureteroscopy and near-infrared fluorescence technology facilitate improved detection of diseased ureteral segments. Key points include the maintenance of principles of open surgery such as a tension-free, watertight, and stented anastomosis. [ABSTRACT FROM AUTHOR]

Background: The ureter is the second most common site affected by urinary tract endometriosis, after the bladder. Optimal strategies in the diagnosis and treatment of ureteral endometriosis (UE) are not yet well defined.Objective and Rationale: The aim of this study was to systematically review evidence regarding the epidemiology, pathophysiology, diagnosis, medical and surgical treatment, impact on fertility and risk of malignant transformation of UE.Search Methods: A systematic literature review, by searching the MEDLINE and PUBMED database until April 2018, was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and was registered in the PROSPERO registry (www.crd.york.ac.uk/PROSPERO CRD42017060065). A total of 67 articles were selected to be included in this review.Outcomes: The involvement of the ureter by endometriosis is often asymptomatic or leads to non-specific symptoms. When the diagnosis is delayed, UE may lead to persistent hydronephrosis and eventually loss of renal function. Ultrasonography is the first-line technique for the assessment of UE; alternatively, magnetic resonance imaging provides an evaluation of ureteral type involvement. The surgical treatment of UE aims to relieve ureteral obstruction and avoid disease recurrence. It includes conservative ureterolysis or radical approaches, such as ureterectomy with end-to-end anastomosis or ureteroneocystostomy performed in relation to the type of ureteral involvement. Fertility and pregnancy outcomes are in line with those observed after surgical treatment of deep infiltrating endometriosis (DIE). Current evidence does not support the potential risk of malignant transformation of UE.Wider Implications: In this article, we review available evidence on ureteral endometriosis, providing a useful tool to guide physicians in the management of this disease. Diagnosis and management of UE remain a challenge. In relation to the degree of ureteral involvement and the association with other DIE implants, the surgical approach should be planned and carried out in an interdisciplinary collaboration between gynecologist and urologist. [ABSTRACT FROM AUTHOR]

Context : Various minimally invasive techniques - laparoscopic, endoscopic or combinations of both - have been described to handle the lower ureter during laparoscopic nephroureterectomy but none has received wide acceptance. Aims : We describe an endoscopic technique for the management of lower end of ureter during laparoscopic nephroureterectomy using a single suprapubic laparoscopic port. : Transurethral resectoscope is used to make a full thickness incision in the bladder cuff around the ureteric orifice from 1 o′clock to 11 o′clock. A grasper inserted through the transvesical suprapubic port is used to retract the ureter to complete the incision in the bladder cuff overlying the anterior aspect of the ureteric orifice. The lower end of ureter is subsequently sealed with a clip applied through the port. This is followed by a laparoscopic nephrectomy and the specimen is removed by extending the suprapubic port incision. Our technique enables dissection and control of lower end of ureter under direct vision. Moreover, surgical occlusion of the lower end of the ureter prior to dissection of the kidney may decrease cell spillage. The clip also serves as a marker for complete removal of the specimen. Results : Three patients have undergone this procedure with an average follow up of 19 months. Operative time for the management of lower ureter has been 35, 55 and 40 minutes respectively. A single recurrence was detected on the opposite bladder wall after 9 months via a surveillance cystoscopy. There has been no residual disease or any other locoregional recurrence. Conclusions : The described technique for management of lower end of ureter during laparoscopic nephroureterectomy adheres to strict oncologic principles while providing the benefit of a minimally invasive approach.

Background: We present a case of asynchronously occurring adenocarcinomas 29 and 36 years after ureterosigmoidostomy for bladder cancer, respectively, at both anastomosis sites. Case presentation: A colonoscopy that was performed on a 69-year-old man because of bloody stool and an elevated carcinoembryonic antigen (CEA) level revealed a polypoid lesion at the right ureterosigmoid anastomosis site 29 years after the patient's ureterosigmoidostomy. Endoscopic resection was performed, and the lesion was diagnosed as adenocarcinoma. Seven years later (36 years after ureterosigmoidostomy), an elevated lesion was detected at the left ureterosigmoid anastomosis site by colonoscopy performed after detection of high CEA levels. Biopsy revealed an adenocarcinoma that was immunohistologically positive for CDX2; sigmoidectomy and ureterectomy were subsequently performed. The pathological diagnosis of the second tumor was adenocarcinoma arising in the ureterosigmoid anastomosis site and invading the left ureter. Conclusions: Diligent long-term follow-up of patients who underwent ureterosigmoidostomy is essential. [ABSTRACT FROM AUTHOR]