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Background: Genitourinary fistula is a distressful condition involving mental, social, marital, and financial repercussions. Objective: The objective of this study is to systematically evaluate etiology, clinical presentation, diagnosis, the timing of repair, and perform a meta‐analysis evaluating the success rate of various treatment modalities with respect to time taken to seek treatment. Search strategy: We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in April 2020 according to the PRISMA statement. Seventeen studies were included in the final analysis and all were retrospective in design. Selection criteria: Each article was rated by the evidence‐based medicine levels of evidence scale and the Methodological Index for Nonrandomized Studies scale for assessment of bias among nonrandomized studies. Main results: Of the 799 fistulae reported in 17 studies, endoscopic management was done in 35.6% (12 studies), whereas surgical management was preferred in 85.6% fistulae (15 studies). The pooled success of endoscopic stenting was 32% (95% confidence interval [CI]: 7–64) and 100% (95% CI: 98–100) in operated patients. Patients who underwent stenting within 2 weeks (20%), 2–6 weeks (21%), and >6 weeks (40%) had pooled success rates of 95% (95% CI: 87–100), 46% (95% CI: 0–100), and 20% (95% CI: 1–49), respectively. Patients who underwent surgical management <6 weeks (15.9%) and >6 weeks (22%) of diagnosis had pooled success rates of 100% (95% CI: 99–100) and 100% (95% CI: 99–100), respectively. Conclusions: Stent placement as early as <6 weeks (preferably < 2 weeks) had better outcomes as compared to >6 weeks. Proceeding to surgery regardless of timing in cases of stent failure seems to be a feasible option. [ABSTRACT FROM AUTHOR]

Abstract Background Subcutaneous ureteral bypass (SUB) device placement is an increasingly popular treatment option for decompression of ureteral obstruction in cats. Mineralization occlusion of the device occurs in a minority of cases but is the most common complication. Objective To evaluate a 2% tetrasodium ethylenediaminetetraacetic acid (tEDTA) solution for treatment of mineralization occlusion in cats with SUBs. Animals Six client‐owned cats (8 obstructed devices). Methods Case series. Each cat was found to have device occlusion based on a combination of ultrasound examination, SUB irrigation, and failure to identify another cause of device obstruction. Each SUB was drained, irrigated using sterile saline, and infused with 1‐2 mL of 2% tEDTA solution. Success was defined as normalization of flow during subsequent ultrasound visualization while irrigating. The volume and frequency of tEDTA instillations, time to achieve device patency, follow‐up biochemical and ultrasound findings, and future reobstruction events were recorded. Results Resolution of mineralization was documented in all 8 SUBs. Reobstruction events occurred in 2 cats, all of which resolved after additional tEDTA infusions, but 1 cat ultimately required device exchange at 356 days from the first tEDTA infusion. In 1 cat, a single infusion was prematurely discontinued because of persistent pelvic dilatation after 1.25 mL of tEDTA had been instilled. No complications were observed. Conclusions and Clinical Importance Tetrasodium EDTA infusions can be safely considered as a treatment option for mineralized SUB devices in cats. This solution was easily infused, well tolerated, and avoided the need for SUB device exchange in the majority of cats in which it was used.

Study Objective: To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded.Design: Prospective case series study.Setting: Tertiary level referral center for endometriosis and minimally invasive gynecology.Patients: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis.Interventions: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded.Measurements and Main Results: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful.Conclusion: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies. [ABSTRACT FROM AUTHOR]

Background: Subcutaneous ureteral bypass (SUB) device placement is an increasingly popular treatment option for decompression of ureteral obstruction in cats. Mineralization occlusion of the device occurs in a minority of cases but is the most common complication. Objective: To evaluate a 2% tetrasodium ethylenediaminetetraacetic acid (tEDTA) solution for treatment of mineralization occlusion in cats with SUBs. Animals: Six client‐owned cats (8 obstructed devices). Methods: Case series. Each cat was found to have device occlusion based on a combination of ultrasound examination, SUB irrigation, and failure to identify another cause of device obstruction. Each SUB was drained, irrigated using sterile saline, and infused with 1‐2 mL of 2% tEDTA solution. Success was defined as normalization of flow during subsequent ultrasound visualization while irrigating. The volume and frequency of tEDTA instillations, time to achieve device patency, follow‐up biochemical and ultrasound findings, and future reobstruction events were recorded. Results: Resolution of mineralization was documented in all 8 SUBs. Reobstruction events occurred in 2 cats, all of which resolved after additional tEDTA infusions, but 1 cat ultimately required device exchange at 356 days from the first tEDTA infusion. In 1 cat, a single infusion was prematurely discontinued because of persistent pelvic dilatation after 1.25 mL of tEDTA had been instilled. No complications were observed. Conclusions and Clinical Importance: Tetrasodium EDTA infusions can be safely considered as a treatment option for mineralized SUB devices in cats. This solution was easily infused, well tolerated, and avoided the need for SUB device exchange in the majority of cats in which it was used. [ABSTRACT FROM AUTHOR]

Background Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. Objective To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. Design, setting, and participants This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. Surgical procedure Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. Outcome measurements and statistical analysis Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitations No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150 min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% ( n = 20) and complications were mostly of low grade. The high-grade complication rate was 2.2% ( n = 4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. Conclusions Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. Patient summary In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures. [ABSTRACT FROM AUTHOR]

Feline ureteral obstructions have emerged as a common problem. Ureteral strictures rarely are reported as a cause and the predisposing factors and clinical course of this condition have not been described. Evaluate cases of feline ureteral strictures and characterize historical features, clinical signs, diagnostic imaging, surgical and endoscopic findings, histopathology, treatment modalities, and short- and long-term outcomes. Ten cats diagnosed with ureteral strictures based on compatible findings from at least 2 of the following: ultrasonography, ureteropyelography, surgical exploration, or histopathology. Retrospective study. Median age, serum creatinine concentration, and size of the renal pelvis were 12 years, 3.7 mg/dL, and 11.75 mm, respectively. Six of 10 cats had hyperechoic periureteral tissue on ultrasound examination at the stricture site. Four cats had evidence of a circumcaval ureter at surgery. Eight cats had an intervention including ureteral stent placement (n = 6) and traditional surgery (n = 2). Seven of 8 cats had decreases in serum creatinine concentration and renal pelvic parameters preceding discharge and 6 had persistently improved results at their last examination. All patients survived to discharge. Median survival time was >294 days (range, 14 to >858 days) with 6/10 cats still alive. Ureteral strictures may occur in cats secondary to ureteral surgery, inflammation, a circumcaval ureter, impacted ureterolithiasis, or for unknown causes. With appropriate and timely intervention, the prognosis for long-term survival is good. In addition to ureteral reimplantation or ureteronephrectomy, ureteral stenting or SC ureteral bypass may be considered as future therapeutic options. [ABSTRACT FROM AUTHOR]

Objectives: The problem of ureteral reconstruction has not been fully solved, despite dramatic developments in surgical methods. Many attempts to repair a ureteral damage with autologous or homologous organ grafts, or with organic substitutes have not really been satisfactory. Also, attempts to use alloplastic and heteroplastic prostheses made of synthetic materials have been equally disappointing. Experimental studies, particularly in dogs, indicate great regenerative abilities of ureters when appropriate surgical techniques are used. Materials and methods: In our experimental study, suitability of the tunica albuginea for reconstruction of the middle part of the ureter was investigated in 20 dogs. The dogs were divided into two groups according to a type of ureteral damage: partial (a patch graft) or complete (a tube graft). The ureteral damage was 2–3 cm long in 10 dogs and 3–3.5 cm long in the subsequent 10 dogs. Each dog underwent two operations. The first operation involved a fenestrating incision in the ureter, 23.5 cm long, so as to preserve the ureteral continuity, and then the produced injury was repaired with a patch of the tunica albuginea, with the 4 Charr catheter being inserted in the ureter. The second operation involved a complete excision of ureteral segments, 2–3.5 cm long, on the contralateral side. The excised length of the ureter was substituted with a tube graft of the tunica albuginea, also using the 4 Charr catheter. Thus, in 21 cases, a partial damage of the ureteral wall was repaired with a patch graft of the tunica albuginea. In 19 cases, a complete damage of the ureter was repaired with a tube graft of the tunica albuginea. Results: Four dogs died after the tube-graft implantation due to urinary infiltration and/or purulent inflammatory changes in the kidneys. Autopsies were performed in all the dogs after they had been put to sleep. Definitely poor results were obtained in case of the complete reconstruction of the ureteral loss with a tube graft of the tunica albuginea, 3–3.5 cm long. Within the graft area, we observed inflammatory infiltrates of varied intensity, fibrosis, cicatricial strictures or ureteral obstruction. Occasionally, necrotic foci, degenerative changes or hydronephrosis were found. In case of the reconstruction with a shorter tube graft, i.e. 2–3 cm long, similar changes were observed, however, they were less intense. Satisfactory results were obtained following the partial reconstruction of the ureteral loss with a patch graft of the tunica albuginea. In this case, we observed generally normal regeneration not only of the transitional epithelium but the muscular layer and ureteral structure as well, with full patency of the ureter preserved. The findings obtained in our study are compatible with the findings of other authors. Conclusions: (1) The success of reconstructive procedures in the ureters can be achieved if the continuity of the ureter is preserved and the catheter is removed after 14 days. (2) The substitution of a complete ureteral loss with a tube-graft of the tunica albuginea results in necrosis of the graft and restenosis. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare no conflicts of interest.

Background: Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation., Objective: To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers., Design, Setting, and Participants: This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016., Surgical Procedure: RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side., Outcome Measurements and Statistical Analysis: Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed., Results and Limitations: The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%., Conclusions: RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures., Patient Summary: We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)