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Objectives: The incidence of transitional cell carcinoma of the renal pelvis and ureter is low, and the standard treatment is nephroureterectomy with a bladder cuff. However, there are special circumstances, from both patient and tumor characteristics, which are subsidiary of a minimally invasive endoscopic treatment, such as percutaneous resection. Very satisfactory results have been obtained with this technique, which has been performed since 1985. Nevertheless, theoretically there exists a potential risk of disseminating tumor cells when performing this technique. The objective of this article is to review our experience, and that of other groups, performing percutaneous resection of upper urinary tract tumors, and to determine the incidence tumor dissemination., Methods: We performed a bibliographic search in Medline (PubMed) and reviewed the articles about upper urinary tract tumors treated by percutaneous resection. We also evaluated the incidence of tumor dissemination related to surgery, Results: Published data show a very low incidence of tumor dissemination after endoscopic resection by a percutaneous approach. Theoretically tumor dissemination can be the result of dissemination to the blood or lymphatic circulation, or the implant of tumor cells in the contiguous or distant urothelial mucosa, or propagation of these tumor cells to the retroperitoneal space or the nephrostomy track., Conclusions: Percutaneous endoscopic resection of upper urinary tract urothelial tumors is a safe and effective technique that enables a minimally invasive and nephron sparing treatment. If some precautions are taken, this surgical technique does not involve a significant risk for tumor cell dissemination.

Low grade and stage upper urinary tract tumors may be treated endoscopically by antegrade or retrograde approach. The approach mainly depends on tumor size and site. Generally, retrograde ureteroscopy is used for small size tumors of the ureter and kidney, whereas the antegrade approach is indicated for bigger tumors in the upper ureter or kidney, or those tumors which cannot be adequately managed in a retrograde manner because of their site (lower calyx) or previous urinary diversion. This article presents the techniques of retrograde ureteroscopy and percutaneous antegrade resection, as well as the equipment needed for adequate endoscopic treatment of the upper urinary tract urothelial tumors.

We develop the diagnostic methodology to select patients with upper urinary tract urothelial tumors who are candidates for percutaneous endoscopic treatment. This treatment is indicated for low grade and stage lesions in the pyelocalyceal system (> 3 cm), lumbar ureter (> 1-2 cm) and for failures of the retrograde approach. In this protocol, we emphasize the performance of intraoperative biopsy and pyelocalyceal mapping, as well as the need of a second look to rule out residual tumor.

Objectives: Upper urinary tract tumors account for 2-4% of urinary tract tumors and 5% of urothelial tumors. The pyelocalyceal system (75%) and distal third of the ureter are the most frequent locolizations. Various series confirm a relatively benign course of low grade and stage tumors, with survivals around 80-66% for pyelic and ureteral tumors respectively. Tumor grade and stage are the most important factors for patient outcome, more than type of treatment undertaken (classic radical nephroureterectomy vs. conservative surgery). With the development of endoscopic techniques and the use of new equipment, both ureteroscopy and nephroscopy have gained a relevant role in the study and treatment of upper urinary tract tumors in selected groups of patients., Methods/results: We describe data from the literature about the nature of urothelial tumors, diagnostic methods, and indications of conservative management. We performed a retrospective chart review of patients undergoing endoscopical procedures (ureteroscopy and nephroscopy) to rule out upper urinary tract urothelial tumors at the Hospital Ramon y Cajal in Madrid between January 1996 andJune 2003. We do a comparative analysis between our results and those referred in the literature and a previous study in our department published in 1996., Conclusions: Both ureteroscopy and nephroscopy are effective and safe procedures in the diagnosis and treatment of suspicious-looking lesions of the urinary tract, with a low complication rate. Main indications are small, papillary, and low grade tumors, confined within the mucosa, with negative urinary cytolo,gy, in patients with associated comorbidity, solitary kidney or bilateral tumors.

Objective: To present the results achieved by rigid transurethral ureteroscopy for the management of ureteral calculi over a period of 10 years., Methods: From January 1991 to November 2000, 735 rigid transurethral ureteroscopy procedures for ureteral calculi were performed in our Lithotripsy Unit. The rigid ureteroscopes utilized ranged from 9.5-11.5 F. There was a higher prevalence of male patients (63%). The mean age was 49.9 years. Calculi were more frequently localized in the pelvic ureter (74.2%). The mean maximum diameter of the calculi was 9.6 mm and caused moderate to severe uropathy in 78.6% of the cases and functional impairment in 3.7% of the cases. After performing ureteroscopy, a double-J catheter was left indwelling in 65.8% of the patients. The patients were discharged from hospital usually 12-18 h after the endoscopic procedure., Results: Of the 735 ureteroscopies performed, satisfactory results were achieved in 676 cases (92%); stone resolution was not achieved in 59 cases. For complete resolution of the calculi, mechanical or electrokinetic fragmentation was used in a high proportion of patients (56.3%). Removal of the stone or stone fragments was mainly by forceps (79.7%); the Dormia basket was used in 18.2% of the cases. The complications occurred during or immediately after the procedure and were minor (10.7%), although there were 3 patients with major complications (2 ureteral eversion and one case of ureteral avulsion)., Conclusions: In our view, rigid transurethral ureteroscopy is a useful, safe and efficient technique in the treatment of calculi in the pelvic ureter, and in selected cases of calculi in the sacral or lumbar level, after failed ESWL. Rigid transurethral ureteroscopy achieves excellent resolution and the complications are scanty.

Objective: To briefly describe the life and works of D.F.J.B. Trehet, a physician of the city of Rouen (France), who was the first to describe the "osseous points" in a renal calculus. Trèhet has not been recognized or referenced for this original observation in the urological publications., Methods: Trehet lived in the period of the Enlightenment and endured the upheavals of the French Revolution. Data gleaned from several sources have permitted and elaborate description of this French physician from both the social and professional perspectives., Results: After completing his studies at the Hôtel Dieu in Rouen, D.F.J.B. Trehet pursued his education at the School of Health in Paris. He read his doctorate's thesis at the Paris School of Medicine in 1803 and published his observation of a renal calculus "with osseous points" in 1812. Other studies by D.F.J.B. Trehet were also published in Le Journal de Médecine, Chirurgie et Pharmacie., Conclusions: D.F.J.B. Trehet should be recognized as the first to describe an osseous renal calculus.

Objective: To analyze our series of patients with renal lithiasis who underwent partial nephrectomy from 1980-1999., Methods: 28 patients who underwent partial nephrectomy were analyzed (22 females; mean age 48.09 years, and 6 males; mean age 60 years). Surgery for lithiasis had been previously performed in 5 renal units. Nine patients had previously undergone ESWL (more than 3 sessions), all of whom subsequently developed multiple residual calculi. Twelve patients had a microbiologically confirmed positive urine culture. The renal lithiasis amenable to treatment by partial nephrectomy was frequently localized in the lower calyces (17 cases)., Results: Histopathological analysis of the nephrectomy specimen showed a prevalence of signs of chronic parenchymal atrophy (25 cases). Three cases showed segmental renal dysplasia (those in whom a superior heminephrectomy was performed for duplex excretory system). Fifty percent of the stone fragments analyzed showed calcium phosphocarbonate. Eight patients had postoperative complications; the most important were two cases of renal cutaneous fistula and one subphrenic abscess. At 9 1/2 years' mean follow-up, renal function is normal in 25 patients. Lithiasis developed in the contralateral unit in 6 cases and in the same renal unit in one case., Conclusions: Partial nephrectomy continues to be a therapeutic option for lithiasis. Its indication depends on the morphological and functional characteristics of the compromised renal unit, especially in those cases in whom renal preservation can be obviated due to its scanty significance.

Objective: To review the embryological and clinical aspects of the different types of pyelocaliceal diverticula, with special reference to the differential diagnosis and treatment., Methods: Images of type I and II pyelocaliceal diverticula are shown. The conditions that cause difficulty in making the differential diagnosis are discussed., Results: Urography continues to be the diagnostic method preferred and is sometimes aided by retrograde ureteropyelography., Conclusions: Pyelocaliceal diverticula are cystic eventrations of the upper urinary tract lying within the renal parenchyma that communicate through a narrow channel into the main collecting system. They occur in 0.2 to 0.5% of the population and are congenital in origin. Calyceal diverticula are frequently found incidentally on routine excretory urograms, but patients may complain of flank pain, hematuria or recurrent urinary infections. In the past, treatment required open renal surgery. Endourologic procedures are widely utilized today.

Objective: To study the phenomenon of biomineralization in an experimental model of lithogenesis by percutaneous renal punction without laparotomy and no antibiotics., Methods/results: The study comprised 4 Brown-Norway rats. Nanobacteria inoculum (X, 2X and 4X) was administered to three rats and the remaining one was used as control. The analytical and radiological findings showing the development of obstructive pyelocaliceal lithiasis in the kidneys of rats no. 2 and 3 are presented., Conclusions: Translumbar percutaneous renal puncture has permitted performing laparotoy without antibiotic coverage, which was the main difficulty of the experimental model of lithogenesis. Nanobacteria were cultured successfully, but not without difficulty, and formation of calculi in the rat pyelocaliceal system was achieved. This experimental model will provide further insight into lithogenesis and will allow us to find the answers to some of the many questions concerning this condition that remain.

The discovery made by the group of Dr. Stella Fatovic-Ferencic in Varazdin (Croatia) of a painting of St. Liborius, patron saint invoked for calculi, and the painting of the Sevillian school (circa 1700) discovered by another group in Spain have led to the retrieval of part of the history of European Urology forgotten 250 years ago. Saint Liborius, bishop of Le Mans (France), died in 397, at the time the barbarian hordes were ravaging the Roman Empire, which had been divided into a Western and an Eastern Empire on the death of Theodosius I. Learning more about St. Liborius is of interest. Here is an example of the Graeco-Roman culture of antiguity that is passed on to the present time. The significance of both paintings and their differences are described. The article concludes that on the basis of his biography, St. Liborius should be considered the patron saint of Urology.

W. H. Wollaston, who first described cystine stones, as well as the most outstanding contemporary figures and their contribution to the understanding of this uncommon type of lithiasis are described.

Objective: To describe a case of adult renal polycystosis causing intercostal hernia with intestinal segment. To our knowledge, no such case has been previously reported in the literature., Methods/results: Diagnosis was by abdominal CT. Treatment was by bilateral nephrectomy and surgical repair of the diaphragmatic and intercostal hernia., Conclusions: Surgery is indicated in adult renal polycystosis if kidney size causes gastrointestinal involvement and above all, if the lungs are compromised by the intercostal diaphragmatic hernia.

Objective: The fact that for an equivalent oversaturation of solutes, urine of lithiasic patients has a greater tendency to form crystals, indicate that urine of stone-formers may contain substances that promote crystallization., Methods: A renal calculus was analyzed by infra-red spectrophotometry, x-ray dispersion energy spectrophotometry, ultraviolet absorption spectrophotometry, acid hydrolysis cationic exchange chromatography, SDA-Page gel electropheresis with Coomassie Blue and amino acid sequence., Results: It was a pure protein calculus formed by a beta 2-microglobulin anomaly. It was a residue that had lost its first 19 amino acids and phenylalanine replaced serine in position 19, Conclusions: Changes in the amino acid sequence of urinary proteins can cause these to behave like urinary calculus-promoting substances.

Objectives: To review the diagnosis and treatment of ureteral stenosis arising from endometriosis and describe a case of mixed (intrinsic and extrinsic) ureteral endometriosis., Methods: The diagnostic and therapeutic aspects of ureteral stenosis due to endometriosis are reviewed. The case of a patient with a nonfunctioning right kidney and hematuria is described. The patient had previously undergone hysterectomy and double adnexectomy for uterine leiomyofibromas and a right ureteral lesion that warranted cuff ureterocystoneostomy leaving the extreme distal third of the pelvic ureter. CT evaluation disclosed a right retrovesical mass. The therapeutic strategy consisted in performing percutaneous nephrostomy, ureteroscopy of nonfunctioning ureter and determining the nature of the retrovesical mass by fine needle punction aspiration biopsy., Results: Percutaneous nephrostomy achieved functional recovery of the renal unit. Endoscopic incision of the stricture with intravesical invagination of the compromised segment was performed with the combined antegrade and retrograde approach. The anatomopathological findings of ureteroscopic biopsy of an intraureteral lesion in the nonfunctioning ureter disclosed ureteral endometriosis. This finding obviated fine needle punction aspiration biopsy and the patient was treated with danazol for 6 months., Conclusions: Diagnosis by ureteroscopy should be considered in intrinsic and mixed forms of ureteral endometriosis. Endoscopic incision of the ureteral stricture combined with hormone therapy is a valid therapeutic option.

Objectives: A new form of minimally invasive treatment of ureteral stricture with the Acucise catheter is described herein., Methods: The method for catheter use for the ureteral incision using radiological control alone is described., Results: The technique is easy to perform. There were no early postoperative complications in strictures at the juxtavesical or upper lumbar ureter., Conclusions: The availability of balloon dilatation catheters equipped with an electrocautery device permits incision of the ureteral stricture using radiological control alone, preferably those in the juxtavesical or upper lumbar ureter. Those localized to other levels of the ureter are not free from vascular or visceral lesions.

Objectives: Ureterointestinal stricture represents a serious problem whose management has traditionally been by open surgery. Endourological treatment is an alternative that is generally free from the complications of open surgery, but with a lower success rate. The efficacy of endourological treatment is analyzed in 14 cases of ureteroileal stricture (12 patients) and the different treatment options are discussed., Methods: Ureteroileal stricture was managed endourologically in 9 of 13 cases (69%) by dilatation (6 cases), incision+dilatation (2 cases) and stenting (1 case)., Results: Of the 6 cases submitted to dilatation, 3 recurred at 6 months, 2 remained patent at 18 and 24 months, respectively, and 1 was lost to follow up because the patient underwent reimplantation (40% success rate). The two cases submitted to incision are patent at 18 and 19 months, respectively., Conclusions: The overall success rate for endourological treatment of ureteroileal stricture is 28% (4/14 cases) at 19 months mean follow up.

Objective: The present study analyzed the hydrodynamic behaviour of the double-J stent., Methods: Thirty-two double-J stents of different sizes and biomaterials (16 new and 16 removed from patients) were hydrodynamically evaluated using two models: a) nephroureterocystectomy surgical blocks harvested from pigs and b) an in vitro experimental model of the upper urinary tract. The following parameters were measured: initial and final weights, encrusted material weight, inside and outside diameters, number, size and distribution of sideholes, wall thickness, drainage area and length of time the catheter was indwelling in the patient., Results: Double-J stent placement in a normal upper urinary tract constitutes a partial obstruction that is proportional to the caliber of the catheter. Ureteral-flow reduction is 83%, 61% and 58% for 5FR, 6FR, and 7FR catheters, respectively. Extraluminal obstruction of the catheter reduces ureteral flow more than intraluminal obstruction (74%, 43% and 25% for extraluminal versus 83%, 66%, 57% for intraluminal for 5FR, 6FR and 7FR, respectively). Vesicoureteral and vesicorenal reflux pressures were 6.2 +/- 0.3 cm H2O and 35.2 +/- 2 cm H2O, respectively., Conclusion: Selection of a double-J stent must be individualized on the basis of indication, time indwelling, sex and route of insertion.

Objective: This paper describes the endoscopic incision of uretero-ileal anastomotic strictures by a combined approach (percutaneous antegrade and endoscopic retrograde) using the intraluminal invagination technique over a balloon dilatation catheter., Methods: The different steps of the surgical procedure of incision of the stenotic segment of different techniques of ureteroileal diversion (Bricker, Camey, ureterosigmoidostomy) are described in detail. Endoscopic images and those from the image intensifier are shown., Results: Of the 6 cases described herein, incision was achieved in 5 and in 1 case stenting of the stenotic segment could not be achieved., Conclusions: Intraluminal invagination of the stenotic segment considerably facilitates endoscopic incision.

Objectives: Herein we describe the technique of endoscopic incision in the treatment of ureterointestinal stricture., Methods: A teflon sheathed stent is placed in the stenotic ureterointestinal segment utilizing a combined approach (percutaneous antegrade endoscopic transrectal) and a balloon is passed over the stent retrogradely. The balloon is then inflated and is pulled retrogradely to invaginate the anastomosis into the rectal lumen. Thereafter, endoscopic incision of all the layers and the entire length of the stricture is performed by electrocautery., Results: The radiological evaluation three months postoperatively show marked morphological and functional improvement of the compromised renal unit., Conclusions: In patients with a ureterointestinal urinary diversion, endoscopic incision of the stricture at the site of the anastomosis is a valid therapeutic technique, after discarding the presence of urinary infection or tumor at this site. Furthermore, open surgery can be done in the event this technique fails to achieve the desired results.

We report 4 cases of primary congenital paraurethral diverticula or cavities (3 diverticula and 1 cyst of Cowper's glands) that were treated by endoscopic surgery. All the foregoing cases were diagnosed as primary in the absence of coexisting pathologies or associated disorders. The wall between the diverticulum and the urethral lumen was sectioned endoscopically. All patients recovered normal clinical and morphological status.

We report three cases of retrocaval ureter with a clear indication for surgery: one patient with severe hydronephrosis and two cases with mild dilatation of the renal pelvis, calyces and upper ureter, both complicated by renal stones. The initial diagnosis was based on the ultrasound and the intravenous urogram findings, and was confirmed by a retrograde pyelogram in combination with cavography and CT. All patients were submitted to surgery (1 nephrectomy and 2 uretero-ureteric anastomosis). Renal stone was resolved at the same time in one case, and by ESWL after surgery in the other.

There is scant literature on bone lithiasis, a disease entity whose diagnosis depends fundamentally upon the anatomopathological findings. The data gleaned from animal experiments have been shown to overlap with those observed in the clinical setting. Conservative treatment should include resection of the urothelial bony metaplasia to avoid recurrence. The importance of making a correct diagnosis cannot be overemphasized since this condition may be associated with a tumoral lesion and a close follow-up is therefore warranted.

Six cases of vascular lesion associated with percutaneous removal of renal calculi are described. The lesions had been caused during percutaneous access or ultrasound fragmentation of the stone. Those that had resolved spontaneously have not been included. When vascular injury is suspected during the procedure, the appropriate measures must be taken to resolve the different complications, such as arteriovenous, arteriocaliceal or venocaliceal fistula. Since there is little reference to this subject in the Spanish literature, the experience described herein may be of interest to the urologist who has only recently begun to perform this technique.

Unlike the other exploratory techniques (US, arteriography, phlebography, CT and MRI), laparoscopy constitutes the only reliable diagnostic method for absent testis, which has a high incidence in children with non palpable testes. The finding of the blind-ending spermatic veins and deferent duct confirms the diagnosis of absent testis.

We analyze the results achieved by extracorporeal piezoelectric lithotripsy (EPL) in 40 renal units with the following anatomic anomalies: solitary kidney (10), chronic pyelonephritis (8), medulospongiosis (6), caliceal diverticula (5), intrarenal cysts (5), pyeloureteric duplicity (3), megacaliosis (1), horseshoe kidney (1), and ureterocele (1). Adequate stone fragmentation was achieved in 80% of the patients with solitary kidney; 20% developed obstructive complications (1 patient with a 15 mm.-stone and 1 patient with obstruction of double-J catheter). At 6 months, stone remnants persist in 71.4% (5/7) after stone fragmentation in those cases with pyelonephrosis. The rates for fragmentation, elimination of remaining stone fragments, and disappearance of pain are 80%, 50% and 100% for diverticular caliceal calculi, and 67%, 50% and 100% for those in kidney with medulospongiosis. We can conclude that placement of a double-J catheter is useful before EPL in patients with solitary kidney and calculi greater than 10 mm. EPL is the first therapeutic approach in symptomatic lithiasis in caliceal diverticula or precaliceal cystic dilatation (medulospongiosis).