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Introduction: Appropriate risk stratification and complete tumor ablation are the key factors to optimize the oncologic outcomes of patients undertaking endoscopic management for upper urinary trac...

This section aims to review general principles of endoscopic management of urethral stricture disease and posterior urethral stenosis, with a special focus on the indications for treatment and technical aspects of urethral dilation and internal incision.

The gold standard treatment for primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent infections is ureteral reimplantation with or without tapering. In infants, open surgery can be technically demanding and associated with significant morbidity. We conducted a systematic review of the literature with special interest in endoscopic management of POM and its outcomes.A search was conducted of the MEDLINE/Ovid, PubMed, Embase, and Web of Science databases. Only full-text articles written in the English language and involving greater than one reported pediatric case per publication were included. Two authors independently extracted data and assessed strength of evidence for each study.We found 11 retrospective and 1 prospective, single institution case series that met selection criteria, describing 222 patients with 237 obstructed renal units. Mean age at time of surgery was 24.6 months. The most common endoscopic approaches were cystoscopy+high-pressure balloon dilation+Double-J ureteral stent placement (49.5%), cystoscopy+incisional ureterotomy+Double-J ureteral stent placement (27.8%), and cystoscopy+Double-J ureteral stent placement (18.9%). For all approaches and age groups, anatomic and functional success rates were 79.3% (146/184) and 76.7% (132/172), respectively. Anatomic success rates were highest in children ≥12 months of age (82.3%, 117/142). Endoscopic retreatment was performed in 15.1% of cases with a 36.7% overall surgical reintervention rate. Forty-one ureters progressed to ureteral reimplantation. Complications were generally mild (Clavien-Dindo Grades I-II), but 12 ureters did develop vesicoureteral reflux. Mean follow-up period was 3.2 years.Endoscopic management for persistent or progressive POM in children ≥12 months of age is a minimally invasive alternative to ureteral reimplantation with modest success rates. In infants, it may best be utilized as a temporizing procedure. Approximately one-third of patients require surgical reintervention.

Endoscopic management of upper tract urothelial carcinoma has become more popular over the last few decades as there has been an impetus for renal preservation in these patients. While radical nephroureterectomy has been the gold standard in treatment of this disease, ureteroscopic and percutaneous management has become a viable option for select patients.The literature on endoscopic management of upper urinary tract tumors was explored. Different management methods are discussed, both from published literature and experience of the authors of this chapter.We review the indications, details of the procedure, and troubleshooting methods in the endoscopic management of upper tract urothelial carcinoma. Imperative indications as well as controversial indications are discussed. The role and efficacy of adjuvant intrarenal topical agents are examined as well as the protocol for administering these agents. Follow-up protocols are also reviewed.In select patients, endoscopic management with ureteroscopy and/or percutaneous resection of upper tract urothelial tumors is appropriate and can preserve renal function while obtaining comparable oncologic control compared with radical surgery.

Ureteroileal anastomosis strictures are well-known complications of ileal conduit urinary diversion that occur in 4% to 8% of patients. Open surgical repair is the standard definitive treatment with minimally invasive, endoscopic approaches developed to prevent the need for major surgery when possible. Robot-assisted surgery has been applied to most primary urologic procedures, but the role of this surgery in the management of complications is undefined. We report our experience with two cases of robotic repair of ureteroileal anastomotic strictures after robot-assisted cystectomy, the first such cases to our knowledge, and review the literature regarding management of these strictures.Two patients underwent robot-assisted ureteroileal anastomosis revision for left-sided strictures of 1 and 6 cm in length after failed endoscopic management. Three ports were used in the first and four in the second procedure. The diseased segment was identified, and the healthy end of the ureter anastomosed to a new site on the conduit with a temporary stent. In the second case, the conduit was mobilized and brought to the end of the ureter for a tension-free anastomosis because of the length of the stricture.Both patients were discharged on the first postoperative day without complications and are without recurrence after nearly 2 and 3 years since the robotic procedure.Minimally invasive definitive revision of ureteroileal anastomotic strictures is feasible with a robotic surgical approach. The advantages of robotic instrumentation allowed successful repair in two patients after previous robot-assisted cystectomy and avoided major open surgery.

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era.We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months.Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively.Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Chronic unilateral hematuria is characterized by intermittent or continuous gross hematuria that cannot be diagnosed using standard radiology and hematology methods. In the past, it was managed with partial or total nephrectomy. In the age of minimally invasive procedures, however, endoscopy has enabled more accurate diagnosis and management. We analyzed our experience with transurethral ureterorenoscopy using a flexible ureteroscope to determine the feasibility and success of endoscopic management of renal hematuria.We reviewed the records of 13 patients who presented with chronic unilateral hematuria, in whom radiologic and laboratory tests failed to reveal the source of bleeding. In the cases in which the lesion was identified, after complete inspection of the collecting systems, the bleeding site was treated ureteroscopically with a holmium: yttrium-aluminum-garnet (YAG) laser.Follow-up ranged from 4 to 60 months (mean 26 mos). During the follow-up of the 13 patients, 11 remained symptom-free, with only one session of flexible ureterorenoscopy necessary. Relapse occurred in two patients after 4 months and 6 months, respectively; during a second session of flexible ureteroscopy, the bleeding site was successfully identified and cauterized with a holmium:YAG laser. No surgical complications occurred.Conservative treatment of patients with chronic unilateral hematuria should always be considered. Laser ureteroscopic treatment is an excellent method and should be considered as the first option for the management of chronic unilateral hematuria.

Introduction: Nonenhanced computed tomography (NCT) is recognised as the most sensitive tool in diagnosis of renal tract calculi. However, its role as the sole imaging investigation, for decisions regarding management is less clear. Objective: To determine the proportion of new stone patient referrals in which management is altered by interpretation of a plain abdominal kidneys, ureters and bladder (KUB) radiograph in addition to NCT. Methods: One hundred consecutive new referrals to a national lithotripsy centre were considered prospectively for treatment of renal tract calculi. Results: A significant change in management was undertaken in 17 patients on the basis of KUB findings. Eleven patients had radio-lucent ureteric stones, for which extracorporeal shockwave lithotripsy (ESWL) was consequently not possible and who required endoscopic management. There were six inaccuracies in measurement of size or positioning on NCT. In a further 43 patients it was not possible to confirm management until the KUB was reviewed, although in these cases ESWL or expectant management was still pursued. Thus additional imaging with a KUB was required in order to confirm optimum management in 60 patients. Conclusion: Additional plain radiography confers a significant advantage in the planning of treatment for urolithiasis once the diagnosis has been established by NCT because of information it provides regarding radio-opacity as well as stone size and visibility. This information cannot be delivered by NCT alone. We therefore recommend that KUB imaging is performed on all new stone patients referred for treatment.

Endoscopic management of posterior urethral valves and congenital ureteroceles is the current standard to relieve the obstruction. While the most commonly used techniques involve cystoscopic incision with cold knife or electrosurgery, an alternative is to ablate the obstructive tissue with laser energy. With increasing prenatal diagnoses, there has been an increasing shift in the timing of intervention toward earlier periods. The literature contains only two reports of laser ablation in neonates for these disease entities.A case series was conducted by retrospectively reviewing our surgical database for all consecutive infants28 days old (i.e., neonates) diagnosed in utero with obstructive uropathy and with postnatal imaging consistent with either urethral valves (anterior or posterior) or ureterocele. Holmium: yttrium aluminum-garnet (Ho:YAG) laser ablation was used as the exclusive modality of endoscopic management during the study period. All patients were followed with voiding cystourethrogram and renal/bladder ultrasounds postoperatively.Seventeen neonates underwent retrograde transurethral laser ablation procedures at a median age of 7 days (range 3-27). There were nine cases of urethral valve ablation (seven posterior, two anterior) and eight ureterocele ablations. Median operative time was 23 minutes (range 18-33). There were no intraoperative complications or reoperative procedures required for any case. All patients voided after postoperative catheter removal, and no patient had evidence of residual valve tissue or urethral stricture at mean follow-up of 10.1 months. All patients with ureterocele demonstrated partial or complete decompression of the ureterocele and improvement in hydroureteronephrosis at 3 months.Ho:YAG laser ablation appears safe, effective, and efficient for the management of urethral valves and ureteroceles in the neonatal period. With a continuing trend toward early definitive intervention for these conditions, laser ablation remains an important alternative to electrosurgery in this population.

Purpose: To compare the efficacy, safety, and features of pneumatic lithotripsy (PL) with those of laser lithotripsy (LL) and present our clinical experience in the endoscopic management of ureteral calculi. Patients and Methods: From August 1994 to February 2000, 285 consecutive patients underwent endoscopic lithotripsy with either the Swiss Lithoclast pneumatic lithotripter (145 patients) or the Ho:YAG laser lithotripter (140 patients) for the treatment of ureteral calculi. Results: In one single session, the overall successful stone fragmentation rate of LL was higher than that of PL (95.7% v 69.7%; P < 0.01). The average time to stone-free status was shorter for LL than for PL (18 days v 31 days; P < 0.01). No major complications were observed in LL, while five ureteral perforations were encountered in PL. Conclusions: Laser lithotripsy has advantages over PL in high efficiency of stone fragmentation and a low complication rate. Laser lithotripsy is a powerful, effective, and safe treatment modality f...

Endoscopic management of ureteropelvic junction (UPJ) obstruction has a success rate of 80% to 86%. We have been performing a ureteral cutting balloon procedure under fluoroscopic control (Acucise endopyelotomy) for UPJ obstruction at Loyola University Medical Center since 1991. The overall success rate in 77 patients was 78%. All patients had a preoperative intravenous urogram or a retrograde pyelogram, but none had vascular imaging studies. Acucise endopyelotomy consisted of a posterolateral incision of the UPJ and placement of an endopyelotomy or double-J stent. Foley catheter placement at the end of the procedure demonstrated significant gross hematuria in three patients (4%). All three remained hemodynamically stable but with significant drops in postprocedure hemoglobin levels, which necessitated blood transfusion. Aggressive management included angiographic studies and embolization of lower-pole branching arteries in two patients (3%). One patient stopped bleeding after being given two units of blood. None of the patients required an open exploratory procedure. Although the risk of vascular injury is low with Acucise endopyelotomy, prolonged postoperative gross hematuria does mandate investigation and observation. Angiographic embolization appears to be the therapeutic modality of choice for patients with hemorrhagic complications after an Acucise endopyelotomy.

Eighteen male patients underwent endoscopic management of urethral obliterations and severe strictures of the subprostatic urethra. Thirteen patients who performed clean urethral self-dilatation after endoscopic repair had a lower incidence of recurrent strictures (P = 0.03) and required fewer visual internal urethrotomies than the initial five patients, who did not self-dilate (P = 0.01). All patients had minimal morbidity and required short hospitalization to achieve adequate urine flow and a stable urethral neolumen during the follow-up period.

Between August 1991 and June 1994, endoureterotomy was performed in nine patients for total ureteral occlusion. Four of these patients had an associated ureterovaginal fistula. The total ureteral occlusions were iatrogenic in eight patients and the result of trauma in one. The prone split leg position was used to facilitate simultaneous antegrade and retrograde ureteroscopy in all nine patients. The "cut-to-the-light" technique was utilized in six patients and a new technique employing a fascial incising needle was used in five patients. Five patients developed ureteral strictures within 5 months of the primary procedure that were corrected endoscopically. With a mean follow-up of 22 months, all nine patients have a successful outcome. Endoscopic management of difficult urteral disease such as total urteral occlusion and ureterovaginal fistula is a useful alternative to open surgery.

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.

We present a technique of transurethral transvesical endoscopic management of an intraperitoneal retrovesical hydatid cyst. Cystoscopy is performed using a 20.8F nephroscope. The cyst is punctured using an 18-gauge, 36-cm needle through the nephroscope operating channel. Saline (20%) is used as scolicidal agent. After balloon tract dilation, the nephroscope is introduced into the cyst, and the hydatid material is evacuated.

A 46-year-old woman presented with total painless gross hematuria, an 8-mm polypoid mass that proved to be a lymphangioma was found in the upper pole collecting system of the left kidney. The mass was resected ureteroscopically with holmium laser fulguration of the base. The few reported cases of this rare lesion suggest that rigorous postoperative surveillance is not necessary for this benign condition.

We report our experience with the holmium laser in the endoscopic management of primary obstructive megaureter (POM) in adults.From February 1997 to September 1998, three women and one man 26 to 63 years old underwent ureteroscopic endoureterotomy for POM with symptomatic vesicoureteral junction obstruction. The left ureter was more commonly affected than the right (R:L 1:3). The diagnosis of POM was based on a clinical history, intravenous urography, diuretic renography (T 1/2), and micturating cystogram. Endoureterotomy of the juxtavesical and intramural part of the ureter was performed in a retrograde fashion using the holmium laser. Incision of the subepithelial part of the ureter and the ureteral orifice was avoided. A pigtail stent was left in situ for 6 weeks. Postoperatively, patients were assessed at 3 months and yearly thereafter. The mean follow-up was 30.5 months.All patients demonstrated symptomatic and radiologic improvement.Endoscopic incision of POM in adults with the holmium laser is safe, simple, and minimally invasive. This procedure should be considered as an initial approach for patients who have failed conservative treatment. However, further follow-up is necessary to determine its long-term efficacy.

To review our institutional experience in the management of ureteroenteric strictures by primary endoscopic intervention or primary open revision.Between January 2000 and December 2007, 28 patients with ureteroenteric strictures underwent endoscopic management (n = 21) or open revision (n = 7). Strictures were characterized with regard to length and side as well as time to failure between the two groups. Success was defined as symptomatic improvement and evidence of patency on follow-up radiologic imaging.Of all study patients, 78.6% were symptomatic on presentation. Endoscopic intervention (balloon dilation, electroincision, or holmium endoureterotomy) was successful in six patients for an overall success rate of 27% with a median follow-up of 21 months. Open revision was successful in 87.5% (7 of 8) patients for whom initial endoscopic surgery had failed. The success rate of primary open revision was 71.4% (5 of 7 patients) with a mean follow-up of 18.1 months. For the entire series, left-sided strictures were more common than right sided strictures; however, side and stricture length were not found to be significant (P0.05) with regard to patency. Functional renal imaging studies were performed in 42.9% of all study patients postoperatively.Endoscopic management continues to have success rates that remain lower than that of open revision. Left-sided strictures remain more common than right-sided strictures; however, side and stricture length were not found to be statistically significant in our series. The lack of consistent postoperative functional renal studies highlights the importance of diligent monitoring and warrants further study to develop a surveillance algorithm.

Fibroepithelial polyps of the ureter are rare benign tumors that have traditionally been managed by open exploration and resection. Endoscopic resection have been regarded as the gold standard for small lesions, while the management modality for long lesions is still controversial. We review our experience with ureteroscopic management of long (6 cm) ureteral fibroepithelial polyps by holmium: yttrium-aluminum-garnet (YAG) laser resection.Five patients with a long ureteral fibroepithelial polyp underwent ureteroscopic resection using a holmium:YAG laser.Endoscopic management was successful in all five patients, and no major complications resulted from the approach. The average length of stay was 3 days (range 2-5 d). The mean length of the lesions were 11 cm (range 6-16 cm). The ureteral stent was removed at 6 weeks. No recurrences were seen during a mean followup of 24.2 months (range 3-51 mos). One ureteral stricture developed at 3 months, and the patient underwent endoscopic treatment by holmium:YAG laser.Endoscopic management of long ureteral fibroepithelial polyps is an acceptable modality with minimal morbidity and durable treatment results. The holmium:YAG laser offers the advantages of facilitating the use of a small-caliber fiber or flexible ureteroscope and allows safe destruction of the stalk and efficient removal of the entire polyp.

To discuss the merits of the endoscopic management of upper-tract transitional-cell carcinoma (UTTCC). We present original data from our institution over an 8-year period and a review of some of the world literature. A discussion of the overall suitability of this modality for both clinician and patient is presented.A retrospective chart review was performed comprising operative logs, departmental databases, and pathologic registers. These sources were analyzed, and data were collected on all patients who underwent ureteroscopic treatment of UTTCC. Patients with at least 6 months of follow-up were included in the study.Forty-five patients (mean age 65 yrs) were identified who had undergone ureteroscopic treatment for UTTCC with either therapeutic or palliative intent between 1998 and 2006. Of these, 19 procedures were performed electively in patients with normal contralateral kidneys. Those patients with low-volume, low-grade tumors on biopsy and negative results of urinary cytologic evaluation recovered well, with few recurrences. None of this group progressed to radical surgery. Of 12 patients never considered for radical surgery, only 1 died of the disease after a median follow-up of 15 months.Elective ureteroscopic holmium:yttrium-aluminum-garnet laser ablation of UTTCC is a safe and effective treatment for a select group of patients. In our institution, patients with normal functioning contralateral kidneys are considered for endoscopic treatment and follow-up of their disease if disease is found to be of low grade and volume. Inadequacies in the staging of UTTCC mean that this may, in some cases, turn out to be suboptimal management, and therefore we maintain a low threshold for recommending radical surgery. For another group of patients with single kidneys, global renal dysfunction, or severe comorbidity, endoscopic treatment can prove a valuable palliative option even in those persons who have a large tumor bulk or relatively rapid disease recurrence.

We report the ureteroscopic unroofing of a symptomatic peripelvic cyst with a holmium laser in a 37-year-old woman. At 1-year follow-up, the patient remains symptom free. Endoscopic management of peripelvic cysts is durable and can be performed safely.

Although extracorporeal shockwave lithotripsy (SWL) is a successful treatment for ureteral calculi, introduction of miniureteroscopes has advanced endoscopic management. We combined the use of a semirigid ureteroscope with a pneumatic lithotripter (Swiss Lithoclast) for the treatment of ureteral calculi. From January 1992 to August 1994, 143 patients (87 male, 56 female; mean age 48.7 years; age range 22-74 years) with urolithiasis underwent endoscopic lithotripsy with the Swiss Lithoclast under general anesthesia. The 0.8 = mm probe was inserted through the deflected working channel (3.4F) of the Micro-6L ureteroscope (tip diameter 6.9F). The calculi were in the distal (N = 96; 67.1%), mid (N = 34; 23.8%), and proximal part (N = 13; 9.1%) of the ureter. The mean stone size was 6.8 mm (range 5-26 mm). Of the 137 patients whose stones we could access adequately, 70 (51.1%) were stone free immediately after the procedure, and another 31 (22.6%) had residual fragments3 mm that passed spontaneously. The remaining 36 patients underwent another 50 procedures; 30 SWL sessions in 26 patients (19%), 17 further endoscopic lithotripsies in 14 (10.2%), and open surgery in 3. Application of the Swiss Lithoclast through semirigid miniureteroscopes is highly effective for endoscopic lithotripsy, regardless of stone composition. Deflection of the probe up to 30 degrees did not impair the disintegration rate. Because of the high migration rate of mid and proximal ureteral stones, the Swiss Lithoclast is not recommended in these cases as a primary procedure. Low capital cost and simple and safe handling are the device's major advantages over laser lithotripsy.

To evaluate the outcome of endoscopic management of upper-tract transitional-cell carcinoma (TCC).From March 1991 to March 2006, 40 patients with upper-tract TCC were treated by an endoscopic approach as the primary management: 37 (90.2%) by ureteroscopy and by percutaneous techniques or both approaches in 2 cases each (5%). Follow-up was between 5 and 115 months (mean 41.6 months). Most of the patients, 26 (65%), had a normal contralateral kidney, and the indication for conservative management was low tumor grade or tumor size (2 cm) and patient commitment to a rigorous follow-up protocol. Absolute and relative indications for conservative management such as solitary kidney were met in 14 patients (35%).Treatment consisted of electrocautery only in 15 cases (36.6%), neodymium:YAG or holmium:YAG laser only in 11 (26.8%), and combinations in 15 (36.6%). Most of the patients (74.3%) had an upper-tract recurrence. The renal-preservation rate was 70.7%, and the survival rate was 80%.Conservative treatment is preferred in patients with bilateral disease, a solitary kidney, or co-morbidities that contraindicate major surgery. Patients with low-grade, low-stage disease and normal contralateral kidneys also benefit from this approach provided adequate endoscopic follow-up can be achieved and the surgeon has a low threshold for carrying out ablative surgery.

Stones in the seminal vesicle are rare. Open surgery to remove either the seminal vesicle or the stone usually is required. We report a case of seminal-vesicle stones compounded by cutaneous fistula that was treated by ureteroscopy, intracorporeal lithotripsy, and fulguration of the fistulous tract.

Complete ureteral obstruction after pelvic surgery is traditionally managed by open repair. Recent advances in endoscopic instruments and techniques have improved the efficacy with which these conditions are treated. Here, we describe our experiences with a holmium:YAG laser in the endoscopic management of complete ureteral obstruction.Retrograde endoscopic ureteroureterostomy using a Ho:YAG laser was performed on five patients with complete ureteral obstruction having a mean length of 0.9 +/- 0.2 cm after gynecologic surgery. The obliterated segment was incised with a 550-microm fiber through a rigid ureteroscope and under fluoroscopic guidance. Afterward, balloon dilatation was performed. A 7F/14F endopyelotomy stent was maintained for a mean time of 7 weeks, and follow-up was conducted via radiologic imaging.Recanalization was possible in all five patients immediately. One month after the initial operation, one patient exhibited a normal ureteral passage, and three other patients exhibited partial ureteral stricture. The remaining patient was lost to follow-up. Of the three patients with partial strictures, two evidenced no stricture after additional endoscopic treatment(s), and the remaining patient eventually underwent open repair. Overall, three of four (75%) patients exhibited normal excretory function without any open surgery and were symptom free with a mean follow-up time of 45 months (range 23-67 months).Although the number of patients in this study was small, it appears that endoscopic ureteroureterostomy with a Ho:YAG laser may constitute a valuable option for the treatment of complete short ureteral obstructions.

To summarize the status of endoscopic treatment for ureterointestinal anastomotic strictures after radical cystectomy.We reviewed the English-language literature identified by PubMed and MEDLINE to evaluate the efficacy of various treatment options for these strictures.Cumulative success rates from multiple studies analyzing patency after balloon dilation, endoureterotomy, and metal stenting specifically for ureteroenteric strictures were 18%, 63%, and 83%, respectively. Studies have not clearly shown any significant advantage over any specific cutting modality. The use of metal stents appears promising but is still fraught with complications of tissue ingrowth and recurrent obstruction. Clinical factors that appear to be associated with a poor prognosis are age60 years, left-sided strictures, length1 cm, stenting4 weeks, and poor function in the affecting kidney.Ureteroenteric strictures remain the most challenging and difficult of all ureteral strictures to treat. An evolution of technology has helped advance the therapeutic options available. Given the rarity of this condition, limited study designs, and small numbers of patients, conclusive statements regarding the optimal treatment for this condition are difficult. Given its patency rates and possible complications, endoureterotomy should be considered the initial treatment of choice in properly selected patients.

To present our clinic experience with the Swiss Lithoclast pneumatic lithotripter in the endoscopic management of urinary calculi.From August 1994 to December 1997, 145 patients with ureteral calculi and 5 patients with urethral calculi were treated with the Swiss Lithoclast.In the ureteral stone group, ureteroscopic addressing of the stones was successful in 133 patients. In 27 patients, the stones were partially fragmented and remained in situ or were pushed back to the calices. They were subsequently treated successfully with SWL. Stones were fragmented in a single session in 101 cases. Complications associated with the procedure included five perforations and four urinary tract infections. All of the five urethral stone patients were treated successfully with pneumatic lithotripsy. The overall successful fragmentation rate thus was 70.7% (106 of 150) and 88.7% (133 of 150) in combination with adjuvant SWL.We have found Swiss Lithoclast pneumatic lithotripsy to be a safe, effective, and economical treatment method for urinary calculi. If combined with other modalities such as SWL, this treatment will be even more effective.

Renal candidial infections have been described in the literature in susceptible populations of all age groups. Systemic antifungal agents have been successful in treating these patients, but in the presence of an obstructed kidney, antegrade (perurethral) or retrograde (percutaneous) drainage of the pelvicaliceal system is mandatory to salvage the kidney. An aggressive percutaneous endoscopic approach for the management of such a case in a young diabetic patient with multiple comorbidities is described here with initial success.

Ureteral injury is an uncommon complication of cesarean section. As with all iatrogenic ureteral injuries, if the problem is not recognized intraoperatively, the manifestations may be protean. The management of ureteral injury that is first recognized in the early postoperative period must be individualized. We present a case of ureteral injury during a cesarean section in which endoscopic techniques were employed successfully to establish kidney drainage and allow ureteral healing, obviating open surgical repair.

Hourglass-shaped vesicoprostatic calculi have been reported as a late complication of prostatectomy and in association with chronic urinary tract infections in young men. The accepted treatment for these calculi has been removal by suprapubic cystostomy. We present a case of a large hourglass-shaped vesicoprostatic calculus managed with a combination of laser and electrohydraulic lithotripsy. Endoscopic management in such cases may result in fewer complications and a shorter hospital stay.