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INTRODUCTION AND OBJECTIVE:Iatrogenic injuries commonly occur at the distal ureter. The gold standard for distal ureteral injury is ureteroneocystotomy, however new techniques such as side-to-side ...

INTRODUCTION AND OBJECTIVE:Radical nephroureterectomy (RNUx) with bladder cuff excision (BCE) is the gold standard for the treatment of non-metastatic UTUC. The optimal method of dististal ureter m...

INTRODUCTION AND OBJECTIVES:To evaluate the impact of distal ureter management on oncological results after Laparoscopic/Robotic nephroureterectomy comparing intra-corporeal versus open extra-vesic...

We assessed the efficacy of extracorporeal shock wave lithotripsy for large (more than 10 mm) ureteral calculi with the unmodified Dornier HM3 lithotriptor.A total of 96 consecutive patients with large ureteral stones were treated with shock wave lithotripsy using an unmodified HM3 lithotriptor. Patients, stone characteristics, preliminary treatment before shock wave lithotripsy, additional procedures after shock wave lithotripsy, complications and clinical outcomes were assessed.Between 2000 and 2003 a total of 96 patients (75 males, 21 females, mean age 51 years [range 16 to 81]) with large ureteral stones underwent shock wave lithotripsy. Average stone size was 14 mm (range 10 to 22), 90 stones were calcified, and 66 stones were located in the upper ureter, 20 in the mid ureter and 10 in the distal ureter. A total of 77 (80.2%) patients underwent a single shock wave lithotripsy session, 18 (18.7%) underwent 2 sessions and 1 (1.1%) patient underwent 3 sessions. The overall stone-free rate was 86.5% (83 patients). Complications occurred in 10 (10.4%) patients. Shock wave lithotripsy failed in 13 (13.5%) patients who were successfully treated with ureteroscopy.Our data show that shock wave lithotripsy for large ureteral stones along the entire ureter with the unmodified HM3 lithotriptor has a high success rate with minimal morbidity. We recommend it as first line treatment.

Purpose: The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data.Materials and Methods: The panel searched the MEDLINE data base for all articles related to ureteral calculi published from 1966 to January 1996. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative treatments of ureteral calculi.Results: The data indicate that up to 98% of stones less than 0.5 cm. in diameter, especially in the distal ureter, will pass spontaneously. Shock wave lithotripsy is recommended as first line treatment for most patients with stones 1 cm. or less in the proximal ureter. Shock wave lithotripsy and ureteroscopy are acceptable treatment choices for stones 1 cm. or less in the distal ureter.Conclusions: Most ureteral sto...

Early in our ureteroscopic experience, in an effort to facilitate retrieval of ureteral calculi with the 11.5F and 12.5F rigid ureteroscopes, the distal ureter was routinely balloon dilated to 24F. Among 131 ureteroscopic procedures all consecutive 108 distal ureteral calculi were successfully removed. However, only 65% of 23 upper ureteral calculi were extracted. A followup excretory urogram (6 weeks or later) in 86 patients revealed no distal ureteral strictures. A followup cystogram in 30 patients showed low grade vesicoureteral reflux in 20% of the patients and none of these individuals was symptomatic. As such, balloon dilation of the distal ureter to 24F appears to be well tolerated. Presently, given the advent of smaller ureteroscopes and lithotriptor probes, such extensive ureteral dilation is necessary only in a minority of patients with distal ureteral calculi. In these few patients with calculi resistant to lithotripsy balloon dilation of the ureter to 24F may allow for successful, safe stone extraction, thereby precluding open ureterolithotomy.

Stones in the proximal, mid and distal ureter in 375 consecutive patients were treated with extracorporeal shock wave lithotripsy (ESWL) in a technically unmodified Dornier HM3 lithotriptor without regional or general anesthesia. Adequate followup was available in 162 patients with proximal, 62 with mid and 146 with distal ureteral stones. The fraction of patients with stone-free ureters within 3 months after ESWL was 96, 97 and 97%, respectively. Of all patients only 13 (3.6%) had residual stones or fragments in the ureter after 3 months. The average number of ESWL sessions was 1.34 for all patients, and 1.36, 1.45 and 1.38 for those with proximal, mid and distal ureteral stones, respectively. A ureteral catheter with saline irrigation was used whenever it was possible to insert a ureteral catheter. Only 15 stones were pushed up to the kidney during catheterization and all other stones were treated in situ. There were more retreatments in patients in whom the stone had not been bypassed by a catheter at the initial ESWL session. During at least 1 treatment session 238 patients had a ureteral catheter with the tip above the stone. Approximately half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous anesthesia with an anesthetic cream containing lidocaine-prilocaine (for proximal and mid ureteral stones). Small supplements of pethidine and diazepam were given to the other patients during the ESWL session. In situ ESWL of ureteral stones as described is a convenient, efficient and attractive procedure that, applied in a consequent manner, theoretically might result in a successful outcome in up to 98% of the patients.

Purpose: We compared our experience with ureteroscopic stone basket manipulation under fluoroscopic guidance to ultrasound ureterolithotripsy for distal ureteral stone removal.Materials and Methods: Retrospectively, we analyzed the medical records of 981 patients with ureteral calculi between January 1994 and December 1995, of whom 483 (49%) were treated for stones in the lower ureter and constituted our study group. The decision of when to perform lithotripsy (group 2) versus a basket procedure (group 1) was based on a prospective nonrandomized study and both groups were compared historically. All 322 patients in group 1 (mean age 49 years, range 14 to 86) primarily underwent ureteroscopic stone basket manipulation using the 4-wire Segura* basket. If the calculus could not be removed with the basket and another procedure was necessary, the case was considered a failure. The 161 patients in group 2 (mean age 37 years, range 14 to 74) underwent initially ultrasound ureterolithotripsy for stone frag...

Ureteroscopy via the transurethral route and limited to the terminal ureter in women lends itself to inclusion in the urological armamentarium. The technique requires no equipment other than routine urological instruments and makes endoscopic inspection, biopsy and resection within the distal ureter possible. The procedure is done with the patient under anesthesia, following urethral dilation to 32F. With the aid of a small caliber cystoscope, 20F or smaller, straight Jewett sounds can be passed into the urethra alongside the cystoscope and directed under cystoscopic control into the ureteral orifice. The orifice is then dilated gently, using 12, 14 and, if necessary, 16F sounds. One of the standard pediatric cystoscopes can then be introduced easily into the orifice. Currently, the technique is being used routinely in women with transitional cell carcinoma involving the ureteral orifice or intramural ureter. In 1 patient a tumor arising from within the lower ureter was resected successfully using a pediatric resectoscope.

Massive unilateral hydroureteronephrosis was created in 20 female dogs by ligating the urographically normal prevesical ureter. Over a 14-day period the obstructed ureter dilated to an average of 15.3 mm. A ureteral tapering procedure was performed by lateral darting and posterior folding of the resultant flap, followed by a cross-trigonal reimplantation. One anastomotic stricture resulted; in the remaining 19 animals, ureteral peristalsis was restored, the ureteral diameter was reduced 61.9 per cent and hydronephrosis was resolved. Histological studies on the tapered segments of these 19 animals showed that the subadventitial blood supply was preserved with fibrotic occlusion of the folded flaps. These results demonstrate that no significant vascular compromise after ureteral tapering and cross-trigonal reimplantation occurs. Success rates comparable to those of conventional ureteral tailoring can be achieved by this technically simplified form of reconstructive surgery.

The replacement of lost ureter with bowel interposition is a feasible alternative in the reconstruction of the urinary tract. When adequate ureteral length is not present, interposition of a portion of small bowel between the proximal and distal ureteral segments is an option that minimizes the amount of bowel in the urinary tract. This, in turn, reduces mucus production and electrolyte absorption in the reconstructed urinary tract, and allows for more bowel to remain as part of the functioning gastrointestinal tract. This procedure allows use of the antirefluxing function of the normal ureterovesical junction when present. We have used successfully interposition of the small bowel between the proximal and distal ureteral segments for undiversion in 5 children. Generally, we strive to join urothelium to urothelium without the use of bowel in urinary tract reconstruction but when this is not feasible, bowel interposition has been a useful option.

Calculi were removed from the upper urinary tracts and the distal ureter in single sessions in 2 patients with the aid of prone flexible cystoscopy and a through-and-through stone basket.

We describe an alternative method for the treatment of an entrapped stone basket. When efforts to remove an engaged stone through the intramural ureter met with marked resistance, the basket with the stone within it was advanced into the renal pelvis. Extracorporeal shock wave lithotripsy then was used to pulverize the stone, allowing successful removal of the basket.

The use of acetylcysteine is described for the relief of mucinous obstruction of the distal ureter after a mid ureteral replacement with ileum. Acetylcysteine (300 cc of 1 per cent) was instilled at low pressure via a nephrostomy tube following documentation of the obstruction with a nephrostogram. Patency of the ureter was achieved within 5 minutes. Re-obstruction ensued but it resolved with repeat percutaneous instillation of acetylcysteine. Patency, confirmed by a followup nuclear renogram at 4 months, has been maintained with 700 mg. acetylcysteine orally 4 times a day.

Involvement of the urethra or distal ureter in 30 to 50 per cent of the patients with carcinoma in situ of the bladder is well known. Carcinoma in situ of the bladder extending to the seminal vesicles rarely has been mentioned. We discuss 2 patients with extension of carcinoma in situ into the seminal vesicles and replacement of the normally present cylindroid mucosal lining. Carcinoma in situ of the ureter, bladder and prostatic ducts also was present in both patients.