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We report the reliability of computerized tomography urography and ureteroscopy in the diagnosis and management of upper tract urothelial carcinoma.From 2015 to November 2018 we prospectively collected and retrospectively analyzed 244 cases of ureteroscopy with available preoperative computerized tomography urography. Computerized tomography urography was categorized as positive, suspicious, unlikely and negative. Correspondence between imaging, ureteroscopy and histology was analyzed. The therapeutic indication, based on 2020 EAU Guidelines and patient clinical data, was recorded before and after ureteroscopy. Cohen's Kappa was used for agreement analysis. Logistic regression was used for prediction of positive ureteroscopy.Ureteroscopy was positive for upper tract urothelial carcinoma in 107/115 (93%), 48/77 (62.3%), 15/27 (55.6%) and 12/25 (48%) cases with positive, suspicious, unlikely and negative computerized tomography urography, respectively. On cytohistology the result was confirmed in 164/182 (90.1%) cases. The positive predictive value of a filling defect, stenosis, thickening and hydronephrosis on computerized tomography urography was 87.7% (121/138 cases), 65.6% (21/32), 69.6% (64/92) and 79.7% (59/74), respectively. On multivariate analysis a filling defect (95% CI 2.76-11.5, OR 5.63, p0.0001) or hydronephrosis (1.04-6.18, OR 2.52, p=0.04) was associated with ureteroscopy outcome. Among cases with positive computerized tomography urography and ureteroscopy, the lesions differed in dimensions (20/107), number (14/107) and site (11/107), for a total of 45/107 (42.1%) cases. The indication of elective treatment changed after ureteroscopy in 37/76 (48.1%) cases (Kappa=0.31), as 17/28 (60.7%), 11/20 (55%) and 11/28 (39.2%) indications were confirmed for endoscopic management, ureterectomy and nephroureterectomy, respectively.The complementary use of computerized tomography urography and ureteroscopy in the diagnostic workup of upper tract urothelial carcinoma should be evaluated.

INTRODUCTION AND OBJECTIVE:The physiology of hydronephrosis is complex, and a well-established definition of obstruction is lacking. Functional magnetic resonance urography (fMRU) has the capacity ...

Computerized tomography urography is used to evaluate patients with gross or microscopic hematuria. Computerized tomography urography is a high radiation dose scan and, thus, it confers a higher risk of secondary malignancy. A computerized tomography urography split bolus protocol reduces radiation exposure but it may reduce sensitivity. In this study we used a theoretical cohort of patients with hematuria in which to model the risk of missing malignancies against the benefit of averting secondary malignancies.We calculated the prevalence of renal cell carcinoma and upper tract urothelial carcinoma in patients with hematuria by pooled analysis of cohort studies, which in conjunction with split bolus sensitivity allows for the estimation of missed malignancies. The number of prevented secondary malignancies was calculated from lifetime attributable risk estimates. Sensitivity analyses were run to determine the minimum sensitivity required for a net population benefit.Estimates of split bolus computerized tomography urography sensitivity ranged from 80% to 100% (mean 95.2%). At the low estimate of 80% sensitivity split bolus computerized tomography urography was beneficial in men and women with microscopic hematuria at ages less than 50 and less than 60 years, respectively. An increase in sensitivity to 90% improved the benefit 1 decade in each gender, representing 68.8% of patients with microscopic hematuria. The overall population of patients with microscopic hematuria benefited from split bolus computerized tomography urography at 91.1% sensitivity. However, in patients with gross hematuria the threshold for an overall population benefit was high at 98.4% sensitivity.Exposure to ionizing radiation risks causing secondary malignancy. These data indicate that split bolus computerized tomography urography may be performed safely in 70% of the population of patients with microscopic hematuria. However, it is not currently advisable in patients with gross hematuria or in other patients at high risk.

INTRODUCTION AND OBJECTIVE:Computed tomography urography (CTU) is the diagnostic tool of choice for evaluating hematuria. In keeping with the ALARA (as low as reasonably achievable) principle, we e...

The AUA (American Urological Association) guidelines for asymptomatic microscopic hematuria recommend that patients undergo computerized tomography urography, which is associated with high doses of ionizing radiation. To our knowledge the associated risk of secondary malignancy and mortality remains unknown. We modeled the risk of malignancy and associated mortality due to ionizing radiation from computerized tomography urography relative to the additional diagnostic benefit offered over renal ultrasound.We performed a PubMed® based literature search to identify model inputs. We obtained estimates of age and gender specific radiation induced secondary malignancy and mortality rates from the BEIR (Biologic Effects of Ionizing Radiation) VII Phase 2 report with dose extrapolation using the linear no threshold model.Patients with asymptomatic microscopic hematuria had a 0.053% and 0.48% prevalence of upper tract urothelial carcinoma and renal cell carcinoma, respectively. Ultrasound had 77% sensitivity for upper tract urothelial carcinoma and 82% sensitivity for renal cell carcinoma. The effective radiation dose of computerized tomography urography was 31.7 mSv. Based on these inputs a population of 100,000 patients with asymptomatic microscopic hematuria would include 53.1 and 478 patients with upper tract urothelial carcinoma and renal cell carcinoma, respectively. On ultrasound alone 98.2 cases of upper urinary tract malignancy would be missed. An additional 149 cases of secondary malignancy would be caused by computerized tomography urography associated radiation with 101 fatalities. A total of 1,018.3 computerized tomography urography studies would need to be performed to detect an additional case of upper tract malignancy.Based on current risk models computerized tomography urography for asymptomatic microscopic hematuria may be associated with a small but significant risk of secondary malignancy relative to the additional diagnostic benefit offered.

SummaryA unique property of ultrasound is its ability to differentiate between cystic and solid masses. Using nephrosonography, 150 renal masses were examined. In 144 of them (96 per cent), the physical state of the mass, that is fluid, solid or complex, was correctly predicted. Nephrosonography is uncomplicated, atraumatic and safe. It is used in conjunction with standard radiological methods of diagnosis such as IVP, nephrotomography and in selected cases with angiography, cyst aspiration and isotope scanning. Generally, when a solid ultrasonic pattern is obtained, arteriography is recommended. If a cystic pattern is obtained, nephrotomography followed by cyst puncture is usually all that is necessary. The treatment of masses producing complex ultrasonic patterns must be individualized. In this diagnostic setting, it should be possible to differentiate benign from malignant renal masses with an accuracy approaching 99 per cent.

We prospectively evaluated magnetic resonance urethrography for depicting obliterative posterior urethral stricture.A total of 25 men with a mean age of 48.7 years (range 21 to 72) with complete posterior urethral stricture were studied preoperatively with axial and sagittal turbo spin-echo T2, sagittal T1 and contrast enhanced sagittal T1-weighted images. Of the 25 patients 22 underwent conventional retrograde urethrography with voiding cystourethrography. For magnetic resonance urethrography aseptic lubricant was infused through the external urethral meatus to dilate the distal urethra up to the stricture. Each imaging result was compared with a surgical specimen or a description of the surgical findings. Measurement errors were analyzed using the Wilcoxon signed rank test. The relationship between true and measured stricture length was evaluated by linear regression analysis.Based on magnetic resonance urethrography findings 2 patients with a less than 1 cm stricture were treated with internal urethrotomy, 21 with a more than 1 cm stricture underwent open urethroplasty and 2 with prostatic displacement and a 4 cm stricture needed the combined perineal and transpubic approach. The mean +/- SD measurement error on magnetic resonance urethrography imaging was significantly lower than that on conventional retrograde urethrography combined with voiding cystourethrography (0.4 +/- 0.4 vs 1.4 +/- 1.1 cm, p0.001). Linear regression analysis showed a stronger linear relationship between magnetic resonance urethrography and surgical measurement (r(2) = 0.62, p0.01).Magnetic resonance urethrography is more effective for evaluating obliterative posterior urethral stricture than retrograde urethrography combined with voiding cystourethrography.

It is debatable whether traditionally used excretory urography or the recently introduced multidetector computerized tomography urography is more accurate for diagnosing upper urinary tract transitional cell carcinoma. We compared accuracy measures of both methods for diagnosing upper urinary tract transitional cell carcinoma in adult patients with hematuria.We retrospectively analyzed consecutive adult patients with hematuria undergoing excretory urography and multidetector computerized tomography urography before any surgery, intervention or treatment from April 2004 to December 2006 in our hospital. The presence of upper urinary tract transitional cell carcinoma on excretory urography and multidetector computerized tomography urography was reviewed independently by 2 uroradiologists who were blinded to clinical information and other imaging results. Final diagnosis of upper urinary tract transitional cell carcinoma was confirmed by histological results. Measures of the diagnostic accuracy of excretory urography and multidetector computerized tomography urography for upper urinary tract transitional cell carcinoma were calculated and compared with reference to the final diagnosis.Of 34 men and 26 women with hematuria (mean age 60.73 +/- 12.95 years) 19 (31.7%) had a final diagnosis of 24 upper urinary tract transitional cell carcinomas. The sensitivity, specificity and accuracy of excretory urography were 0.750, 0.860 and 0.849, respectively. In contrast, the sensitivity, specificity and accuracy of multidetector computerized tomography urography were 0.958, 1.000 and 0.996, respectively. Overall the area under the receiver operating characteristic curve for multidetector computerized tomography urography was significantly larger than that for excretory urography (0.978 vs 0.815, p = 0.005).Multidetector computerized tomography urography is more sensitive, specific and accurate than excretory urography in the diagnosis of upper urinary tract transitional cell carcinoma in adult patients with hematuria. Therefore, multidetector computerized tomography urography rather than excretory urography should be the first choice noninvasive imaging modality for diagnosing upper urinary tract transitional cell carcinoma.

We analyzed the diagnostic value of multidetector computerized tomography urography for transitional cell carcinoma in patients with gross hematuria.All consecutive adult patients with gross hematuria who underwent multidetector computerized tomography urography in a 23-month period were prospectively enrolled. Transitional cell carcinoma and its location on multidetector computerized tomography urography were recorded at a prospective reading with knowledge of the pertinent history and at a retrospective reading while blinded to all information. Histological evidence of transitional cell carcinoma served as the gold standard for final diagnosis. Patients who were lost to followup, refused biopsy/surgery for clinically suspicious neoplasms or had negative diagnostic evaluation but a followup of less than 1 year were excluded from study. We analyzed the diagnostic value of multidetector computerized tomography urography for transitional cell carcinoma by location with reference to final diagnosis.A total of 139 patients were eligible for study, of whom 24 were excluded from analysis. There was no difference in demographic features between included and excluded patients. Of the 115 included patients 60 had a final diagnosis of a total of 77 transitional cell carcinomas in the renal pelvis, ureter or bladder. Overall sensitivity, specificity and accuracy of multidetector computerized tomography urography for diagnosing transitional cell carcinoma were 0.857, 0.980 and 0.963 at the retrospective reading, and 0.961, 0.988 and 0.984 at the prospective reading, respectively. Multidetector computerized tomography urography had the highest accuracy for diagnosing renal transitional cell carcinoma and the lowest sensitivity for detecting ureteral transitional cell carcinoma.Multidetector computerized tomography urography is an accurate, noninvasive imaging modality for diagnosing transitional cell carcinoma in patients with gross hematuria. However, careful assessment of the ureter for multidetector computerized tomography urography is required for detecting ureteral transitional cell carcinoma.

The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty.A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups.Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts.To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

Recurrent ureteropelvic junction obstruction after open pyeloplasty is a serious complication for which treatment remains challenging. We identified risk factors for persistent obstruction.We retrospectively reviewed the charts of 401 children who underwent open dismembered pyeloplasty between 1997 and 2005. Of these children 21 (5.2%) experienced recurrent ureteropelvic junction obstruction. Age, prenatal diagnosis, hydronephrosis grade, differential renal function, incision location (flank or dorsal lumbotomy), retrograde pyelography and stent placement were analyzed. Univariate and multivariate analyses were performed to identify risk factors for pyeloplasty failure.Median age at surgery was 21 months and median followup was 36 months. Of the 401 patients dorsal lumbotomy was performed in 171 (42.6%) and a flank incision was used in 230 (57.4%). Retrograde pyelography was done in 195 patients (48.6%) and stents were used in 352 (87%). Age, prenatal diagnosis, degree of hydronephrosis, differential renal function and stent placement did not have an impact on pyeloplasty outcome on univariate analysis. Recurrent ureteropelvic junction obstruction developed in 14 of 171 patients who had originally undergone dorsal lumbotomy vs 7 of 230 who had originally undergone a flank incision (8.1% vs 3.1%, p = 0.02) as well as in 17 of 206 who did not undergo initial retrograde pyelography vs 4 of 195 who did (8.3% vs 2.1%, p = 0.005). On multivariate analysis incision type and lack of retrograde pyelography showed significant association with pyeloplasty failure despite adjustment for other risk factors (p0.05, OR 3.2 and 4.4, respectively).In this series lack of retrograde pyelography and dorsal lumbotomy were independently associated with a higher risk of recurrent ureteropelvic junction obstruction. While retrograde pyelography or a flank approach could not be directly shown to prevent recurrent ureteropelvic junction obstruction, electing to perform retrograde pyelography may be a proxy for better perioperative planning, including the choice of incision, and it may ultimately increase the chances of successful pyeloplasty.

Vascular targeted photodynamic therapy represents the newest generation of photodynamic therapy and a new paradigm for minimally invasive ablative therapy. We report a pilot trial of vascular targeted photodynamic therapy to evaluate the effect on porcine renal tissue.Pigs underwent continuous infusion of WST-09 (Negma-Lerads, Toussous le Noble, France) and concurrent illumination with interstitial laser at a wavelength of 763 nm to the lower pole of the kidney. Drug doses were 0.5 to 1.0 mg/kg and light doses were 100 to 200 J. Nuclear renography was performed on postoperative day 5. On postoperative day 7 arteriography, pyelography, computerized tomography of the abdomen and necropsy were performed.Four of 7 animals completed therapy and all evaluations. Three animals died, including 1 of surgical complications and 2 of an anaphylactoid reaction to the Cremophor solvent in the compound. All kidneys in surviving animals functioned on nuclear renography. Renal function remained unchanged. No lesions or urine leakage was visible on imaging. On necropsy lesion size was 5 x 4 x 3 to 7 x 7 x 14 mm depending on the drug/light dose. Histology showed a distinct demarcation between the treated zone and the surrounding parenchyma at higher doses. Lesions were well demarcated with necrotic tubules, glomerular fibrinoid necrosis, capillary loop thrombosis, interstitial hemorrhage and lymphocytic infiltrates.Significant tissue effect with some necrosis was seen at these low drug/light combinations. This study provides the initial proof of principle that justifies further preclinical investigation of vascular targeted photodynamic therapy for renal tumors. A newer, water based formulation should decrease the incidence of reactions in swine. This newer formulation may allow further safe investigation of this novel treatment paradigm.

A prospective randomized study was performed to compare the results of laparoscopic dismembered pyeloplasty using transperitoneal and retroperitoneal approaches.A total of 40 patients with primary ureteropelvic junction obstruction were included in the study. The patients were prospectively randomized between transperitoneal (20 patients, group 1) and retroperitoneal (20 patients, group 2) laparoscopic Anderson-Hynes pyeloplasty. All the patients were assessed preoperatively by excretory urography, diuretic isotope renography and computerized tomography angiography. The patients were followed at 3 and 6 months postoperatively, and then every 6 months. Evaluation was performed by excretory urography and diuretic renography. Both approaches were compared regarding operative time, morbidity, hospital stay, convalescence and functional outcome. The preoperative demographic data of the patients and radiological and operative findings were statistically correlated to the operative time.The preoperative data of both groups were comparable. All the procedures were successfully completed with laparoscopy. Mean operative times were 149 and 189 minutes for the transperitoneal approach and retroperitoneoscopy, respectively (p = 0.02). In groups 1 and 2 there were complications in 3 and 5 patients, respectively. Morbidity, hospital stay, convalescence and success rate had no significant differences between the groups. None of the patient parameters apart from the approach had a significant impact on operative time.Laparoscopic dismembered Anderson-Hynes pyeloplasty has a satisfactory functional outcome and low morbidity regardless of the approach. Nevertheless, with early experience retroperitoneoscopy is associated with a longer operative time.

Paraureteral or Hutch diverticula are congenital bladder diverticula that occur at or adjacent to the ureteral hiatus and are associated with vesicoureteral reflux in the majority of cases. Surgical treatment has traditionally been ureteral reimplantation with or without diverticulectomy. We present our experience with endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula.Of 745 patients undergoing endoscopic treatment for vesicoureteral reflux between 2002 and 2006, 17 (2.3%) had paraureteral diverticula located at the refluxing ureter. The hydrodistention implantation technique was used and dextranomer/hyaluronic acid copolymer was used as bulking material. Success was defined as vesicoureteral reflux grade 0 on postoperative voiding cystourethrogram at 1 to 3 months after a single treatment.A total of 20 refluxing ureters with associated paraureteral diverticula were treated in 17 patients. Of the cases 14 were unilateral and 3 were bilateral. Reflux was grade I in 6 patients, grade II in 4, grade III in 8, grade IV in 1 and grade V in 1. A mean of 1.2 ml bulking agent was injected per ureter. Overall success was 81% (13 of 16 patients) after a single injection. Success per vesicoureteral reflux grade was 100% (6 of 6 patients) for grade I, 100% (3 of 3) for grade II, 63% (5 of 8) for grade III, 100% (1 of 1) for grade IV and 100% (1 of 1) for grade V. Endoscopic treatment failed in 3 patients. Multivariate analysis identified large diverticular size and high bulking agent volume as predictors of treatment failure. Age, reflux grade and the presence of unilateral vs bilateral paraureteral diverticula did not impact outcome.Endoscopic injection of dextranomer/hyaluronic acid copolymer is an excellent choice for the treatment of vesicoureteral reflux associated with paraureteral diverticula because it has a high success rate and avoids open surgery.

We investigated the characteristics and diagnosis of primary asymptomatic ureteral calculi.During a period of 12 years asymptomatic ureteral stones were prospectively investigated at the Urological Stone Center. We studied mode of diagnosis, stone size, localization, composition, hydronephrosis grade and patient characteristics.Between 1995 and 2006 a total of 40 patients with asymptomatic ureteral stones were identified among 3,711 patients with ureteral stones (1.1%). Mean age of the 33 male and 7 female asymptomatic patients was 58.3 years (range 28.1 to 87.1). Localization of stones was 19 proximal, 3 mid and 18 in the distal ureter. Mean stone size was 10.0 mm (+/-6). Mode of diagnosis of asymptomatic calculi was randomly diagnosed hydronephrosis in 10 patients (25%), microscopic hematuria in 8 (20%), randomly diagnosed stone on other than urological x-ray examination in 13 (32.5%) and stone diagnosed during followup after previous nephrolithiasis in 9 patients (22.5%). Primary therapy was extracorporeal shock wave lithotripsy in 35 patients (87.5%), ureterorenoscopic lithotripsy in 4 (10%), spontaneous stone passage before scheduled treatment in 1 and open ureteroneocystostomy in 1 patient.De novo asymptomatic ureteral calculi do exist. Characteristics of this small group of patients with ureterolithiasis have not been described thus far. Diagnosis is usually made during routine health care examinations, during the evaluation of nonurological diseases and during followup of patients who previously had nephrolithiasis. A large proportion of patients exhibit some degree of hydronephrosis as a sign of silent obstruction.

We studied the relationship among vesicoureteral reflux, urinary tract infection and permanent renal damage in children.We retrospectively analyzed 303 children younger than 2 years with a first time, nonobstructive, culture verified urinary tract infection. The protocol included ultrasonography and voiding cystourethrography within 3 months after urinary tract infection, and (99m)technetium dimercapto-succinic acid scintigraphy after 1 to 2 years.Vesicoureteral reflux was found in 36 of 163 boys (22%) and in 44 of 140 girls (31%). Of the 303 patients 80 (26%) had permanent renal damage according to dimercapto-succinic acid scintigraphy. The rate of abnormality increased significantly with grade of vesicoureteral reflux in boys and girls. The relative risk of renal damage was significantly increased in patients with vesicoureteral reflux grade II and higher. Maximum C-reactive protein concentration, maximum temperature during urinary tract infection, presence of vesicoureteral reflux and febrile recurrences of urinary tract infection were significantly related to permanent renal damage. In stepwise logistic regression vesicoureteral reflux was the only independent variable for boys, while C-reactive protein and vesicoureteral reflux were independent factors for girls.There was a significant relationship between grade II vesicoureteral reflux and higher and permanent renal damage in boys and girls. However, while the association between renal damage and vesicoureteral reflux was evident in boys, the role of urinary tract infection and renal inflammation seemed to be equally or more important in girls. These findings support the concept that renal damage is associated with vesicoureteral reflux and is often congenital in boys, while in girls it is more related to urinary tract infection with vesicoureteral reflux as a reinforcing factor.

We compared the exclusion rate for potential living renal donors evaluated with computerized tomography angiography and radionuclide renal scintigraphy (renal scan) vs excretory urogram, renal scan and renal arteriography.From March 2004 through February 2006, 603 consecutive patients were evaluated as potential living renal donors. From March 2004 through February 2005, 270 consecutive patients underwent evaluation with excretory urogram, renal scan and renal angiography (group 1). Of these patients 16 underwent computerized tomography to evaluate abnormalities detected on excretory urogram. From March 2005 through February 2006, 333 consecutive patients underwent evaluation with computerized tomography angiography and renal scan (group 2). The number of patients excluded for medical reasons and/or radiographic abnormalities was determined for the 2 groups.More than twice as many patients evaluated with computerized tomography were excluded. In group 1, 7% of patients (20 of 270) were excluded from donation due to radiographic findings vs 16% (53 of 333) in group 2 (p=0.0016). Of the patients 26% and 23% were excluded from renal donation for medical reasons in groups 1 and 2, respectively (p=0.5059).Multidetector row computerized tomography angiography increases the detection of incidental radiographic abnormalities as well as the renal donor exclusion rate. The increased sensitivity of computerized tomography angiography has created a dilemma for those determining patient eligibility for kidney donation because the clinical significance of many of these findings is unclear. Additional studies should address the significance of these incidental findings so that patients are not needlessly excluded from kidney donation.

We determined the usefulness of computerized tomographic urography for the initial evaluation of patients with hematuria as an alternative to excretory urography.A total of 259 patients (140 men and 119 women), age range 20 to 100 (mean 59.4) years, underwent computerized tomographic urography for the evaluation of hematuria and were available for followup. A cohort of 253 patients (153 men, 100 women), age range 21 to 92 (mean 57.6) years, underwent conventional excretory urography and were evaluated for comparison.A source of hematuria was identified in 107 patients (41.3%) in the computerized tomographic urography cohort and in 103 patients (40.7%) in the excretory urography cohort. Computerized tomographic urography alone identified a source of hematuria in 25.5% of these patients with the most commonly diagnosed lesions being renal calculi (18.9%), ureteral calculi (2.7%) and renal pelvic masses (2.3%) in the upper tract (0.94 sensitivity), and bladder masses (8.1%), prostatic abnormalities (5.4%) and inflammatory disorders (3.5%) in the lower tract (0.40 sensitivity, 0.99 specificity). The overall detection rate (19.5%), most commonly diagnosed lesions, and lower urinary tract sensitivity and specificity were similar in the excretory urography cohort. However, excretory urography exhibited a markedly lower sensitivity in detecting upper tract lesions (0.50).Computerized tomographic urography exhibited a significantly higher sensitivity than conventional excretory urography in detecting upper tract pathology (94.1% vs 50%). However, sensitivity for detecting lower tract lesions was low (40% or less), suggesting that computerized tomographic urography offers a comprehensive alternative to excretory urography but does not obviate the need for adjunctive cystourethroscopy for accurate evaluation of the lower urinary tract.

as duplicated systems and compound calyxes can be navigated with confidence. Radiography assisted navigation can augment visual navigation compromised by blood or debris. During percutaneous nephrolitotomy (PCNL), roadmapping allows more precise placement of the dilation balloon. CONCLUSIONS: This novel application of fluoroscopy can be applied whenever a pyelogram would be helpful. With additional experience and optimization of the technical aspects this can provide another tool for complex endourologic procedures. Future research will be needed to quantify the benefits in regards to operative success, operative time, and radiation exposure.

INTRODUCTION AND OBJECTIVES: Between 2004-2011, 773 kidney transplantations were performed in our centre. 40 patients presented ureteral stenosis as a complication (5.1%). Our first option to repair it is open surgery, performed in 27 patients. Instead of this, we choose endoscopic techniques (balloon dilatation) as an alternative in patients with high-surgical risk or with re-stenosis after surgery, with poor results. The aim of our study is to evaluate the efficacy of Memokath 051 stent in high surgical risk patients and in those in which the surgery or dilatations have failed. METHODS: Prospective study over 11 patients transplanted in 2004-2011, who had ureteral stenosis with renal function repercussion. Indications for metallic stenting were: re-stenosis after surgical treatment (3 patients) and severe comorbidities contraindicating surgery (8 patients). All patients had a nephrostomy placed previously and at least 2 failed endoscopic balloon dilatations. Antegrade pyelography showed stenosis in distal ureter in 9 cases and in pyeloureteral union in 2. Follow-up after was made with serum creatinine levels, simple Xray, ultrasonography and renal scintigraphy in some cases. RESULTS: Between February 2009 and February 2012, 12 stents were placed in 11 patients through anterograde transrenal approach. Radiologic control after the procedure showed successful resolution of the stricture in all the cases. We observed 2 transitory haematuria, but there were no major immediate complications in any case. As a long term complications, we found 1 stent migration after 30 days and one patient with a new proximal stenosis after 7 months, both of them needing stent replacement. One patient had spontaneous stent migration to the bladder after 29 months, without needing a new stent because of normal renal function. Finally, one patient had severe chronic allograft dysfunction with recurrent acute pyelonephritis and we decided to perform transplantectomy. Due to their severe comorbidities, 2 patients died with functional stent in situ (after 5 and 15 months). Another 2 patients with nonobstructive chronic allograft dysfunction, were reintroduced to haemodialysis program after 7 and 18 months, and died later because of their diseases. After a mean follow-up of 52.5 months (33-69), we have 6 patients with stable renal function and without clinically significant hydronephrosis. CONCLUSIONS: The management of ureteral stenosis with ureteral stent Memokath 051 is minimally invasive, safe and effective, and can be a long-term alternative to surgical treatment in selected cases.

INTRODUCTION AND OBJECTIVES: Between 2004-2011, 773 kidney transplantations were performed in our centre. 40 patients presented ureteral stenosis as a complication (5.1%). Our first option to repair it is open surgery, performed in 27 patients. Instead of this, we choose endoscopic techniques (balloon dilatation) as an alternative in patients with high-surgical risk or with re-stenosis after surgery, with poor results. The aim of our study is to evaluate the efficacy of Memokath 051 stent in high surgical risk patients and in those in which the surgery or dilatations have failed. METHODS: Prospective study over 11 patients transplanted in 2004-2011, who had ureteral stenosis with renal function repercussion. Indications for metallic stenting were: re-stenosis after surgical treatment (3 patients) and severe comorbidities contraindicating surgery (8 patients). All patients had a nephrostomy placed previously and at least 2 failed endoscopic balloon dilatations. Antegrade pyelography showed stenosis in distal ureter in 9 cases and in pyeloureteral union in 2. Follow-up after was made with serum creatinine levels, simple Xray, ultrasonography and renal scintigraphy in some cases. RESULTS: Between February 2009 and February 2012, 12 stents were placed in 11 patients through anterograde transrenal approach. Radiologic control after the procedure showed successful resolution of the stricture in all the cases. We observed 2 transitory haematuria, but there were no major immediate complications in any case. As a long term complications, we found 1 stent migration after 30 days and one patient with a new proximal stenosis after 7 months, both of them needing stent replacement. One patient had spontaneous stent migration to the bladder after 29 months, without needing a new stent because of normal renal function. Finally, one patient had severe chronic allograft dysfunction with recurrent acute pyelonephritis and we decided to perform transplantectomy. Due to their severe comorbidities, 2 patients died with functional stent in situ (after 5 and 15 months). Another 2 patients with nonobstructive chronic allograft dysfunction, were reintroduced to haemodialysis program after 7 and 18 months, and died later because of their diseases. After a mean follow-up of 52.5 months (33-69), we have 6 patients with stable renal function and without clinically significant hydronephrosis. CONCLUSIONS: The management of ureteral stenosis with ureteral stent Memokath 051 is minimally invasive, safe and effective, and can be a long-term alternative to surgical treatment in selected cases.

Treatment in infants with prenatally diagnosed, severe hydronephrosis remains controversial. We measured anatomical parameters using magnetic resonance urography to create a pelvic index ratio, which we correlated with outcome to assess its value.We reviewed 35 cases of prenatally diagnosed severe hydronephrosis, including grade III in 19 and grade IV in 16. By 6 weeks after birth all patients had undergone repeat ultrasonography, diuretic renography and magnetic resonance urography. Magnetic resonance urography was used to measure the distance (D) from the bottom of the lowest renal calyx to the ureteropelvic junction and the total longitudinal length (L) of the caliceal system. The pelvic index ratio, defined as D/L, assesses the level at which the ureter inserts into the renal pelvis.All cases were initially managed conservatively. Pyeloplasty was required in 16 kidneys (mean patient age +/- SD 7.5 +/- 3.9 months) because of deterioration in renal function. All patients were well at a mean followup of 3.8 years. The remaining 19 cases continued to be managed conservatively. By a mean of 5.4 years spontaneous resolution of prenatally diagnosed severe hydronephrosis had occurred in 7 of 19 cases, while 12 were downgraded to grades I-II. The mean pelvic index ratio in surgical cases was 0.26 +/- 0.13 and in nonsurgical cases it was 0.12 +/- 0.11, indicating that ureters inserted significantly higher in surgical cases (p = 0.0012). Of 9 kidneys with a pelvic index ratio of greater than 0.3 pyeloplasty was required in 8, while 10 of 12 with a pelvic index ratio of less than 0.1 were managed conservatively.Pyeloplasty is likely to be required if the pelvic index ratio is greater than 0.3 and conservative management is likely to succeed if the ratio is less than 0.1. The pelvic index ratio can be calculated easily even in the neonatal period. It appears to be prognostic for pyeloplasty in cases of prenatally diagnosed, severe hydronephrosis.

We present our experience with dynamic contrast enhanced magnetic resonance urography for evaluation and treatment in infants born with prenatally recognized hydronephrosis. We determined the characteristics of renal dysgenesis in this population.We reviewed magnetic resonance urography images done within the first 6 months of life in 67 infants born with prenatally recognized hydronephrosis. High resolution imaging was used to establish a morphological diagnosis. Functional evaluation was used to assess obstruction and individual renal function. Voiding cystourethrography was performed in 62 patients.Our study included 67 infants (87 renal units). There were 54 boys and 13 girls with a mean age of 2.8 months (range 0.9 to 4.6). Of these 87 renal units 30 (35%) had ureteropelvic junction obstruction, 18 (21%) had primary megaureters, 10 (11%) had nondilating vesicoureteral reflux, 10 (11%) had fetal folds, 8 (9%) had posterior urethral valves, 6 (7%) had ectopic ureters, 4 (5%) had multicystic dysplastic kidneys and 1 (1%) had a normal study. Magnetic resonance urography revealed renal dysgenesis in 24 renal units (28%), consisting of loss of corticomedullary differentiation, renal cystic changes distinct from multicystic dysplastic kidneys, solid renal dysplasia, hypoplasia and dysmorphic calyces.Magnetic resonance urography is an excellent addition to our armamentarium for evaluating neonatal hydronephrosis and renal dysgenesis. Due to its comprehensiveness magnetic resonance urography has the potential to become the study of choice for evaluating infants with significant prenatally recognized hydronephrosis. However, further prospective, comparative studies in larger patient populations are needed to justify the cost and the need for sedation in infants.

Purpose: The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial.Materials and Methods: A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures.Results: A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-...

Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center.All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes.The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable.Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

PURPOSE: We evaluated the diagnostic potential of magnetic resonance urography (MRU) in pediatric patients with a solitary kidney and/or dysplastic orthotopic or ectopic renal buds. We present our evolving experience with this imaging procedure.MATERIALS AND METHODS: A total of 30 patients with a mean age of 43.8 months with a known or suspected solitary kidney with or without clinical symptoms underwent ultrasound of the urinary tract as well as voiding cystourethrogram, renal static dimercapto-succinic acid (DMSA) scintigraphy and MRU. The results of these diagnostic imaging studies were then compared with each other and set against the results of the final diagnosis established at surgery and by histology, if available.RESULTS: Dysplastic orthotopic or dystopic renal buds suspected on ultrasound in 11 of the 30 patients were confirmed in all 11 by MRU. While accompanying ectopic ureteral insertions were shown in only 3 patients by ultrasound, they were visualized in all 4 by MRU. The other 7 patients with dysplastic renal buds had orthotopic ureteral orifices. DMSA scintigraphy failed to detect 10 renal buds.CONCLUSIONS: The diagnostic value of MRU appears to be superior to that of other imaging tests, even to that of DMSA scintigraphy, which with voiding cystourethrography is currently considered the gold standard for evaluating sonographically suspected solitary kidneys with contralateral orthotopic or ectopic renal buds and ectopic ureteral insertion.

We evaluated magnetic resonance urography (MRU) appearances in symptomatic hydronephrosis in pregnancy and compared urographic patterns in physiological and calculous disease.A total of 24 consecutive pregnant women with symptomatic hydronephrosis underwent MRU, comprising an overview fast T2-weighted examination of the abdomen and pelvis, and thick slab, heavily T2-weighted MRU images, followed by focused, high resolution T2-weighted sequences obtained in an axial and coronal oblique plane through the level of ureteral caliber change.Of these 24 pregnant women 15 were found to have physiological hydronephrosis, 7 had calculous disease and 2 had preexisting urinary anomalies. MRU findings in physiological hydronephrosis cases were extrinsic compression of the middle third of the ureter, no filling defect and a collapsed ureter below it. Obstruction by ureteral calculi was seen at points of ureteral narrowing in the ureter, that is at the vesicoureteral junction in 2 cases, in the compressed mid ureter in 3 and at the pelviureteral junction in 1. Nonobstructive renal calculi were seen in another patient. Calculi presented throughout pregnancy but physiological hydronephrosis presented only in the late second and third trimesters. With distal calculi the MRU appearance was the double kink sign with constriction at the pelvic brim and the vesicoureteral junction with a standing column of urine in the pelvic ureter. There was renal edema and perirenal extravasation. Small calculi were only identified using high resolution T2-weighted magnetic resonance imaging.MRU is a valuable and well tolerated investigation for evaluating painful hydronephrosis in pregnancy. There are characteristic and differing urographic appearances in physiological and calculous obstruction.

We evaluated whether findings on voiding cystourethrography suggesting ureteropelvic junction (UPJ) obstruction coexists with vesicoureteral reflux (VUR) are associated with parameters on dynamic renal scintigraphy that support significant obstruction.We reviewed records of 44 patients referred for scintigraphy after voiding cystourethrography performed at age 1 day to 9.4 years (mean 7 months, median 1.7 months) showed VUR and findings suggestive of UPJ obstruction (blockage of contrast material at the UPJ, contrast dilution in the renal pelvis, slow renal pelvic drainage). Results were correlated with Society for Fetal Urology hydronephrosis grade and ureteral morphology.Halftime was in the obstructive range (20 minutes or greater) for 7 of 47 kidneys (15%). The prevalence of a post-furosemide pelvicaliceal drainage halftime in the obstructive range increased with hydronephrosis grade (0% grade 1, 17% grade 2, 50% grade 3 to 4, p = 0.002) but did not vary with ureteral morphology (p = 0.08). In 12 of 38 cases (31%) where suspected UPJ obstruction was unilateral and a contralateral kidney was present differential uptake of the affected kidney was less than 45%. The prevalence of differential uptake less than 45% was higher in patients with than without ureteral dilatation (48% vs 12%, p = 0.02) but did not vary with hydronephrosis grade (p = 0.93).In children with VUR and suspected coexisting UPJ obstruction dynamic renal scintigraphy may support significant obstruction when hydronephrosis is at least moderate in degree or ureteral dilatation is present but is unlikely to do so if neither is observed.

An estimated 150,000 children are born with birth defects each year. One of the most frequent genitourinary abnormalities is horseshoe kidney (HSK). The incidence of HSK in the population is estimated to be 1/400 to 1,600 births based on autopsy data from the 1940s and 1950s. We prospectively evaluated the incidence of HSK based on radiographic studies to determine the contemporary incidence of HSK.In a 6-month period patients undergoing abdominal computerized tomography, renal ultrasonography and excretory urography were screened for HSK. After identification medical charts were reviewed for demographics, history, study indication and findings. A literature review of 12 studies of 825 patients with HSK was compared with the current series with regard to common associated findings.From 15,320 radiographs 23 patients were identified with HSK for an overall incidence of 1/666. Computerized tomography, excretory urography and ultrasound identified 16, 5 and 2 patients, respectively, while 16 were male, 7 were female, 20 were adults and 3 were children. The most common concomitant urological disorder was nephrolithiasis in 9 patients (39%), prompting operative intervention in 4. The radiographic incidence of HSK closely matched data from autopsy series and yet it differed from that in current radiographic series using ultrasound in the perinatal period.Our radiographic evaluation of the HSK incidence closely matches past autopsy series. This finding suggests that the incidence of HSK remains stable despite an increasing number of birth defects. Moreover, it appears that radiographic studies can accurately estimate the incidence of congenital anatomical disorders. Our data suggest that HSK is a relatively benign condition with a low requirement for operative intervention in these incidentally identified patients.

Purpose: Complex injuries of the upper ureter with significant loss of length are difficult to manage. Traditional options include nephrectomy, bowel interposition and autotransplantation. The advent of laparoscopic donor nephrectomy has created a new option when preservation of functioning renal parenchyma is desirable. We update our experience with severe iatrogenic ureteral injuries requiring laparoscopic nephrectomy and autotransplantation.Materials and Methods: Seven patients with severe ureteral injuries were referred for definitive management. In all cases preoperative evaluation demonstrated comparable split renal function and anatomy not amenable to routine reconstruction. Transperitoneal laparoscopic nephrectomy and autotransplantation to the ipsilateral pelvis were attempted.Results: Of the patients 5 had a history of nephrolithiasis with intervention resulting in the ureteral injury and 5 underwent prior endoscopic or open management of the defects. All cases were associated with dense...

A prospective randomized controlled trial was conducted to evaluate whether postoperative ureteral stenting is necessary after ureteroscopic laser lithotripsy.A total of 58 patients with unilateral ureteral stones were randomized into either stented or unstented groups. Ureteroscopic laser lithotripsy was performed using a semirigid ureteroscope (6.5/7Fr) and holmium laser without ureteral orifice dilation. There were no selection criteria regarding stone size, location, preoperative ureteral obstruction and hydronephrosis. Endoscopic evidence of stone impaction or mucosal edema/damage did not exclude a patient from the study. Ureteral perforation on completion retrograde pyelogram was the only intraoperative criterion for study exclusion. Postoperative pain scores and symptoms were recorded. Excretory urography was performed to document stone-free status and stricture formation. Radionuclide scan was performed selectively to exclude functional obstruction when ureteral narrowing was found on excretory urogram.Mean stone size +/- SD was 9.7 +/- 4.0 mm. (range 4 to 27). Proximal ureteral stones accounted for 43% of all stones. Stented and unstented groups were comparable with respect to demographic data, stone parameters, preoperative obstruction and hydronephrosis. There was no significant difference in operating time, laser energy used, stone impaction and mucosal edema/damage between the 2 groups. Postoperative pain and symptoms were more severe and frequent (p0.05) in the stented group. However, there was no difference in the incidence of postoperative sepsis and unplanned medical visits. The stone-free and stricture formation rates showed no statistical difference between the 2 groups.Ureteral stenting is not necessary after uncomplicated ureteroscopic laser lithotripsy for ureteral stones. Ureteral stent increases the incidence of pain and urinary symptoms but does not prevent postoperative urinary sepsis and unplanned medical visits. Severity of preoperative obstruction and intraoperative ureteral trauma were not shown to be determining factors for stenting.

We performed this study as a comprehensive evaluation of variables reported to affect lower pole stone clearance after shock wave lithotripsy using artificial neural network analysis.The radiographic images and treatment records of 680 patients with lower pole renal calculi treated with primary shock wave lithotripsy using the Wolf Piezolith 2500 (Wolf, Knittlingen, Germany) lithotriptor were retrospectively evaluated by applying artificial neural network analysis. Successful stone clearance was defined as absent fragments of any size detected on plain x-ray with tomography and/or excretory pyelography performed 6 months after treatment. Prognostic variables included patient characteristics, laboratory values, stone characteristics and the spatial anatomy of the lower pole, as defined by infundibular length, diameter, caliceal pelvic height, 2 measurements of the lower infundibulopelvic and infundibuloureteropelvic angles as well as the pattern of dynamic urinary transport.Artificial neural network analysis had 92% accuracy for correctly predicting lower pole stone clearance. The pattern of dynamic urinary transport represented the most influential predictor of stone clearance, followed by a measure of the infundibuloureteropelvic angle, body mass index, caliceal pelvic height and stone size. Anatomical measurements of lower pole anatomy and classification of the type of urinary transport were well reproducible with low intra-observer and interobserver variability (correlation coefficient alpha0.8).In a comprehensive analysis of variables reported to influence lower pole stone clearance artificial neural network analysis predicted stone clearance with a high degree of accuracy. The relative importance of dynamic urinary transport in lower pole stones and the usefulness of artificial neural network analysis to predict shock wave lithotripsy outcomes in individuals must be confirmed in a prospective trial.

A new technique for replacing the ureter based on the Yang-Monti principle is introduced to overcome the drawbacks of the classic ileal ureter.Between March 2001 and June 2002 ureteral replacement by ileum was indicated in 10 patients, including 9 with long or multiple strictures due to bilharzial (6), tuberculosis (3) and a low grade lower ureteral tumor (1). The technique involved isolation of a 5 to 7.5 cm. ileal segment, which was further subdivided into 2 or 3 equal parts. Paramesenteric incision along the longitudinal axis of these segments followed by unfolding resulted in a 12 to 18 cm. ileal strip. Tubularization of this strip led to the formation of an ileal tube with a suitable caliber. The latter was implanted into the bladder by submucosal (nonrefluxing) ileovesicostomy.Mean followup +/- SD was 9.6 +/- 2.4 months (range 6 to 13). Mean serum creatinine remained stable in all patients. Split kidney function (mercaptoacetyltriglycine clearance) was stable in 7 cases and improved in 3. Antegrade urography revealed dynamic unidirectional nonobstructed flow. Reflux was noted in only 1 case. Excretory urography and/or magnetic resonance urography showed excellent configuration of the substitute without evidence of dilatation or obstruction.The new technique offers certain distinct advantages. A short bowel segment is included with the consequent absence of metabolic complications. It allows construction of an ileal ureter with a suitable cross-sectional diameter without the need for tailoring and makes possible the use of an antireflux technique.

Purpose: The ideal imaging study for evaluation of the upper urinary tract in patients with microhematuria has been debated. We prospectively compared the diagnostic yield of computerized tomography (CT) to excretory urography (IVP) in the initial evaluation of asymptomatic microhematuria.Materials and Methods: Between December 1998 and June 2001, 115 patients presenting with asymptomatic microhematuria underwent CT and IVP before cystoscopy. Helical CT images with 5 mm. adrenal and kidney slices with and without contrast material were followed by delayed 5 mm. ureteral contrast images through the bladder base. Each CT and IVP was examined by a radiologist who was blinded to the result of the other imaging study. Diagnostic yields of the imaging techniques were compared using the test of 2 proportions and chi-square analysis.Results: Radiographic abnormalities were noted on CT or IVP in 38 patients. Sensitivity was 100% for CT and 60.5% for IVP, and specificity 97.4% for CT and 90.9% for IVP. CT a...

Purpose: We developed a minimally invasive (noncystoscopic) method for retrieving ureteral stents.Materials and Methods: A total of 30 consecutive patients underwent placement of a ureteral...

Purpose: We assessed clinical and ultrasound predictors of the spontaneous resolution of prenatally diagnosed, primary nonrefluxing megaureter.Materials and Methods: Primary nonrefluxing megaureter was prenatally diagnosed in 54 neonates from 1993 to 1998, including 15 in whom it was bilateral (69 megaureters). Median followup period from birth to the last radiology examination was 25.8 months (range 2.3 to 72).Results: Of the patients 10 underwent surgical repair for severe hydroureteronephrosis, including decreasing renal function on diuretic renography in 1, and an episode of bilateral obstruction and acute renal failure in 1. Hydroureteronephrosis resolved in 39 cases (72%) and persisted in 5 at 30 to 72 months of followup. Laterality, gender and retrovesical ureteral diameter had no significant effect on the resolution rate (p >0.05). Mean initial ureteral diameter in patients with resolution was less than in those without resolution and in those who underwent surgery (0.8 versus 1.15 and 1.3...

Lower pole renal stones are well known to show a poor stone clearance rate after extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia). In the current study we analyzed several anatomical factors as predictors of lower pole stone clearance that may be used to indicate the usefulness of ESWL in such patients.Between January 1993 and October 2000, 63 patients with a unilateral single lower pole stone of 2 cm. or less were included in the study. Excretory urography was done to determine the lower infundibulopelvic angle, caliceal pelvic height, lower infundibular length and diameter, lower infundibular length-to-diameter ratio and number of lower pole minor calices. Stone-free status was assessed by x-ray.The overall stone clearance rate was 54% (34 of 63 patients). While caliceal pelvic height, lower infundibular diameter, length, length-to-diameter ratio and number of minor calices were different in the stone-free and residual stone groups on univariate analysis, multivariate logistic analysis revealed that the lower infundibular length-to-diameter ratio, diameter and number of minor calices were independent predictors of successful stone clearance. The 13 patients (20.6%) who showed all 3 favorable anatomical factors (lower infundibular length-to-diameter ratio less than 7, diameter greater than 4 mm. and a single minor calix) achieved an impressive 84.6% stone clearance rate. In patients with only 1 or 2 favorable factors the stone clearance rate was still greater than 60%. In contrast, the stone clearance rate was only 6.7% in the 15 patients who showed none of these factors.From this study it is apparent that successful ESWL is highly sensitive to the anatomy of the lower pole of the kidney. If a patient with a lower pole stone has at least 1 of the favorable factors identified in this study, ESWL may be advocated as first line therapy with a greater than 60% prospect of a successful outcome. Other treatment options should be considered in those without any of these predictive factors.

Purpose: Cystosonography with echo contrast is an imaging modality developed to avoid x-ray exposure during detection of vesicoureteral reflux. The main role of cystosonography has been limited to screening for reflux in the female and for followup of both sexes. In males the radiographic voiding cystourethrogram is still considered the gold standard for urethral evaluation. We determined whether cystosonography during the voiding phase (voiding cystourethrosonography) can adequately visualize the male urethra and differentiate the normal from the obstructed urethra.Materials and Methods: 100 males underwent cystosonography with echo contrast to detect vesicoureteral reflux. During the voiding phase the urethra was studied with ultrasound. The transperineal sagittal approach was chosen because the bladder neck and proximal part of the urethra were better visualized with the probe maintained coaxial to these structures. In every case in which ultrasound urethral imaging was considered abnormal a ra...

The diuretic radionuclide urogram is a simple, rapid and non-invasive technique to determine whether true obstruction exists in dilated nephroureteral systems. The methodology, results and interpretation of 102 studies in 41 patients are presented and compared to the conventional methods of assessing hydroureteronephrosis.

Purpose: The assessment of hydronephrosis due to chronic partial ureteral obstruction is controversial. We determined whether a new radiographic technique for assessing kidney function, electron beam computerized tomography (CT), can detect altered renal physiology due to chronic partial ureteral obstruction. We also compared and contrasted electron beam CT with standard well tempered diuretic mercaptoacetyltriglycine (MAG-3) urography.Materials ands Methods: Six pigs underwent creation of unilateral partial ureteral occlusion or sham operation. Three weeks after surgery diuretic enhanced MAG-3 renal scan was done and 48 hours later contrast enhanced electron beam CT was performed.Results: Mean differential function plus or minus standard error of mean of the obstructed kidney was 5.6% ± 2.4% on MAG-3 renography. In contrast, electron beam CT revealed significantly preserved mean renal function at 24.5% ± 2.7% (p

The bladder or Boari flap is a useful technique for ureteroneocystostomy when the distal ureter is too short to reach the bladder without undue tension. We report our experience with laparoscopic Boari flap ureteroneocystostomy in the chronic porcine model.Six female farm pigs underwent unilateral laparoscopic Boari bladder flap ureteroneocystostomy. Refluxing direct ureteral reimplantation was performed in the initial 3 animals. In the next 3 animals a submucosal tunnel was formed to achieve nonrefluxing ureteroneocystostomy into the Boari flap. The animals were sacrificed 6 weeks after surgery. At sacrifice ascending cystography, ipsilateral antegrade pyelography and autopsy examination of the ureteroneocystostomy site was performed.No intraoperative or postoperative complications were noted. Average operative time was 140 minutes. Postoperatively serum creatinine and hemoglobin were normal in all pigs. All 3 animals with direct ureteroneocystostomy into the Boari flap had free reflux into the kidney and all 3 with a submucosal tunnel reimplant had no reflux on ascending cystography and free drainage on antegrade pyelography. Autopsy confirmed a patent anastomotic site in all 6 cases.Laparoscopic ureteroneocystostomy using the Boari bladder flap technique is feasible. Our survival porcine model confirms the successful application of the refluxing and nonrefluxing technique of ureteral reimplantation. Clinical application of the technique has the potential to decrease patient morbidity associated with traditional open surgery.

We sought to determine whether drainage across the ureteropelvic junction, as indicated by diuretic renography 3 months after pyeloplasty, is an adequate predictor of surgical success.The medical records of 150 children who underwent pyeloplasty from 1986 to 1995 were reviewed. After excluding nonevaluable cases a total of 127 renal units remained for investigation. Preoperatively each renal unit was examined with a standardized (well-tempered) furosemide stimulated renal scan. Postoperatively 60 renal units were evaluated with standardized diuretic renal scans at 3 and 12 months, 33 renal units at 3 months only and 34 renal units at 12 months only. Surgical success was defined by half-time less than 20 minutes on a standardized diuretic renogram.Of the 33 renal units with a single postoperative study at 3 months 32 (97%) had halftime less than 20 minutes on diuretic renography. The remaining patient in this group with half-time greater than 20 minutes showed 60% improvement in half-time and did not require reoperation. Excluding those without delayed followup, surgical success was obtained in 93 of the 94 (99%) renal units. Among the 60 renal units evaluated with 2 postoperative renal scans success was noted in 48 (80%) and 59 (98%) at 3 and 12 months, respectively. Stenosis did not recur in 48 renal units with half-time less than 20 minutes 3 months after repair. In 1 case that had been treated for postoperative urinoma half-time was greater than 40 minutes at 3 months and repeat pyeloplasty was required.Half-time less than 20 minutes 3 months after pyeloplasty predicts surgical success. Most renal units that improve but still have half-times greater than 20 minutes on an early diuretic renogram will demonstrate continued improvement in drainage patterns at 12 months. Those renal units that show no improvement at 3 months may require reoperation and those with half-time less than 20 minutes at 3 months do not require further evaluation.

Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution.We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively.Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2.The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

Purpose: We assessed variability in the interpretation of diuresis renography that may result from using different methods of clearance half-time determination.Materials and Methods: We reviewed 152 diuresis renography studies performed at diagnosis or during followup of 53 children enrolled in a prospective study assessing the natural history of unilateral neonatal hydronephrosis. Studies were classified as nonobstructive, indeterminate or obstructive using 4 methods of half-time determination. Intermethod correlation and agreement were evaluated. We compared the proportion of nonobstructive, indeterminate and obstructive classifications by each method, and the interpretation of individual studies based on each method.Results: Among methods we noted a high degree of correlation and fair to excellent agreement (Spearman ρ = 0.86 to 0.92 and κ = 0.57 to 0.86, respectively). However, in 27.8% of intermethod comparisons the proportion of studies classified as nonobstructive, indeterminate and obstructive dif...