Search

Purpose: We sought to characterize and 3-dimensionally reconstruct the distribution of the autonomic innervation of the human ureter.Materials and Methods: Three male and 3 female pairs of ureters were evaluated at 2 mm serial transverse sections along the entire length of the ureter. The location of nerve tissue was immunohistochemically identified using the neuronal marker, S100 protein. ImageJ software was used to calculate nerve count and density in the adventitia and smooth muscle. Blender® graphics software was used to create a 3-dimensional reconstruction of autonomic nerve distribution.Results: Within the adventitia nerve density was highest in the mid and distal ureter (females 2.87 and 2.71 nerves per mm2, and males 1.68 and 1.69 nerves per mm2) relative to the proximal ureter (females and males 1.94 and 1.22 nerves per mm2, respectively, p >0.0005). Females had significantly higher nerve density throughout the adventitia, especially in the distal ureter (2.87 vs 1.68 nerves per mm2, p

We describe the indications, technique and outcome of transrenal antegrade ureteral occlusion.An institutional database was used to retrospectively identify patients who underwent image guided transrenal ureteral occlusion between December 1998 and March 2014. Platinum coils were deployed into the distal ureter or 4 to 5 cm proximal to the site of ureteral leak. Gelfoam® pledgets were injected in the ureter at the level of the coils. Additional coils were deployed to trap the pledgets in the distal ureter.Between December 1998 and March 2014, 12 men and 12 women with a mean age of 69 years (range 45 to 87) underwent fluoroscopically guided, transrenal antegrade ureteral occlusion for intractable hematuria in 7 and urinary fistula in 17. A total of 39 ureteral units were occluded, including 3 on the right side, 6 on the left side and 30 that were bilateral. Ureteral occlusion was successful in 35 of 37 renal units (94.6%) as determined by post-procedure antegrade nephrostogram and resolution of clinical symptoms of hematuria and/or urinary leakage. Repeat occlusion was necessary to achieve total ureteral occlusion in 2 of 35 renal units (5.7%).Percutaneous ureteral occlusion with platinum coils and Gelfoam offers a treatment option for patients with refractory urinary fistula and intractable hematuria in whom standard methods of urinary diversion fail.

Purpose: The optimal technique of excising the juxtavesical ureter and bladder cuff during laparoscopic nephroureterectomy is still evolving. We report on a novel transvesical needlescopic (2 mm. instrumentation) assisted technique of en bloc retrieval of the juxtavesical ureter and bladder cuff during laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma.Materials and Methods: Retroperitoneal laparoscopic nephroureterectomy was performed in 8 patients using this technique. Two needlescopic ports (2 mm.) inserted suprapubically into the bladder were used in combination with a cystoscopically positioned Collins knife.Results: Satisfactory circumferential detachment of the bladder cuff and en bloc mobilization of 3 to 4 cm. of the intact pelvic extravesical ureter were achieved transvesically in each case in a manner comparable to open surgery.Conclusions: This technique simulates established open surgical principles of treating the distal ureter during laparoscopic nep...

Two patients with large volume disease in markedly dilated ureters were treated endoscopically by wide dilation of the ureteral orifice and passage of larger nonureteroscopic endoscopes. The larger instruments provided better vision and the ability to work with larger tools, which greatly facilitated treatment without complication in patients who otherwise would have undergone an open procedure.

Purpose: The conventional technique for ureterocystoplasty includes complete mobilization and incision of the ureter. We describe a modified procedure in which the distal 3 cm. of ureter are left in place and intact.Materials and Methods: This modification has been used in our last 13 cases of ureterocystoplasty. The first 7 patients with followup of more than a year (mean 28 months) are included in this series, and 6 have undergone video urodynamic evaluation before and after reconstruction.Results: Clinical results have been good. Four patients who have been toilet trained are continent. There have been no problems from stagnant urine in the intact ureter with only 1 case of pyelonephritis and no bladder calculi. Mean bladder capacity on cystometrogram has increased from 103 to 236 ml. after reconstruction and reached 137% of expected capacity for age and size (range 110 to 155%). No uninhibited contractions or problems with compliance have been noted.Conclusions: The distal ureter may be left i...

Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients.Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter.Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty.Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.

Treatment of distal ureteral stones with the Dornier HM3 lithotriptor**Dornier Medical Systems Inc., Marietta, Georgia. depends on the localization and positioning of the calculus from a transgluteal approach. We found the Stryker frame gantry modification preferable to the standard gantry for treatment of stones in the distal ureter. We report the use of this gantry adaptation in 22 cases of distal ureteral stones. The calculi were localized in 100% of the cases and were fragmented successfully with 1 treatment in 89%. In no case was the procedure aborted secondary to nonvisualization of the calculus. Failure to disintegrate the stone requiring retreatment occurred in 11% of the cases, and was attributed to stone characteristics and not due to difficulty with visualization or placement of the calculus within the F2 focus. The average fluoroscopic time was 45seconds. The Stryker frame modification to the standard Dornier HM3 lithotriptor allows for improved visualization and easier localization of...

An unusual case of late ureteral obstruction following a Politano-Leadbetter ureteroneocystostomy performed 11 years previously is reported. Fibrosis of the distal ureter associated with vascular compression of the extravesical ureter presumably led to development of a ureteral intramural diverticulum. This case illustrates the necessity of careful ureteral placement and emphasizes the importance of close followup for many years, even in asymptomatic patients.

Ureteroscopy has been used for the treatment of calculi throughout the ureter. The results of ureteroscopic stone removal were reviewed in 100 patients. Similar results were compared in 30 patients undergoing ureterolithotomy and 32 treated by basket manipulation. Success of ureteroscopic removal was related to the location of the calculus: 50 per cent in the proximal, 80 per cent in the mid and 99 per cent in the distal ureter. Hospital stay, costs and narcotic analgesic use were significantly less for ureteroscopic stone removal than for open surgical lithotomy. The success rate for ureteroscopic removal of distal calculi (99 per cent) was higher than for blind basketing procedures (59 per cent). Ureteroscopy should be considered the technique of choice for the removal of distal ureteral calculi. It is an acceptable alternative for treatment of calculi throughout the urinary tract.

The blind empirical practice of ureteral reimplantation for all types of ureterovesical obstruction is founded on entirely speculative concepts of the nature of the obstruction. A significant proportion of ureterovesical obstructions are caused by a tilt-valve type of abnormality of the distal ureter with a normal juxtavesical segment. These can be corrected rationally by an extravesical ureteroureteroplasty. This procedure was done between 1968 and 1975 to relieve obstruction of 9 ureters in 8 children. The pathological anatomy found in these cases is defined and the technique of operative recognition and reconstruction is described. With adequate operative recognition and appropriate case selection relief of obstruction was achieved and maintained in 7 of the 9 ureters.

Malacoplakia of the urinary tract affects primarily the bladder and secondarily the distal ureter. Characteristic gross and microscopic lesions have been well described. A case of malacoplakia is reported in a 55-year-old woman who presented with hydronephrosis in a solitary kidney. The only lesion in the urinary tract was an apple-core type mass of the distal ureter, which was resected. This represents a rare and unusual presentation of malacoplakia. The differential diagnosis and pertinent literature are discussed.

The ureter is accessible to direct vision for diagnosis and treatment because it is pliable and attached firmly to the bladder. Instrumentation is in the process of development. A generally applicable technique for rigid ureteroscopy within the distal ureter and examples of use in patients with stricture, transitional cell carcinoma and calculi are reported.

We report a case of unilateral ureteral obstruction owing to carcinosarcoma of the distal ureter. Tumor recurred 6 months after ureteronephrectomy and the patient died 2½ years later. A review of the literature revealed only 3 other cases of ureteral carcinosarcoma, all of which had a similar aggressive course. Recognition and separation of this entity from the more usual transitional cell carcinoma are important because of its apparent poorer prognosis.

We report a case of inverted Y duplication of the ureter in association with an obstructing ectopic ureterocele and paraureteral diverticulum. Preoperative radiological studies demonstrated the ureterocele and diverticulum but they failed to show the duplex distal ureter. The duplicated section of ureter was excised and a Cohen reimplantation was performed. The presence of a large ureterocele obstructing the bladder neck, a diverticulum, failure of reflux into the ectopic segment and poor function of the affected kidney all contributed to the difficulties in establishing a preoperative diagnosis.

The cobra-shaped distal ureter is not pathognomonic of a ureterocele. It may be seen with incomplete distal ureteral obstruction owing to tumor or calculus. The appearance of the wall surrounding the dilated distal ureteral segment is a more important finding to differentiate a ureterocele and a pseudoureterocele. The wall of a ureterocele is thin, while the lucency surrounding a pseudoureterocele is thicker and poorly defined.