Ex-Vivo Ureteroscopy at the Time of Live Donor Nephrectomy

Background and Purpose: Potential transplant renal allograft recipients exceed the number of donors. Our institution now considers patients with small, unilateral, nonobstructing, incidental renal calculi for possible renal donation. We adopted ex-vivo ureteroscopy (ExURS) to render these kidneys stone free at the time of renal transplantation. We examined the safety and efficacy of ExURS. Patients and Methods: After confirming a lack of significant metabolic defects on 24-hour urinalysis, 23 patients with small nonobstructing unilateral nephrolithiasis detected on preoperative CT angiography underwent donor nephrectomy. Immediately after cold perfusion, ExURS was performed with ice cold saline irrigation. Retrospective review was performed. Results: Pyeloscopy was successfully performed in all 23 patients. A total of 28 calculi, mean largest diameter 3.9-mm (range 3-6-mm), were visualized in 19 kidneys. Basket extraction and holmium laser lithotripsy was performed in 12 and 6 kidneys, respectively. Treatment rendered 17/19 stone-containing kidneys stone free with a mean treatment time of 6.2 minutes (3-10-min). There were no intraoperative complications. Median serum creatinine level of recipients at 1 month and 1 year were 1.4+/-1.8-mg/dL and 1.3+/-0.6-mg/dL, respectively. At a median follow-up of 63+/-47.2 months, there were no transplant urinary calculi among the recipients. Conclusions: ExURS safely renders live donor kidney allografts stone free with low risk of recurrence. When used appropriately, ExURS could safely increase the number of potential kidney donors and minimize the risk of adverse stone events.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90444/1/end-2E2010-2E0627.pd

Authors' Response to Letter to the Editor

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98450/1/end%2E2012%2E1527.pd

Long-term Outcomes of Immediate Versus Delayed Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose: To compare immediate nephroureterectomy with delayed nephroureterectomy after a trial of nephron-sparing endoscopic surgery in patients who were treated initially at our institution from 1996 to 2004 for upper tract urothelial carcinoma. Patients were monitored for upper tract recurrences, metastases, cancer-specific and overall survival. Survival outcomes and perioperative measurements were compared between treatment groups. Results: Of 73 patients, 62 underwent immediate nephroureterectomy and 11 proceeded to nephroureterectomy after failed endoscopic management. Mean follow-up for all patients was 58 months and 75 months for patients who were alive at last follow-up. Patients treated initially with endoscopy averaged a surveillance procedure every 3.7 months and had a median delay to nephroureterectomy of 10 months. Perioperative measurements at time of nephroureterectomy did not differ between groups. Overall survival 5 years from initial resection in the delayed group and from nephroureterectomy in the immediate group was 64% and 59%, respectively; the corresponding 5-year cancer-specific and metastasis-free survival estimates were 91% vs 80% and 77% vs 73%, respectively (P>0.05). Pathologic progression from low to high-grade occurred in three of seven patients from the delayed group. Conclusions: Failure of endoscopic management necessitating nephroureterectomy does not appear to affect survival outcomes compared with immediate nephroureterectomy in patients with upper tract urothelial carcinoma. A trial of endoscopic management can be considered in patients with low-grade disease and a normal contralateral kidney. Endoscopy is a viable option when there are imperative indications for nephron sparing in the setting of high-grade disease.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90447/1/end-2E2011-2E0220.pd

Definitive Management of Failure After Pyeloplasty

Introduction: Failure after pyeloplasty is difficult to manage. We report our experience managing pyeloplasty failures. Methods: We retrospectively reviewed the case log of a single surgeon, from August 1996 to August 2014, to identify all patients undergoing a surgical procedure after failed pyeloplasty. We excluded patients without follow-up exceeding 1 year from initial postpyeloplasty procedure. Failure was defined as a need for additional definitive intervention. Results: Of 247 laparoscopic pyeloplasties, 68 endopyelotomies and 305 simple laparoscopic nephrectomies reviewed, 41 were performed after previous pyeloplasty and had sufficient follow-up. Laparoscopic nephrectomy was performed in nine patients. All three secondary laparoscopic pyeloplasties were successful. Of 29 secondary endopyelotomies, 10 (34%) were successful. Of the 19 failures after secondary endopyelotomy, 12 patients had tertiary pyeloplasty (5 laparoscopic and 7 open surgical), 5 (26%) underwent tertiary endopyelotomy, and 2 (11%) required nephrectomy. Our overall endopyelotomy success rate was 38% (13/34) vs 100% (11/11) for secondary or tertiary pyeloplasty (4 patients lost to follow-up). Median time to failure was 5 months for endopyelotomy. Median follow-up for patients free from intervention was 40.2 months. Conclusions: Secondary pyeloplasty (including both laparoscopic and open surgical approach) is more than twice as successful as endopyelotomy after failed pyeloplasty. Secondary pyeloplasty is an excellent alternative to endopyelotomy in select patients with failure after initial pyeloplasty.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140085/1/end.2015.0837.pd

Ureteral Stents for Impassable Ureteroscopy

Background: For the narrow ureter that will not accommodate a ureteroscope, it is common practice to place a ureteral stent, to allow subsequent ureteroscopy in the passively dilated ureter. Surprisingly, there are limited data on the effectiveness or safety of these maneuvers. Methods: We retrospectively analyzed patients managed with ureteral stent placement followed by another attempt at ureteroscopy after an initial attempt of flexible ureteroscopy failed because the ureteroscope would not pass up an otherwise normal ureter. Results: Of 41 patients with follow-up who underwent ureteral stenting for this reason, the ureteroscope passed with ease poststenting in 29 (71%) and there was continued resistance in 12. Of these 12 patients, the ureteroscopy was continued despite resistance in 9, while another stent was placed in the remaining 3. Of these three patients, the third attempt at ureteroscopy was successful in two, and further attempts at ureteroscopy were not made after the third attempt failed in one. With a mean overall follow-up of 32 months, two patients (5%) developed ureteral strictures. Both were among nine patients in whom repeat ureteroscopy was performed despite resistance, with a rate of obstruction of 22% in this subgroup. Overall, ureteral stenting allowed successful ureteroscopy in 98% of patients. Conclusions: Ureteral stenting with subsequent ureteroscopy is a successful and safe method of addressing a narrow ureter that initially does not allow passage of a flexible ureteroscope, as long as persistent subsequent attempts to insert the ureteroscope are made only if it passes easily.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140373/1/end.2012.0414.pd

Urologic laparoscopy with a new blunt-tipped trocar: Safe, rapid access without the use of fascial sutures

Fifteen patients underwent successful laparoscopic procedures where a new blunt-tipped trocar was used both to gain initial access to and to insufflate the abdominal cavity. The use of this new trocar obviates the need for the use of the Veress needle and appears to be both time-saving and possibly safer. Unlike the Hasson-type trocar, the blunt trocar technique does not require the use of fascial sutures for prevention of air leaks.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31560/1/0000487.pd

Solitary Common Iliac Artery Inflammatory Aneurysm in a Healthy Woman: Case Report and Review of the Literature

Inflammatory aneurysms represent only 3–10% of all aortoiliac aneurysms and tend to be more common in men. We report a case of a solitary inflammatory aneurysm of the right common iliac artery in a healthy young woman. The patient presented with persistent abdominal and right flank pain. She had no risk factors for vascular disease, except mild hypertension and a strong family history of aneurysm disease. Her work-up demonstrated a 3.0 cm right common iliac artery aneurysm with intramural thrombus, focal calcification, and perianeurysmal inflammation without evidence of systemic atherosclerosis. There was right hydroureteronephrosis secondary to ureteral compression by the inflammatory aneurysm. She underwent open right common iliac artery aneurysmorraphy with polytetrafluoroethylene interposition graft and concomitant ureterolysis without complication. She remains asymptomatic more than 1 year postoperatively with no evidence of additional aneurysm disease, resolution of her hydroureteronephrosis, and normal kidney function. We report a rare case of a solitary inflammatory aneurysm of the right common iliac artery in a healthy young woman, with a review of the current literature on inflammatory aneurysms.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41370/1/10016_2005_Article_7713.pd

Symptomatic Subcapsular and Perinephric Hematoma Following Ureteroscopic Lithotripsy for Renal Calculi

Objective: Ureteroscopic lithotripsy (URSL) is believed to be associated with less risk of symptomatic renal hematoma than extracorporeal shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL). We sought to document the rate of and risk factors for this rare complication following URSL for renal calculi. Methods: With Institutional Review Board approval, we reviewed 1087 cases of URSL performed between July 2009 and October 2012 for four surgeons. We identified cases for renal calculi complicated by symptomatic ?hematoma? by searching electronic medical records of patients undergoing URSL with a web-based search tool and cross-referencing with a departmental quality improvement database for postoperative complications. Chi-squared tests were used to assess risk factors. Results: Among 877 renal units exposed to URSL for renal calculi, 4 were complicated by symptomatic subcapsular hematomas (SH) and 3 by symptomatic perinephric hematomas (PH), yielding a 0.5% and 0.3% rate for each complication, respectively. Pain was the primary presenting symptom. Almost all cases presented within 24 to 48 hours postop. Two PH patients required postoperative blood transfusion. Four patients (two SH, two PH) were hospitalized for observation. Ureteral sheaths were used in two cases (one PH and one SH). There was no association with age, diabetes, body mass index (BMI), or operative duration (p-values all>0.05). However, hematoma did correlate with female gender, preoperative hypertension, preoperative ureteral stenting, intraoperative ureteral sheath use, and postoperative ureteral stenting (all p-values<0.0001). Conclusions: While symptomatic hematoma is a complication of URSL, the rate of such outcome (0.8%) is far less than that reported by prior series with SWL and PCNL. This may partially be attributable to collection biases, where subclinical cases are not imaged, or anchoring biases, where clinicians attribute symptoms to another possible etiology. This outcome can be morbid, but can often be conservatively managed with observation.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140379/1/end.2014.0176.pd

Success of Ureteral Stents for Intrinsic Ureteral Obstruction

Purpose: Previous reports suggest a high success rate for retrograde ureteral stenting for intrinsic ureteral obstruction, but few preoperative predictors of success have been offered. We reviewed our experience to look for factors that suggest failure of stents for intrinsic ureteral obstruction. Materials and Methods: We retrospectively reviewed the outcome of retrograde ureteral stent placement for intrinsic ureteral obstruction without concurrent or intended definitive management of the obstruction. Results: Thirty-eight patients treated for intrinsic ureteral obstruction, representing 41 ureteral units (UUs), were monitored for an average of 25.5 months. The overall success rate was 88%. Of the successes, 13 UUs had definitive therapy to permanently remove the cause of obstruction, obstruction resolved in 12 UUs after stent placement, and 11 UUs were managed with indwelling stents. Therapy failed in five UUs, with a median time to failure of 1.9 months. Of the UUs in which failure occurred, three failures were caused by misdiagnosis; in the remaining two, the stent did not correct the obstruction. On univariate analysis, male sex (P = 0.006), increased creatinine level as a presenting symptom (P = 0.002), and more severe preoperative hydronephrosis (P = 0.042) were predictive of failure. Adverse events were low, with complications from stenting occurring on only four of 41 UUs. Conclusion: If initial stent placement was possible, intrinsic ureteral obstruction was managed successfully in 88% of patients. Given high success and minimal complications, retrograde placement of ureteral stents can be performed to treat patients with intrinsic ureteral obstruction. Treatment failure is more likely to occur in men and patients with severe hydronephrosis or an elevated creatinine level.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63109/1/end.2007.0201.pd

Open surgical partial nephrectomy for upper tract urothelial carcinoma

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106973/1/iju12301.pd