Fistulization between ectopic ureteral stump and uterus following nephroureterectomy: case report.

Ureterouterine fistulas are rare surgical complications with fewer than 30 reported cases in the literature to date. Rarer yet is a fistula between an ectopic ureter and the uterus, with only one case described previously (Shibata et al. in J Urol 153: 1208-1210, 1995). Herein, we present the first case, to our knowledge, of a fistula between an ectopic ureteral stump (from a prior nephroureterectomy) and the uterus

Robotic ureterolysis for relief of ureteral obstruction from retroperitoneal fibrosis

Objective: To review our experience with robotic surgery for the management of retroperitoneal fibrosis (RPF) with ureteral obstruction. Ureteral obstruction is common in retroperitoneal fibrosis RPF. Methods: Since April 2006, 21 patients have presented to our institution with ureteral obstruction, apparently from RPF. All underwent robotic biopsy. If frozen pathology reveals malignancy, is equivocal, and/or the fibrotic reaction is extensive, we stent the obstructed side(s) and await final pathology. If RPF is confirmed, medical therapy is initiated to relieve obstruction; failures receive salvage ureterolysis. Lymphomas are referred to medical oncology. If frozen pathology demonstrates RPF, immediate ureterolysis is performed, if technically feasible. Ureterolysis is not performed for uninvolved contralateral systems. We reviewed data with institutional review board approval. Results: Of 21 patients, 3 were diagnosed with lymphoma and 18 with RPF. Seventeen patients (21 renal units) with RPF received robotic ureterolysis (11 primary, 6 salvage); the other patient died of trauma before intervention. The only perioperative complication, an enterocutaneous fistula, required bowel resection. Three patients required a secondary procedure to relieve obstruction. At a mean follow-up of 20.5 months, no renal unit has evidence of obstruction, and all patients have improved or resolved symptoms. Furthermore, none of the 13 patients who underwent a unilateral ureterolysis have had disease progression to the contralateral side. Conclusions: Robotic ureterolysis can be performed with minimal morbidity and provides durable success rates for relief of symptoms and obstruction in RPF. Biopsy remains integral to ruling out lymphoma. Empiric contralateral ureterolysis may not be necessary. © 2011 Elsevier Inc

Metabolic Syndrome and Nephrolithiasis Risk: Should the Medical Management of Nephrolithiasis Include the Treatment of Metabolic Syndrome?

This article reviews the relationship between metabolic syndrome (MetS) and nephrolithiasis, as well as the clinical implications for patients with this dual diagnosis. MetS, estimated to affect 25% of adults in the United States, is associated with a fivefold increase in the risk of developing diabetes, a doubling of the risk of acquiring cardiovascular disease, and an increase in overall mortality. Defined as a syndrome, MetS is recognized clinically by numerous constitutive traits, including abdominal obesity, hypertension, dyslipidemia (elevated triglycerides, low high-density lipoprotein cholesterol), and hyperglycemia. Urologic complications of MetS include a 30% higher risk of nephrolithiasis, with an increased percentage of uric acid nephrolithiasis in the setting of hyperuricemia, hyperuricosuria, low urine pH, and low urinary volume. Current American Urological Association and European Association of Urology guidelines suggest investigating the etiology of nephrolithiasis in affected individuals; however, there is no specific goal of treating MetS as part of the medical management. Weight loss and exercise, the main lifestyle treatments of MetS, counter abdominal obesity and insulin resistance and reduce the incidence of cardiovascular events and the development of diabetes. These recommendations may offer a beneficial adjunctive treatment option for nephrolithiasis complicated by MetS. Although definitive therapeutic recommendations must await further studies, it seems both reasonable and justifiable for the urologist, as part of a multidisciplinary team, to recommend these important lifestyle changes to patients with both conditions. These recommendations should accompany the currently accepted management of nephrolithiasis

Robot-assisted reconstructive surgery for ureteral malignancy: Analysis of efficacy and oncologic outcomes

Background and Purpose: There have been previous reports of the use of robotic technology for the surgical treatment of ureteral neoplasms such as transitional-cell carcinoma. These have lacked long-term follow-up, been isolated cases, or focused on only the distal ureter. This investigation examines a series of mid and distal ureteral neoplasms managed with surgeon controlled robotic techniques at a tertiary care medical center. We present perioperative data and long-term follow-up, with emphasis on oncologic outcomes. Patients and Methods: This series includes six consecutive patients who have undergone robot-assisted surgical extirpation of mid and distal ureteral malignancies since 2008. Four patients underwent robot-assisted distal ureterectomy with ureteroneocystostomy, and two underwent midureter segmental excision with ureteroureterostomy. Patient demographics, intraoperative data, final pathology results, and oncologic follow-up were reviewed retrospectively. Results: Total mean operative time was 268.5 minutes, including the cystoscopy and change of position component of the procedure; mean estimated blood loss was 72.5 mL, and the mean length of stay was 1.8 days. All four patients who underwent distal ureterectomy also had excisions of the ipsilateral bladder cuff-three needed a psoas hitch to facilitate the ureteroneocystostomy. Final pathology results revealed four cases of transitional-cell carcinoma, one case of ureteral carcinoma in situ, and one case of non-Hodgkin diffuse-type B-cell lymphoma. The only complication was a small hydrocele in one patient. All patients underwent standard surveillance protocol, with a recurrence in the bladder developing in one patient. Ureteral obstruction did not develop in any patient postoperatively. Mean length of follow-up was 33 months. Conclusions: Robot-assisted surgery is well suited for the complex reconstruction of the mid and distal ureter after excision of low-grade malignant lesions. This series demonstrates that this surgical approach offers excellent intermediate-term oncologic outcomes with preservation of ipsilateral renal function. We believe that robotic surgery may be considered as a first-line option for the minimally invasive excision and reconstruction of low-grade, localized ureteral malignancy in selected patients at centers with experienced teams. © 2012, Mary Ann Liebert, Inc

Instrumentation and Surgical Technique: Step-by-Step Percutaneous Nephrolithotomy: Multiple Access

© 2014 by John Wiley & Sons, Ltd. All rights reserved. The best treatment for the majority of patients harboring large renal calculi is percutaneous nephrolithotomy. Stone volume and collecting system anatomy may make it necessary to undertake this procedure using a multi-access approach. Patient preparation, technical aspects of the procedure including intraoperative trouble-shooting, and postoperative care are reviewed in this chapter

Robotic renal and upper tract reconstruction

Robotic techniques provide clear advantages for minimally invasive upper tract reconstruction, though the objective benefits need further delineation. These procedures are in their early experience, and larger series with prospective randomized comparison with the standard of care are warranted. Low volume of upper tract reconstruction in general will likely require multi-institutional study. Continued study of cost-effectiveness is necessary to define the optimal role for robotic reconstruction in both medical and economic terms. © 2008 Wolters Kluwer Health|Lippincott Williams & Wilkins

Safety and efficacy of removable inferior vena cava filters in anticoagulated patients undergoing percutaneous nephrostolithotomy

Background and Purpose: Increasing numbers of patients are receiving a diagnosis of thrombophilic conditions necessitating chronic anticoagulation therapy. The best management approach for such patients needing percutaneous nephrostolithotomy (PCNL) has not been established. Discontinuing anticoagulation therapy before PCNL is needed to prevent hemorrhage, placing some of these patients at risk for thromboembolic events. We describe the use of removable inferior vena cava filters (RIVCF) in patients undergoing PCNL who are at risk for a venous thromboembolic event. Patients and Methods: A retrospective study of outcomes of PCNL with RIVCF placement was conducted. Results: Four patients underwent PCNL with RIVCF placement on the same day of the procedure. The mean age was 49 years (range 35-69 years). PCNL was performed on a total of six renal units with a mean of 2.2 (range 1-3) operations per renal unit. Five of six (83%) renal units were rendered stone free. There were no complications associated with either the PCNL or RIVCF placement. No patient had a thromboembolic event or received blood products. Two of the four patients underwent successful removal of the RIVCF, and one elected to keep the device in place. The device could not be extracted in the other patient. The average length that the filters were in place was 52.5 days. Patients resumed anticoagulation therapy shortly after RIVCF removal. Conclusion: RIVCF placement is a safe and effective method of preventing venous thromboembolic complications in thrombophilic patients needing PCNL. Patients should be informed, however, that RIVCF removal is not always possible. © 2013 Mary Ann Liebert, Inc

Adenomatoid of the adrenal gland

Adenomatoid tumors are common in the genital tract but rare in the adrenal gland. These tumors can be difficult to diagnose when present in extragenital sites. This type of adrenal tumor lacks specific radiographic features and can be confused preoperatively with more common adrenal gland tumors. We present the case of a 54-year-old man with an incidental right adrenal mass with calcified components and elevated urinary levels of homovanillic acid that was found to be an adenomatoid tumor of the adrenal gland. © 2005 Elsevier Inc