Dov Lask

Changing Trends in the Management of Iatrogenic Ureteral Injuries

PURPOSE We evaluated changing trends in the management of late diagnosed iatrogenic ureteral injuries before and after the introduction of percutaneous nephrostomy. MATERIALS AND METHODS The study included 44 patients of whom 24 were treated primarily by immediate reconstructive surgery from 1979 to 1984 and 20 were treated primarily by percutaneous nephrostomy tube insertion beginning in 1985. RESULTS Six of the 24 patients underwent ureteroneocystostomy and 18 underwent end-to-end uretero-ureteral anastomosis to repair the injury. Postoperatively 18 patients had a urinary tract infection. Hospital stay after reconstructive surgery ranged from 14 to 35 days (average 18). Long-term followup showed a normal upper urinary tract in 22 patients and mild to moderate hydroureteronephrosis in 2. Of the 20 patients who underwent percutaneous nephrostomy 16 (80%) had complete spontaneous recovery of the injured ureter after 14 to 66 days (average 32). Hospital stay after the insertion of the percutaneous nephrostomy tube ranged from 3 to 5 days. Urinary tract infection developed in 4 patients and mild hydronephrosis was noted in 1 on long-term followup. CONCLUSIONS The primary management of ureteral injury by percutaneous nephrostomy resulted in significantly decreased reoperation and morbidity rates, and enabled spontaneous recovery of the injured ureter in the majority of patients.

Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair – clinical characteristics and oncological outcomes

Study Type – Therapy (case series)
Level of Evidence 4

Metastatic renal carcinoid: case report and review of the literature

Primary renal carcinoid tumor is a rare tumor of the kidney. Metastatic renal carcinoid tumor has not been described in the medical literature. We report a case of renal metastasis of a primary bronchial carcinoid tumor and review the literature about renal carcinoid tumors.

Urinary tract infection in men younger than 45 years of age: is there a need for urologic investigation?

OBJECTIVES To determine in a prospective study whether urinary tract infection (UTI) in men younger than 45 years of age is associated with anomalies of the genitourinary tract that necessitate additional urologic evaluation. UTI in young men is uncommon. In these patients, it is customary to follow the same policy as that for children or older men and to routinely perform urologic investigations. METHODS Twenty-nine consecutive, otherwise healthy, male patients aged 16 to 45 years (mean 30.5) were hospitalized for a first event of acute UTI. All patients underwent an imaging evaluation, including ultrasonography and intravenous urography. Those with macroscopic hematuria underwent cystoscopy. Uroflowmetry was performed at least 1 month after recovery, and patients with a maximal flow rate of less than 15 mL/s underwent a pressure flow study. RESULTS Significant urethral stricture was excluded in all patients. Twenty-seven patients (93%) had a postvoid residual urine volume of less than 20 mL, and only two had values of 120 and 200 mL. The imaging and cystoscopic evaluation demonstrated a normal urinary tract in all patients. The maximal urinary flow rate was greater than 15 mL/s in 22 patients (76%) and lower than 15 mL/s in 7 patients (24%). In the latter group, urodynamic investigations, including free flowmetry and/or pressure flow study, revealed normal lower urinary tract function in 6 patients and a bladder outflow obstruction in 1 (3%). CONCLUSIONS A first event of UTI in men younger than 45 years is usually not associated with significant structural or functional urinary tract abnormalities. Therefore, no radiologic, endoscopic, or urodynamic investigation is required.

The Impact of Retrograde Intrarenal Surgery for Asymptomatic Renal Stones in Patients Undergoing Ureteroscopy for a Symptomatic Ureteral Stone

BACKGROUND AND PURPOSE In the era of rigid ureteroscopy (URS) for ureteral stones, asymptomatic renal stones were often left in place. With the advent of flexible URS, however, the treatment of such renal stones became an attractive option. Data are scarce regarding the impact of retrograde intrarenal surgery (RIRS) performed at the time of URS for a symptomatic ureteral stone in comparison with ureteral stone removal alone. The purpose of the study was to compare the outcomes of URS combined with RIRS with URS alone. PATIENTS AND METHODS A comparison between patients who underwent URS and RIRS (group A, n=47) and a matched control group of patients undergoing URS alone (group B, n=47) was performed. Matching was based on ureteral stone size and location, and preprocedural Double-J stent placement. RESULTS The median size of the largest ureteral stone in both groups was 8 mm with a mean total stone burden of 52.9 mm(2) (28.9) and 47 mm(2) (21.1) in groups A and B, respectively. Median renal stone size was 9 mm with a mean total stone burden of 84.1 mm(2) (40.3). Mean surgery time in groups A and B was 68 minutes (19.61) and 39 minutes (15.96), respectively (P<0.001). Median hospital stay was 1 day for both groups. The success rate for ureteral stone removal was 98% and 100% in groups A and B, respectively. Success rate for RIRS was 85% (40/47 cases). Hospitalization length and complications, mainly postoperative fever, did not differ significantly between the groups. CONCLUSIONS Managing asymptomatic renal stones at the time of URS for symptomatic ureteral stones significantly prolongs surgery duration but does not lengthen hospital stay, increase complications, or lower success rates. This combined approach reduces the need for future procedures and is probably more cost effective.

Abdominal compartment syndrome: urological aspects.

ACS is prevalent in various surgical conditions and in a large percentage of critically ill patients. Measuring the IAP is important in the early diagnosis of ACS and can be easily done by measuring the intravesical pressure. ACS adversely affects many organ systems; the pathogenesis of renal dysfunction is probably multifactorial, from a combination of reduced cardiac output, reduced GFR mediated by secretion of renin and angiotensin, aldosterone-mediated water reabsorption, increased renal parenchymal pressure and direct compression of the renal vein. Successful treatment requires a high index of suspicion, prompt recognition and early surgical abdominal decompression.

Ureteral Ultrasonic lithotripsy revisited: A neglected tool?

BACKGROUND AND PURPOSE Ultrasonic lithotripsy was one of the first modalities used for treating renal and ureteral stones. However, in recent years, it has been largely replaced by newer techniques such as laser lithotripsy with rigid as well as flexible ureteroscopes. The aim of this study was to review the results and our current indications for ureteroscopic ultrasonic lithotripsy (UUL). PATIENTS AND METHODS Between October 2000 and May 2002, 340 ureteroscopies were performed for the treatment of ureteral stones in the Rabin Medical Center. Of this series, 9 patients (2.6%) underwent UUL using a semirigid 8F ureteroscope (Wolf) and an Olympus ultrasonic lithotripter (LUS-1) with a 4.5F hollow probe. Four patients had Steinstrasse following shockwave lithotripsy, four had large (1-2-mm) ureteral stones, and one had an impacted calcified ureteral double-J stent. Stones >5 mm were initially fragmented by the holmium laser (550-microm fiber). A double-J stent was placed in all patients. The mean follow-up time was 20 months. RESULTS The mean operative time was 84 minutes. No intraoperative complications occurred. The mean hospital stay was 3.9 days. Eight patients became stone free after the first procedure, and the other underwent secondary ureteroscopy, which rendered him stone free. CONCLUSIONS Patients in whom UUL is performed are relatively complex stone patients. The use of ultrasonic lithotripsy following, or in combination with, laser or ballistic devices utilizes the unique properties of UUL, which combines stone fragmentation and efficient removal of small fragments. The technique was particularly useful in patients with Steinstrasse or a large stone burden. Thus, UUL has a limited but significant role in the treatment of ureteral stones.

Intrarenal foreign body presenting as a solid tumor

A 45-year-old man underwent radical nephrectomy for an asymptomatic solid renal mass radiographically interpreted as a tumor. The pathologic examination revealed an intrarenal sponge forgotten during nephrolithotomy performed 5 years previously. The sponge was surrounded by a thick fibrous capsule. This case suggests that foreign body should be included in the differential diagnosis of a suspected renal mass in patients with a history of previous surgery.

Ectopic Splenic Tissue Simulating a Renal Mass

A 64-year-old patient who underwent splenectomy presented clinically with ectopic splenic tissue simulating a solid renal mass. The splenic origin of the mass was assessed by radionuclide spleen scan. Nephrectomy was avoided.

The pattern of radionuclide scrotal scan in torsion of testicular appendages

The aim of this study was to define the radionuclide scrotal imaging (RSI) pattern in cases of torsion of testicular appendages and to correlate it with the duration of symptoms. Two hundred and seventeen patients with acute scrotal pain were evaluated prospectively during the past 13 years. Two groups of patients were defined according to the interval between the onset of symptoms and the performance of RSI: group A comprised patients in whom RSI was performed within 5 h after the onset of symptoms, while group B comprised patients in whom RSI was performed between 5 and 24 h after the onset of symptoms. An SPX-4 Elscint or an Apex 405 gamma camera with a parallel hole or converging collimator was used. Between 5 and 15 mCi of technetium-99m pertechnetate was injected as a bolus intravenously. The radionuclide angiogram consisted of six to eight consecutive 5-s frames. The scrotal static scan was obtained immediately following the radionuclide angiogram. The “hot dot” sign, which is a small spot of increased tracer perfusion and uptake on RSI, was not present during the first hours after the onset of symptoms. Therefore, RSI is inaccurate and is not indicated for the diagnosis of torsion of testicular appendages of less than 4–5 h duration. The hot dot sign was, however, demonstrated on the RSI in 45% of the patients with scrotal pain lasting between 5 and 24 h. The overall sensitivity and accuracy of RSI in diagnosing torsion of testicular appendages in this group of patients were 68% and 79%, respectively. In all the patients with a positive hot dot sign, torsion of testicular appendages was found at exploration (specificity 100%). Therefore, the hot dot sign was found to be pathognomonic of torsion of testicular appendages.