Moderate Hydronephrosis among Acute Ureteral Calculus on Ultrasonographic Imaging in a Tertiary Care Center in Nepal: A Descriptive Cross-sectional Study

Introduction: Ureteric calculi are lying at any point of ureter from the pelvic ureteric junction to the vesicoureteral junction. If left untreated, ureteropelvic junction obstruction can lead to hydronephrosis. With the improved availability of computed tomography and ultrasound scanning, hydronephrosis is being diagnosed more frequently. The main aim of this study is to find out the prevalence of moderate Hydronephrosis among ureteral calculus on ultrasonography imaging in a tertiary care center of Nepal. Methods: A descriptive cross-sectional study was conducted among 110 acute ureteral calculus cases at Radiodiagnosis and Imaging Department of Chitwan Medical College and Teaching Hospital, Bharatpur from 15th August 2020 to 15th May 2021. The ethical approval was taken from the Institutional Review Committee of same institution. Convenient sampling technique was used to select the participant. . The collected data was entered in excel 16 and analysed in Statistical Package for Social Sciences. Point estimate at 95% Confidence Interval was done and frequency and percentage were calculated Results: Out of the 110 cases of acute ureteral calculus, 31 (28.2%) (19.79-36.60 at 95% Confidence Interval) has moderate hydronephrosis in the ultrasonographic imaging. The mean age of participants was 31.61±8.51 years and male to female ratio was 1.97:1. Vesicoureteric junction was the most common site for ureteric calculus 39 (35.5%). Conclusions: The ultrasound is an easy method to be applied, and a fast one to help and diagnose obstructive hydronephrosis. The main causes of hydronephrosis are kidney stones, followed by ureteral stones, with a moderate degree of hydronephrosis.

Ureteral Dissection Is a Risky Factor for Ureteral Rupture, the First Case Report.

Backgroundureteral dissection（UD）is a rare condition which occurs when injury through the intima and occasionally the media allows entry of urine and separation of the inner and outer ureteral layers. Ureteral rupture (UR) is an urgent disease when ureter wall injures through entire layers, generally caused by ureteral calculus, frequent application of ureteral endoscope, trauma, oppression of tumors, iatrogenic injury and with urine flowing into peripheral space easily causes peritonitis, so patients usually present features of peritonitis prior to signs of urinary tract. Ureteral dissection found in ureteral rupture is the first report. Case presentation21-year-old male and 43-year-old female complained of left and right lumbago respectively with no obvious predisposing cause. Bilateral ureter dilation and contrast agent extravasation observed in imageological examination was the same point between the two patients. Delayed computed tomography (CT) and retrograde pyelography both show double lumen sign and damaged intima. All imaging results throw light on the nature of this disease, like formation of aortic dissection (AD). ConclusionThe emphasis of this study lies in imaging manifestations of UD to enable radiologist to find it accurately and rapidly, and also demonstrates that delayed CT and retrograde pyelography can effectively diagnose ureteral dissection with very high accuracy.

Development and validation of a preoperative nomogram for predicting patients with impacted ureteral stone: a retrospective analysis

Background To develop and validate a practical nomogram for predicting the probability of patients with impacted ureteral stone. Methods Between June 2020 to March 2021, 214 single ureteral stones received ureteroscopy lithotripsy (URSL) were selected in development group. While 82 single ureteral stones received URSL between April 2021 to May 2021 were included in validation group. Independent factors for predicting impacted ureteral stone were screened by univariate and multivariate logistic regression analysis. The relationship between preoperative factors and stone impaction was modeled according to the regression coefficients. Discrimination and calibration were estimated by area under the receiver operating characteristic (AUROC) curve and calibration curve respectively. Clinical usefulness of the nomogram was evaluated by decision curve analysis. Results Age, ipsilateral stone treatment history, hydronephrosis and maximum ureteral wall thickness (UWTmax) at the portion of stone were identified as independent predictors for impacted stone. The AUROC curve of development and validation group were 0.915 and 0.882 respectively. Calibration curve of two groups showed strong concordance between the predicted and actual probabilities. Decision curve analysis showed that the predictive nomogram had a superior net benefit than UWTmax for all examined probabilities. Conclusions We developed and validated an individualized model to predict impacted ureteral stone prior to surgery. Through this prediction model, urologists can select an optimal treatment method and decrease intraoperative and postoperative complications for patients with impacted ureteral calculus.

EFFICACY AND SAFETY OF URSLAND MINI-PCNL FOR TREATMENT OF IMPACTED LARGE UPPER URETERAL CALCULI: A PROSPECTIVE STUDY.

Background: For the management of large impacted upper ureteral calculi, the available minimally invasive endourologic methods are minipercutaneous nephrolithotomy (Mini-PCNL), ureteroscopic lithotripsy (URSL), and laparoscopic ureterolithotomy. This study aimed to compare Mini-PCNLand URSL, and to evaluate the better choice for large impacted upper ureteral calculi. Methods: Between January 2017 and December 2020, at the Urology Unit, Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences (JNIMS), Porompat, Imphal, 40 patients with large impacted upper ureteral calculi (>15 mm) who were consecutively enrolled were included. The patients were randomly divided (1:1) into Mini-PCNL and URSL groups. The primary endpoint was the success of stone removal measured 1 month postoperatively and the secondary endpoints were intraoperative and postoperative parameters and complications. Results: Eight patients after URSLand 2 patients after Mini-PCNLneeded auxiliary ESWLtreatment. The stone clearance rate in the Mini-PCNL group was 95 % (19/20) and 75 % (15/20) in the URSL group. Operation-related complications were similar among the two groups (all p > 0.05). Hospital stay was shorter in the URSL group compared with Mini-PCNL (p < 0.001). However, the mean operative duration was shorter in the URSLgroup compared to the Mini-PCNLgroup (p < 0.001). Conclusions: Mini-PCNL and URSL are suitable treatment options for impacted upper ureteral calculus with a diameter of >15 mm. Though the success rate and stone clearance rate are lower but acceptable, URSL could be considered if the patient is not suitable for general anesthesia and with other comorbidities, or if it is the patient's preferred treatment option

Incidental discovery of endourethral clip migration 10 years after radical prostatectomy: A case report and review of the literature

Introduction: Surgical clips (SCs) have been widely used for a variety of surgical procedures over the years. Despite their advantages and proven effectiveness, several clip-related complications have been reported, creating dilemmas as to their optimal use. Case description: Herein, we present a rare delayed and incidental discovery of two endourethral metallic SCs in a 77-year-old male seeking treatment for acute renal colic. The patient had undergone open radical retropubic prostatectomy 10 years ago, and had an uneventful postoperative recovery. Computed tomography scan revealed left-sided hydronephrosis secondary to proximal ureteral calculus, as well as SCs at the level of vesico-urethral (VUR) anastomosis. Flexible cystoscopy confirmed the imaging findings, showing two endourethral clips, partly obstructing the VUR. Firstly, a serial wire-guided dilation took place, followed by left ureteral double-J stent placement. Unfortunately, the clips could not be concurrently removed due to their firm attachment to the bladder neck. Hence, our patient was scheduled for transurethral resection of the bladder neck and simultaneous endoscopic clip removal. Conclusions: To the best of our knowledge, this is the first report to highlight such a delayed incidental finding, 10 years after open retropubic radical prostatectomy (RRP), during a JJ stent insertion for obstructive uropathy without previous clip-induced lower urinary tract symptoms. Although rare, physicians should be aware of the potential clip-related complications arising either in the short- or long-term postprostatectomy setting.

Gastrointestinal perforation in anti-NXP2 antibody-associated juvenile dermatomyositis: case reports and a review of the literature

Background To summarize the characteristics of gastrointestinal (GI) perforation in anti-nuclear matrix protein 2 (NXP2) antibody-associated juvenile dermatomyositis (JDM). Methods Five patients with GI perforation from a JDM cohort of 120 cases are described. Relevant literature was reviewed. Results Five patients, including four females and one male, were included in the study. The age of onset of these patients ranged from 3.3 to 9.5 years with the median age of 5.0 years. When these patients were complicated by GI perforation, childhood myositis assessment score (CMAS) ranged from 1 to 5 with the median score of 2. Myositis-specific antibody (MSA) spectrum analysis indicated that the five patients were anti-NXP2 antibody positive. The initial symptoms of GI perforation were progressive abdominal pain and intermittent fever. Two patients also presented with ureteral calculus with hydronephrosis and ureteral stricture. Surgery was performed in four patients. One patient failed to undergo a repair as the perforation was high in position. For the other three patients, perforation repair was successful, of which two patients failed due to recurrent perforation. At 24 months postoperative follow-up, one patient was in complete remission on prednisone (Pred) and methotrexate (MTX) treatment, and her ureteral stricture had disappeared. The other four patients died. Adding these cases with 16 other patients described in the literature, the symptom at onset was progressive abdominal pain, which often occurred within 10 months after JDM was diagnosed. Perforation most commonly occurred in the duodenum, although it also occurred at multiple sites or was recurrent. The mortality rate of GI perforation in JDM was 38% (8/21). Conclusions All the five perforation cases in our study subjected to MSA analysis were anti-NXP2 antibody positive. The symptom at onset was abdominal pain. The most common site of perforation was the duodenum in the retroperitoneum, and the lack of acute abdominal manifestations prevented early diagnosis. GI perforation may be a fatal complication in JDM, and early diagnosis is very important. More research is needed to determine the pathogenesis and predictive factors of GI perforation in JDM.

Ureteral Dissection is a Transient Process Before Ureteral Rupture: A Case Report

Background: Ureteral dissection（UD）is a rare condition which occurs when injury through the intima and occasionally the media allows entry of urine and separation of the inner and medial ureteral layer just like the formation of aortic dissection. Ureteral rupture (UR) is generally caused by ureteral calculus, operation of ureteral endoscope, trauma, tumors, iatrogenic injury and easy to cause peritonitis, so patients usually show symptoms of peritonitis prior to signs of urinary tract. Ureteral rupture caused by ureteral dissection is rarely reported. Case presentation:21-year-old male and 43-year-old female were both admitted into hospital because of abdominal pain. Enhanced CT and retrograde pyelography showed “double lumen sign” in the right proximal ureter and contrast extravasation in the perinephric gap. The male is dead due to serious condition but the female is in good condition without complication after correct and timely therapy. Conclusions: UD is a transient process viewed by enhanced CT or retrograde pyelography offering a warning sign of UR in order to improve prognosis.