Symptomatic renal papillary varicosities and medullary nephrocalcinosis

Background Nephrocalcinosis is often asymptomatic but can manifest with renal colic or hematuria. There is no reported association between nephrocalcinosis and renal vascular malformations, which may also be a source of hematuria. We herein present a case of a patient with hematuria related to nephrocalcinosis and renal papillary varicosities. These varicosities were diagnosed and successfully treated with flexible ureteroscopy and laser fulguration. Case presentation A 24-year-old female with a history of epilepsy (on zonisamide), recent uncomplicated pregnancy, and new diagnosis of nephrocalcinosis presented with right flank pain and intermittent gross hematuria. Imaging revealed intermittent right sided hydronephrosis. A cystoscopy identified hematuria from the right ureteral orifice. Diagnostic flexible ureteroscopy revealed numerous intrapapillary renal stones and varicose veins of several renal papillae. A 200 μm holmium laser fiber was used to unroof these stones and fulgurate the varicosities with resolution of her symptoms for several months. She later presented with left-sided symptoms and underwent left ureteroscopy with similar findings and identical successful treatment. Conclusion Unilateral hematuria from discrete vascular lesions of the renal collecting system may be obscured by other benign co-existing conditions, such as nephrocalcinosis and nephrolithiasis. Although a simultaneous presentation is rare, flexible ureteroscopy with laser fulguration offers an ideal diagnostic and therapeutic modality for these concurrent conditions if symptoms arise.

Case Report: Mini-endoscopic combined intrarenal surgery in an en-bloc kidney transplant

Background Overall incidence of stones in kidney transplant recipients is 1%. En-bloc kidney transplant is a rare anatomical condition in which kidney stones treatment can be extremely difficult to treat. As far as we know, no cases of staghorn calculi in en-bloc kidney transplant have been published so far. Case presentation A 27-year-old woman presented to the Emergency Department because of asthenia, adynamia and weight loss associated with lower urinary tract symptoms and subfebrile temperature. Ten years before, she had undergone an en-bloc kidney transplant because of end-stage renal disease secondary to perinatal asphyxia syndrome. One kidney was implanted capo-volta in the right iliac fossa and the other one in the right flank. NCCT scan showed incomplete staghorn calculi in the iliac fossa transplanted kidney. Besides, severe dilation of the native and the right flank transplanted kidney, due to two ureteral stones of 6 and 7 mm impacted in the uretero-ureteral anastomosis, was found. After hospital admission and under ceftriaxone prophylaxis, an attempt to perform primary RIRS following our COVID protocol was carried out. Nevertheless, we ended up placing a JJ stent because once the guidewire passed through the ureteral stones, purulent material came out from the ureteral orifice. She stayed 9 days in-hospital for management of postobstructive polyuria and was discharged with oral antibiotics. Three weeks afterward, we removed the stent and performed flexible ureteroscopy and holmium laser lithotripsy of the ureteral stones. In the same procedure, we performed Mini-ECIRS (21 French) previous ultrasound-guided upper pole puncture. Postoperative NCCT scan showed neither residual fragments nor operative complications. Conclusion This is the first clinical case reporting Mini-ECIRS in a patient with an en-bloc kidney transplant. This endourological approach seems to be a feasible, safe and effective approach to treat stones in this anatomically challenging condition.

Magnetic Agarose Microspheres/Hyaluronic Acid Hydrogel as a Trackable Bulking Agent for Vesicoureteral Reflux Treatment

Vesicoureteral reflux (VUR) is one of the most common congenital anomalies in the kidney and the urinary tract. Endoscopic subureteral injection of a bulking agent has become popular in VUR treatment due to its high success rates, few complications, and a straightforward procedure. In this study, a novel magnetic bulking agent was prepared by embedding Fe3O4 magnetic nanoparticles in cross-linked agarose microspheres with diameters of 80–250 μm and dispersing the magnetic microspheres in a hyaluronic acid hydrogel. The bulking agent has good biocompatibility and biosecurity validated by the tests of cytotoxicity, in vitro genotoxicity, animal irritation, skin sensitization, acute systemic toxicity, and pathological analysis after the injection of the bulking agent extract solution into healthy mice as well as injection of the bulking agent into VUR rabbits. The VUR rabbits were created by incising the roof of the intravesical ureter to enlarge the ureteral orifice. The success rate of the bulking agent in treating VUR rabbits using a subureteral transurethral injection technique was 67% (4/6) or 80% (4/5, excluding the unfinished rabbit), and no migrated particles were found in the organs of the rabbits. The transverse relaxation rate of the bulking agent was 104 mM−1s−1. After injection, the bulking agent was long-term trackable through magnetic resonance imaging that can help clinicians to inspect the VUR treatment effect. For the first time, this study demonstrates that the bulking agent with a long-term stable tracer is promising for endoscopic VUR treatment.

Malakoplakia of the bladder near the ureteral orifice: a case report

Malakoplakia, a rare acquired granulomatous disease, affects many systems, including the urogenital tract. The literature describes malakoplakia of different viscera, and satisfactory results have been obtained after treatment. We reported a 48-year-old patient with diabetes who received multiple treatments in our hospital for bladder malakoplakia near the ureteral orifice. Despite aggressive treatment, the patient had recurrent bladder malakoplakia and even developed right ureteral orifice stenosis, which resulted in urinary obstruction and hydronephrosis. We believe that malakoplakia in the bladder near ureteral orifice should receive more attention. Satisfactory results may not be obtained through antibiotic treatment alone, and early antibiotic therapy combined with full surgical excision may be a better choice.

Cystoscopic features of the ureteral orifices in children with vesicoureteral reflux

Purpose – to establish cystoscopic prognostic criteria for vesicoureteral reflux (VUR) in children. Materials and methods. Clinical material covers 270 patients with VUR II–IV grades aged 9 months to 14 years and 22 healthy children. The study included patients with VUR in the period of clinical and laboratory remission without symptoms of neurogenic bladder. During cystoscopy, the condition of the bladder mucosa was assessed; location, shape, hydrodistention degree, and ureteral orifices contractility. Results. Patients with VUR were diagnosed ureteral orifices in the form of: horseshoes – 127 (47.04%) patients, stadium – 106 (39.26%) and golf holes – 37 (13.7%). They were in the zones: A – 13 (4.81%) children, B – 154 (57.04%), C – 67 (24.81%), D – 36 (13.33%), and were characterized by the hydrodistention degree: H0 – 7 (2.59%) patients, H1 – 173 (64.07%), H2 – 60 (22.22%) and H3 – 30 (11.11%). In children with VUR, sluggish peristalsis of the ureter orifices clearly prevailed – 252 (93.33%) cases, relative to active peristalsis in only 18 (6.67%) patients. Conclusions. For ureteral orifices in the form of a stadium and with more pronounced signs of deepening, which are shifted to zone B and laterally to the sidewall of the bladder, with a hydrodistention degree above H1 has a positive association with VUR at the highest specificity of tests. Unfavorable prognostic diagnostic markers for effective minimally invasive interventions in patients with VUR should be considered ureteral orifices, which combine such morpho-topographic characteristics as pronounced signs of deepening to the shape of a golf hole, lateralization to the sidewall of the bladder in zone D, and hydrodistention H3 degree. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: vesicoureteral reflux, ureteral orifice, cystoscopy, children.

Holmium laser-assisted laparoscopic partial cystectomy for bladder cancer: technical feasibility and outcome

BackgroundIn selected patients with bladder cancer, partial cystectomy is an alternative treatment for bladder preservation with fair oncologic result. During partial cystectomy, tumor margin demarcation is difficult. Various methods were introduced, however, there is no standard for tumor margin demarcation. We aimed to introduce and provide our experience with holmium laser-assisted method with ten patients.MethodsFrom March 2016 and February 2019, patients who want partial cystectomy for bladder cancer were enrolled in this study. Inclusion criteria were stage T2 or T3 disease and tumor location restricted within the dome, and lateral, posterior side of the bladder were included. Transurethral holmium laser-assisted mucosal incision was made and deepened until perivesical fat. Minimal Safety margin for 5–10 mm were spared, and tumor removal was done laparoscopically.ResultsTen patients underwent holmium laser-assisted laparoscopic partial cystectomy. All procedures were done without complication. The tumor locations were laterally in seven patients, dome in two patients, and posterior wall in one patient. Pathologic examination of surgical margin showed no cancer cell involvement in all cases. There were no recurrences or metastases for 12 months follow up.ConclusionsHolmium laser-assisted laparoscopic partial cystectomy is effective and safe technique. To achieve precise and appropriate surgical margin during the laparoscopic partial cystectomy, holmium laser resection provides feasible and safe method that assists in bladder incision with minimal ureteral orifice involvement.Trial registrationRetrospectively registered.

Case Report: Metachronous bilateral upper tract and bladder urothelial carcinoma: a long-term follow-up

Background: Upper tract urothelial carcinoma (UTUC) is a malignant disease of the urothelial cell lining the upper urinary tract from renal calyces, pelvises, and ureter down to the ureteral orifice. Urothelial carcinoma is a multifocal malignant tumor which tends to reoccur after treatment. Radical cystectomy shows that upper tract recurrence occurs in 0.75% to 6.4% of patients. The occurrence of contralateral UTUC after nephroureterectomy is rarer with a prevalence of 0.5%. Case presentation: The case of a 43-year-old male with metachronous bilateral UTUC was reported. The patient had undergone gemcitabine-cysplatine neoadjuvant chemotherapy followed by radical cystectomy and orthotopic neobladder for urothelial carcinoma of the bladder cT2N0M0. Left hydronephrosis was discovered three months after the procedure. The patient was diagnosed with left UTUC cT4N0M0 of renal pyelum after a series of examinations. A left open radical nephroureterectomy was conducted to remove the mass followed by adjuvant chemotherapy. This was followed up with routine ultrasound and magnetic resonance imaging (MRI) every three months with a “tumor-free” period of 26 months. Meanwhile, the patient was re-admitted with fever and an increase in creatinine value of 4.3. After further workups, the patient was diagnosed with UTUC cT2N0M0 of the right renal pyelum. A kidney sparring approach with laser evaporation of the tumor was conducted followed by eight cycles of Gemcitabine intracavity antegrade per nephrostomy. After the regimen was finished, an MRI evaluation was conducted to assess treatment results, and the mass had decreased. Conclusions: This report showed a rare case of urothelial cell carcinoma recurrences. From bladder urothelial carcinoma to left UTUC and then to contralateral UTUC. It is important to evaluate the upper tract to reduce the risk of recurrence.

SPECIFIC FEATURES OF ENDOSCOPIC CORRECTION TECHNIQUE OF VESICOURETERAL REFLUX IN CHILDREN

Vesicoureteral reflux (VUR) is one of the most frequent diseases in pediatric urology studied since the 19th century. It has an increased risk of infection of the urinary tract, sclerosis of the renal parenchyma and development of reflux-nephropathy with an outcome in renal failure. Several treatment options have been developed for patients with VUR. For 50 years, open ureteral reimplantation has been considered the «gold standard» of treatment, but over the past 20 years there has been a shift towards less invasive methods, primarily endoscopic administration of bulking agents. In order to increase the effectiveness of endoscopic treatment, several basic recommendations for the operation have been identified and many volume-forming drugs have been developed. The most important is the correct choice of one of the three main methods of drug administration and the hydrodilation of the ureteral orifice during injection. Performing of endoscopic correction in compliance with all the rules and the use of the latest generation of bulking agents ensure the frequency of elimination of VUR up to 90% after the first injection.

Transurethral resection of bladder cancer involving the orifice of the ureter

In 90-95 % of cases, urothelial cancer primarily affects the bladder and in about 5-49 % of patients it can be located near or completely close the orifice of the ureter. Metachronous urothelial cancer of the upper urinary tract occurs, as a rule, 3 or more years after transurethral resection of the primary bladder tumor or radical cystectomy, and its frequency with involvement of the ureteral orifice ranges from 0 to 20 %, reaching 51 %. Currently, there are no clear recommendations and diagnostic and treatment algorithm for the management of this category of patients. This review examines the frequency, possible causes and risk factors for recurrence of upper urinary tract tumors, indications for organ-preserving treatment, features of surgical technique for transurethral resection of ureteral orifice tumors, emerging complications and methods of their prevention.

A Double Metachronous Ureter Metastasis following Curative Resection of Rectal Cancer

A malignant ureteral obstruction is most often due to primary tumors of the ureter. However, it can occur secondary due to external tumor compression or metastatic infiltration. Distant metastases to the ureter are extremely rare. We present a case of a rare double distant metachronic metastasis to the right ureter as well as to the right renal pelvis in a 58-year-old female with a history of anterior resection for rectal cancer 2 years earlier. She presented with recurrent urinary tract infection and right hydronephrosis caused by an ureteral mass. The patient underwent a right nephroureterectomy via laparotomy. Two metastases of the rectal cancer in the ureteral mucosa were verified at histology. On account of the infiltration of the right ureteral orifice, a completion transurethral resection of the tumor was performed. A follow-up 3 and 6 months later showed no signs of tumor relapse and the patient was doing well. The differential diagnosis of malignant ureteral obstruction in patients with history of colorectal cancer should include the rare possibility of distant metastasis from the primary tumor.