Renal abnormalities associated with Mayer-Rokitansky-Küster-Hauser syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital disorder affecting female reproductive system (agenesis of uterus and upper part of vagina) alone (type 1), or associated with abnormalities of other organs and systems (type 2). We report a case of a 21-year-old woman diagnosed with MRKH due to primary amenorrhea during puberty and operated for formation of neovagina. She was admitted to the Department of Urology with abdominal pain and oligoanuria, where the physical examination and imaging studies revealed a malformation of the upper urinary tract: a solitary dystopia of kidney in the pelvis with stenosis of ureteropelvic junction and hydronephrosis. After initial desobstruction with a DJ stent, a pyeloplasty was performed. Females with primary amenorrhea are often delayed with the diagnosis of potential MRKH syndrome, and those diagnosed with the syndrome should undergo detailed examination to exclude concomitant urinary abnormalities.

Uncovering Silent Fungal Infections complicating Obstructive Uropathy due to Renal Papillary Necrosis in Diabetic patients – A step towards preventing Recurrent Obstructive Uropathy.

Introduction and Objectives: Renal papillary necrosis is one of the common causes of obstructive uropa-thy in diabetic patients. During removal of necrosed renal papilla, many patients were observed to have fluffy necrotic material in the ureter, and renal pelvis, and a few among them present again with recurrent episodes of obstructive uropathy and sepsis following DJ stent removal. Our study aimed to identify thesignificance of this fluffy necrotic material and its evaluation by histopathological examination (HPE). Materials and Methods: This is a prospective observational study done in our institute by compiling data of 56 patients admitted with obstructive uropathy secondary to renal papillary necrosis who underwent a protocol-based treatment from 2016 to 2019. All these patients underwent initial DJ stenting followed by check flexible ureteroscopy or nephroscopy after 6 weeks. The white, necrotic fluffy material collected during initial DJ stenting or with subsequent flexible ureteronephroscopy was sent for HPE. All these patients were followed up for 1-3 years. Results: Out of 56 patients, 15 patients had fluffy necrotic material in the bladder on initial cystoscopy, of which 1 patient was diagnosed with aspergillosis and 1 patient with candida infection on HPE. During check flexible ureteroscopy (FU), 19 patients had minimal burden of fluffy necrotic material in renal pelvis, of which one patient was diagnosed with aspergillosis, one with candida (same patient diagnosed on cystoscopy), and one patient with both aspergillus and candida colonies on HPE. 5 patients had the significant burden of fluffy necrotic material in the renal pelvis, requiring removal via percutaneous nephroscopic access. Among these 5 patients, 2 were diagnosed with aspergillosis and 1 with candida infection on HPE. A total of 32 patients had single papilla, and 24 had multiple papillae in the pelvicalyceal system. 5 out of 7 patients with positive fungal pathology had negative fungal cultures. Compared to our historical data of 4% mortality and 22% recurrent obstructive uropathy in the 3 years preceding the adoption of this protocol, with the present protocol, no patient developed recurrent pyelonephritis during follow-up of 1–3 years after DJ stent removal following complete evacuation of necrotic material and appropriate antifungal treatment. Conclusion: This study highlights the need for check ureterorenoscopy and removal of all necrotic papillae and debris to establish a microbiological and histopathological diagnosis along with proper antifungal treatment to prevent episodes of recurrent pyelonephritis and obstructive uropathy.

Success Rate on Double-J Stenting on Gynecological Cancer Patients: A Meta-Analysis Study

Background. Metastatic cervical cancer in the ureter may lead to obstructive uropathy due to mechanical ureteral blockage. The insertion of a double-J (DJ) stent is a urinary diversion option that can be offered to the patients, but it becomes challenging due to the high rate of failures. This study aim to analyze the success rate on DJ Stent placement on patients with gynecological malignancy. Methods. The study was a systematic review using medical journals collected from Google Scholar, BMJ and PubMed. The journals were searched from 2015 to 2020. The database search throughout 2015-2020 using “Double J Stent’, “Gynecological”, “Malignancy”, “Kidney failure”, “Hydronephrosis” and “Urethral Obstruction”. A literature search was performed and evaluated based on established criteria. The quality assessment of included studies done according to the PRISMA. Meta analysis were done using the fixed effect model or random effect model. Results. The identified article on each med were collected using Mendeley Desktop software. There were 101 scientific publication from PubMed, 232 from Scopus, 1 from Cochrane and 60 from reseachgate results found using the combined keywords. The total of 7 publications matched all the inclusion criteria in this study. Conclusions. Patient’s general well-being could be measured by the staging of the malignancies and kidney function laboratory test. Another factor should be think through was the side effects of the chemotherapy or radiotherapy, as well as the compliance of the patient during stent maintenance.

COMPARISON OF EFFICACY BETWEEN LASER AND PNEUMATIC LITHOTRIPSY FOR URETERAL STONE MANAGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: This study aimed to evaluate the efficacy of ureteroscopy lithotripsy (URS) using laser lithotripsy compared to pneumatic lithotripsy for ureteral stone management. Material & Methods: A systematic search was conducted in PubMed and ScienceDirect. The search and screening process in this study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline to include relevant RCTs. The included studies were assessed for their risks of bias using the Cochrane risk of bias tool 2 (RoB 2). The comparison of outcomes, which includes stone-free rate, DJ-Stent use, and mean fragmentation time between laser and pneumatic lithotripsy was analyzed using Review Manager 5.4. Results: A total of 11 RCTs evaluating a total of 235 patients with ureteral stone were analyzed in this review. Compared to pneumatic lithotripsy, laser lithotripsy has a significantly higher stone-free rate (OR 2.39, 95% CI 1.78-3.21, p < 0.001), longer mean fragmentation time (MD 4.11, 95% CI 3.17-5.04, p < 0.001), and lower DJ stent use rate (OR 0.53, 95% CI 0.36-0.76) based on the forest plot analysis. Conclusion: Patients undergoing laser lithotripsy have a higher stone-free rate, a lower DJ stent use rate, and albeit a longer mean fragmentation time compared to pneumatic lithotripsy.

Submucosal impaction of a forgotten DJ stent: addressing the unexpected

A 16-year-old man with horseshoe kidney presented with a right-sided forgotten double J stent (DJS), 1 year after bilateral percutaneous nephrolithotomy. X-ray of the kidney, ureter and bladder showed bilateral residual stones with no encrustations or stone formation on the DJS. Initial attempt of DJS removal using 22 French (Fr) cystoscope and 6/7.5 Fr semirigid ureteroscope failed due to resistance while pulling the DJS and inability to uncoil the upper end of DJS. Finally, percutaneous antegrade scopy was done suggestive of submucosal impaction of the forgotten DJS in upper ureter. The overlying mucosal bridge was cut using holmium: Yttrium Aluminum Garnet (YAG) laser and the DJS was retrieved. The index case highlights an unusual cause of entrapment of the DJS and whenever resistance is encountered, the use of force should be avoided and the cause of resistance should be troubleshooted, thereby preventing serious injuries like ureteral avulsion.

Long surgical waiting list times are associated with an increased rate of negative ureteroscopies

Introduction: Negative ureteroscopy (NURS) is “a ureteroscopy in which no stone is found during the procedure.” We aimed to determine the association between the surgical waiting list time (WLT) and the NURS rate. Methods: We retrospectively analyzed all patients scheduled for ureteroscopy in our center between January 2017 and July 2019. The inclusion criterion was unilateral semirigid ureteroscopy for a single ureteral stone; exclusion criteria were renal-only stones, incomplete ureteroscopy, and stones >10 mm. We analyzed age, gender, body mass index, stone size, density and location, presence of a temporary double-J (DJ) stent, use of medical expulsive therapy, and WLT. Complications while waiting for surgery were also collected and analyzed. Results: We included 219 patients, 41 (18.7%) of whom had NURS. The median WLT was 74 days (interquartile range [IQR] 45–127). Variables protective against NURS were large stone size (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.66–0.93), presence of a temporary DJ stent (OR 0.43, 95% CI 0.2–0.8), and radiopaque stones (OR 0.44, 95% CI 0.21–0.88). A long WLT (>60 days) increased the risk of NURS (OR 2.18, 95% CI 1.02–4.61). Complications requiring emergency department visits while waiting for surgery were documented in 58/137 (42.3%) patients with indwelling DJ stents; nonetheless, a WLT greater than the median was not associated with an increased risk of complications (p=0.38). Conclusions: Long WLT has an independent, direct, and linear correlation with NURS rates. Patients at higher risk of NURS, may be offered preoperative re-evaluation with a computed tomography scan in a resource-limited setting.

Diagnostic and Interventional Radiology Management of Ureteral Iatrogenic Leakage after Gynecologic Surgery

Objective: To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks. Methods: A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach. Results: DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients. Conclusion: Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

Calyceal Diverticulum: A Case Report

Calyceal diverticulums are often benign and asymptomatic. On the other hand, some interventions are necessary in several symptoms. Radiological imaging is performed to made dianoses, but somehow can pose misinterpretation of radiological imaging results and mistreatment from the urologist. To present a case of a calyceal diverticulum treated with open diverticulectomy. This study reported a case of a calyceal diverticulum in a 30-year-old man with an almost 1-month history of left flank pain. The patient undergone several imaging diagnostics, before finally diagnosed calyceal diverticulum with a stone inside it. The patient had underwent open diverticulectomy. Initially, cystoscopy and insertion of Double J Stent (DJ Stent) were done, and then using the lumbotomy approach the incision that had been made. This case demonstrated the use of imaging combined with urologist interpretation and surgical management which was successfully treated the patient’s clinical problems.