The anatomy of the kidney and ureter

The kidneys are placed retroperitoneally on the posterior abdominal wall, the right lower than the left. At the renal hilum are found, from before back, the renal vein, artery, pelvis of the ureter and a small posterior artery branch. There are also lymphatics and sympathetic fibres (T12–L1), which account for referred renal pain to the lower abdominal wall and external genitalia. The pelvis of the ureter divides into two or three major calyces, which divide into minor calyces, each indented by a renal papilla, onto which discharge the renal tubules. The three fascial layers are: the capsule, which is easily stripped from the healthy kidney; the perinephric fat; and the investing renal fascia, which adheres to the structures at the hilum and usually tamponades a closed rupture of the kidney, which can thus be treated conservatively. The ureter is 25 cm long, comprising the pelvis and an abdominal, pelvic and vesical portion; the last acting as a sphincter. The ureter is crossed by the gonadal vessels and may be injured here in gynaecological surgery. The ureter can be identified as it constantly crosses the common iliac artery at its bifurcation and then lies on the anterior aspect of the internal iliac artery.     

特殊侧卧截石体位同步会师式治疗复杂肾及输尿管结石（附5例报告）

目的：探索复杂难治的肾及输尿管结石,采用特殊侧卧截石体位,利用腔镜技术,同步会师式治疗的可能性.方法：对5例复杂性肾结石患者,采用斜侧45°卧位,患侧下肢伸直或屈曲固定于脚架上,对侧下肢屈曲外展同定于手术床旁的支架上.行经皮肾镜,碎除肾盂结石后,顺行进入输尿管,同时经尿道置入输尿管镜,在上下导丝及输尿管镜光源的引导下,上下共同前进,碎石或切开狭窄段,直至上下输尿管镜会师.结果：5例患者均手术成功,无一例中转开放,术后复查腹部平片.1例肾盏残余结石直径0.6 cm.术后自行排出.输尿管狭窄患者拔除双J管后1个月复查,输尿管通畅,肾脏无积水.结论：采用特殊侧卧截石体位,同时在输尿管镜及经皮肾镜下,进行上下会师式手术,对于肾结石并输尿管长段石街和结石手术后输尿管长段狭窄等复杂结石患者.完全利用腔镜技术进行治疗,是安全可行的.     

The anatomy of the kidney and ureter

The kidneys are placed retroperitoneally on the posterior abdominal wall, the right lower than the left. At the renal hilum are found, from before back, the renal vein, artery, pelvis of the ureter and a small posterior artery branch. There are also lymphatics and sympathetic fibres (T12–L1), which account for referred renal pain to the lower abdominal wall and external genitalia. The pelvis of the ureter divides into two or three major calyces, which divide into minor calyces, each indented by a renal papilla, onto which discharge the renal tubules. The three fascial layers are: the capsule, which is easily stripped from the healthy kidney; the perinephric fat; and the investing renal fascia, which adheres to the structures at the hilum and usually tamponades a closed rupture of the kidney, which can thus be treated conservatively. The ureter is 25 cm long, comprising the pelvis and an abdominal, pelvic and vesical portion; the last acting as a sphincter. The ureter is crossed by the gonadal vessels and may be injured here in gynaecological surgery. The ureter can be identified as it constantly crosses the common iliac artery at its bifurcation and then lies on the anterior aspect of the internal iliac artery.     

Rigid ureteroscopy: a reliable, non-aggressive technic. Apropos of 51 cases treated for ureteral lithiasis

The authors obtained 82% good results by using rigid ureteroscopy to treat a total of 55 calculi in a series of 51 patients and they propose the following therapeutic approach: calculi in the lumbar ureter are frequently difficult to reach (54% failures). There is no harm in gently trying to remove the stone by ureteroscopy which, in the event of failure, can be followed by percutaneous surgery or posterolumbar incision. Rigid ureteroscopy is easier and more reliable in the case of calculi in the iliac or pelvic ureter (7% failures) and the indications can be extended.     

Rigid and flexible ureteroscopy. Apropos of 200 consecutive cases

191 patients underwent a total of 200 ureteroscopies. Indications for these were as follows: ureter stones (172 cases); ureteral anomalies undiagnosed by other methods (20 cases); therapeutic ureteroscopy (8 cases). Stones: ureteroscopy for stones was carried out using either a rigid instrument (156 cases) or a flexible ureteroscope (16 cases). The localization of the stones was pelvic (123 cases), iliac (18 cases) or lumbar (10 cases). The stones were either removed directly using the basket under visual control (74/139 cases), or removed by ultrasonic/laser fragmentation (65/139 cases). As regards the rigid ureteroscope, success rates were 89% (139/156); 15 patients required additional therapy. Repeated ureteroscopic interventions always provided positive results. As concerns flexible ureteroscopy, we only had one positive result; 15 failure cases warranted repeated additional treatments. In three instances, failure with flexible ureteroscopy was corrected by using the rigid device during the same surgical period. We observed a single case of major complication in this series, i.e., a laterovesical urinoma which necessitated surgical drainage and was linked to the lack of ureteral drainage following ureteroscopy. Diagnostic ureteroscopic examinations: in 20 instances, ureteroscopy allowed to diagnose with precision the ureteral abnormality. No complication was reported following diagnostic ureteroscopy. Therapeutic ureteroscopy: such interventions were carried out to introduce a guide into the renal cavities (3 cases); to remove a double J stent, the lower extremity of which had moved up into the ureter (3 cases); or to carry out endoscopic ureterotomy (2 cases). Ureteroscopy is a safe and reliable method for the treatment of ureteral stones, and more particularly of stones localized in the distal part of the ureter.(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of transurethral ureteroscopy on the management of ureteric calculi

Transurethral ureteroscopy has now been used in an attempt to retrieve ureteric calculi in 48 patients. Six stones were located in the upper ureter, 11 in the middle and 31 in the lower third of the ureter. Successful retrieval was achieved in 27 patients at the first attempt and in 4 at a second ureteroscopy. Of the 17 failures, 7 patients have required open ureterolithotomy, 3 percutaneous nephrolithotomy and the remainder passed their stones either after in situ disintegration or ureteric meatotomy. There have been no serious complications to date. Transurethral ureteroscopy should now be regarded as the procedure of first choice in the management of ureteric calculi.     

经皮肾通道顺行输尿管软/硬镜联合输尿管镜治疗恶性输尿管梗阻

目的探讨斜仰卧截石位经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤致输尿管梗阻的安全性及临床效果。 方法回顾性收集并分析2016年10月至2019年1月我院收治的25例恶性肿瘤引起的输尿管梗阻患者的资料,上述患者均因常规逆行膀胱镜或输尿管镜置双J管失败,进而以斜仰卧截石位利用经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管。 结果25例患者（32侧输尿管梗阻）中,1例因肿瘤侵犯输尿管造成双侧输尿管管腔完全闭塞,双J管置入失败。其余24例均成功放置双J管（成功率93.7%）。手术时间平均（57.4±22.4）min,平均住院时间（5.5±1.9）d,术中无严重肾出血,无输尿管穿孔及撕脱。术后6~14 d拔除肾造瘘管,拔除肾造瘘管后随访12个月,肾积水缓解。 结论斜仰卧截石位皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤引起的输尿管梗阻安全、有效,值得临床推广。     

ESWL in situ or ureteroscopy for ureteric stones?

Summary As documented by follow-up data on ureteric stones in 1259 ureteric units treated, ESWL in situ on advanced lithotriptors with stone location by ultrasonography and fluoroscopy was successful without any retrograde ureteric manipulation in 98% of stones in the upper, 71% in the iliac, and 84% in the distal ureter; 85% of the units were stone-free within 3 months: ancillary measures were needed in 11% and the stone-free state was reached after a median of 39 days. The results obtained with treatment after manipulation of the stone from the upper and mid-ureter by retrograde instrumentation were similar, but ancillary measures were needed in 20% of cases. Endoscopic management with rod-lens ureteroscopes was highly efficient in the distal and midureter, but involved a complication rate of about 11% and required general anaesthesia. In the upper ureter it was abandoned in favour of the two former methods. Endoscopic stone removal has been greatly facilitated by the development of ultrathin, semirigid ureteroscopes 6.2–9 F in diameter, as well as by laser and pneumatic lithotriptors that operate through their minute working ports. Of the stones impacted in 127 ureteric units, 97% were successfully managed at the first attempt, involving an overall complication rate of 6%. Although ESWL in situ without any instrumentation remains the primary treatment of choice for stones in the upper and distal ureter, primary ureteroscopy is again being employed more frequently for stones in the iliac ureter, which are more difficult to focus, and small stones in the distal ureter, as well as in patients unwilling to accept the prolonged time until the urinary tract becomes stone-free after ESWL. This resulted in an increase in the frequency of ureteroscopy as the primary treatment for ureteric stones from 9% in 1990 to 32% in 1991.     

Antegrade ureteroscopy for stone removal

Antegrade ureteroscopy, using the 11-French ureteroscope via a percutaneous transrenal access, provides safe and easy endoscopic exploration of the ureter above the level of the iliac vessels. The technique has proven to be reliable and effective for the removal of obstructing proximal ureteral calculi: all of the 22 patients who underwent antegrade ureteroscopy were stone-free after treatment. Since the introduction of this new technique in our department, no more open surgery has been required to manage ureteral calculi.     

Laparoscopic ureterolithotomy of an iliac ureteral stone forgotten for more than eight years

IntroductionLaparoscopic ureterolithotomy recently rises as a new option in the treatment of ureteral calculi, particularly those of the greatest size, hardness or impactation. We describe such an indication to resolve a case of forgotten for more than eight years and severely obstructive ureteral stone.Patient and methodA 64 years-old male received extracorporeal shock wave lithotripsy for a right distal ureteral stone and, simultaneously, a left impacted iliac ureteral calculi was discovered, at the confluence of an incomplete duplication of the ureter, for which treatment was recommended, but deferred by the patient. Eight years after, the same stone caused a massive dilatation with poor function of the upper pole moiety and slightly preserved function of the lower pole moiety of the left kidney. Two intents of retrograde ureteroscopy failed because of impossibility to reach the stone. Transperitoneal laparoscopic ureterolithotomy was performed in lateral decubitus position, with double J in place and three 10 mm ports. After identification of the dilated ureter, an V-shape ureterothomy was made and the stone mobilized and extracted. The ureter was stented and the ureterothomy closed with intracorporeal suture. The patient had a postoperative stage of four days and a mild functional recovery.DiscussionIf the usual treatment options (extracorporeal lithotripsy and ureteroscopy with intracorporeal lithotripsy) failed, then laparoscopic ureterolithotomy is less invasive than open ureterolithotomy. However, the indications of laparoscopic ureterolithotomy are restricted because substantial laparoscopic experience is needed to cope with possible technical difficulties.     

An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter

The pulsed dye laser was used to fragment ureteric calculi in 10 pig ureters, compared to electrohydraulic disintegration in six pig ureters. The stones were impacted in the proximal ureter and approached by rigid ureteroscopy. Four ureters did not have stones impacted but had ureteroscopes passed. The stones were fragmented and the particles left to pass spontaneously. The degree of inflammatory reaction was graded at the site of fragmentation as well as in the middle and lower ureter. The degree of inflammation seen at the site of fragmentation was significantly less in the laser group than in the electrohydraulic group (p = 0.0027). It was noted that the degree of inflammation seen in the lower ureter was significantly greater than that seen at the site of fragmentation (p = 0.01), and that this grade of inflammation correlated well with the size of ureteroscope used (p = 0.0026). Further, the degree of dilatation of the ureter and pelvicalyceal system was significantly greater when the larger calibre ureteroscope had been used (p = 0.0056) ranging up to hydronephrosis with flattening of the papillae. If there is any parallel which can be drawn between the pig ureter and the human ureter then it suggests that ureteroscopy is more significant than the modality of fragmentation used. The contribution of the laser may therefore be more by the miniaturization of instrumentation which will be made possible than by any advantage it may have as a fragmenter.     

输尿管镜手术时入镜困难66例临床分析

目的:探讨输尿管镜手术时入镜困难的原因与对策。方法:2003年4月～2005年12月共作输尿管镜手术1256例次,其中66例发生入镜困难,均采用相关方法处理。结果:6例采用技巧性旋转入镜成功,53例采用调节体位输尿管扩张等方法入镜成功,2例中转开放手术,5例插管后行ESWL。结论:克服输尿管镜入镜困难的要点是熟悉输尿管的解剖结构与镜下的立体空间感及操作技巧。     

Arterial compression of the right common iliac vein; an unusual anatomical variant

Compression of the left common iliac vein by the right common iliac artery has been well described (Cockett's syndrome).The authors describe a case report of compression of the right common iliac vein by the right internal iliac artery. The patient presented with ipsilateral lower limb oedema. Venography showed smooth extrinsic compression of the right common iliac vein. The CT scan was initially interpreted as showing no extrinsic mass or obvious compressing lesion and lymphography was normal. It was the duplex scan which showed the bifurcation of the right common iliac artery crossing the right common iliac vein and causing significant extrinsic compression.     

Candida infection associated with a solitary mycotic common iliac artery aneurysm.

We report on a case of an isolated common iliac artery aneurysm infected by Candida albicans. To our knowledge, only one other case of this condition has been reported. The patient, a 49-year-old man with diabetes mellitus and a history of fungal urinary tract infections, had recurrent right knee pain and swelling. The knee effusion grew C albicans. Mild right hydronephrosis and a 4.6-cm aneurysm of the right common iliac artery without involvement of the aorta or iliac bifurcation was revealed by means of a computed tomography scan. The aneurysm wall was inflammatory, and there was associated purulence at the time of operation. The right ureter was densely adherent to the anterior aspect of the aneurysm, but could be palpated and dissected free because of a ureteral stent that was placed before the surgical incision. The aneurysm was resected, and the proximal and distal margins were oversewn without graft placement. C albicans was found in the resected aneurysm. The patient recovered without limb-threatening ischemia or claudication, but the distance he could walk remained limited because of right knee symptoms. The aneurysm may have formed by direct extension of infection from the right ureter or by hematogenous or lymphatic spread. This case raises interesting issues about operative strategies and etiology.     

简化输尿管镜术治疗输尿管结石(附470例报告)

目的 探讨及总结简化输尿管镜术治疗输尿管结石的疗效及诊治经验。方法 在门诊内镜手术室骶管阻滞麻醉或尿道表面麻醉下行输尿管镜术加气压弹道碎石术治疗输尿管结石470例。结果 459例一次性碎石成功，成功率为97．7％。其中输尿管上段结石成功率为50％，中段98．0％，下段为100％。结论 简化输尿管镜术治疗输尿管结石创伤小、安全可靠，不须住院，医疗费用较低，对中下段结石成功率较高，可作为其内镜治疗的首选方法。     

Ureteroscopic injuries to the upper urinary tract

Kaufman reported a severe ureteral injury following ureteroscopy in 1984. His commentary summarizes the important messages in this article well: The intent of this report is not to denegrate the splendid advances in nephroscopy and ureteroscopy, but rather to introduce a sobering message that the patient must be informed of the inherent risk of such procedures and that the urologist must be wary of the problems that might occur. Problems have been known ever since endoscopic instrumentation was first introduced, and every experienced urologist has had his share of problems associated with stone extraction and other endoscopic procedures. Traditional teaching in urology has been to eschew manipulation of stones in the upper two thirds of the ureter because the lumbar ureter is mobile and more easily damaged by instrumentation than the pelvic segment. Endoscopic visualization of stones in the upper ureter allowing accurate grasping of calculi would appear at first to provide an element of security heretofore unachievable, but urologists nonetheless should be mindful of the hazards of any type of stone extraction from the upper ureter. Urologists must be ready and equipped to handle emergencies associated with new instruments and techniques, and the patients must be apprised of the exigencies. "Caveat emptor" (buyer beware) could not be a more apt or timely maxim in our specialty. Ureteroscopy has greatly aided many patients, and a large number of urologists have integrated this procedure into their daily practices.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff

Various hand-assisted and purely laparoscopic nephroureterectomy techniques have been described in the urologic literature. We describe a technique of hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff that duplicates open surgical excision of these structures and obviates bladder trocar placement and midprocedural patient repositioning. The patient is placed in a modified dorsal lithotomy position with the tumor side elevated 30 degrees. Allen stirrups are utilized to allow simultaneous access to the urethra. A transperitoneal hand-assisted laparoscopic nephrectomy is performed. The technique is modified in that the ureter is clipped prior to the kidney dissection to avoid distal migration of tumor cells during kidney manipulation. After the kidney is isolated, the intact ureter is liberated distal to the intramural hiatus. The remaining dissection is completed intravesically under cystoscopic guidance. While the surgeon's intra-abdominal hand places the ureter on tension, the cystoscopist transurethrally excises the bladder cuff and intramural ureter with a Collings knife. The complete surgical specimen is removed en bloc through the hand port. The bladder is not closed. A urethral catheter connected to straight drainage remains until the seventh postoperative day, when a cystogram is performed; if it is normal, the catheter is removed.     

Management of complete ureteral avulsion in ureteroscopy

Ureteral avulsion is an uncommon yet severe complication of ureteroscopy. Among 8336 patients who received ureteroscopic procedures in our hospital from December 2001 to December 2011, we encountered two cases of ureteral avulsion. The first of these experienced disruption at the ureteropelvic junction due to extraction of the tubular ureter from the urethra, which was corrected by immediate open surgery to reposition and anastomose the ureter. The second patient sustained a proximal ureteral disruption following retrieval of the ureteroscope, which was wedged in the narrow lumen of the proximal ureter, and led to simultaneous extraction of the distal ureter. Immediate surgical intervention was performed to maintain ureteral continuity. Mild hydronephrosis was observed in kidneys that were ipsilateral to the ureteral avulsion in both patients. However, no physical discomfort or loss of renal function was indicated after 12 months.     

研发胆道取石硬镜经T管瘘道治疗胆道术后残留结石

目的探讨胆道结石术后用研发胆道取石硬镜（或输尿管镜）经T管瘘道探查和治疗残余结石的疗效。方法回顾性分析在利多卡因凝胶5~10ml注入瘘道局部麻醉后采用研发的胆道取石镜（或输尿管镜）经T管瘘道探查和治疗42例胆道结石术后病例的资料。结果全组42例患者中前期（2010年3月以前）20例中有10例顺利完成探查或取石术,另10例在探查胆总管下段时,腹痛明显而中止改用纤维胆道镜探查,后期（2010年3月以后）的22例有19例完成胆道探查或取石,有3例在探查胆总管下段时腹痛难忍中转纤维胆道镜探查。1例腹腔镜胆总管切开术后52d拔T管,经瘘道胆道取石镜探查发现瘘道未形成,出现胆汁性腹膜炎,后开腹手术治愈,其余病例无并发症出现。结论胆道结石术后经T管瘘道常规使用研发胆道取石硬镜（或输尿管镜）探查和治疗胆道残余结石,安全有效,操作简便,为临床提供一种治疗胆道术后残留结石的新方法,有临床推广价值。     

Safety and outcome of rigid ureteroscopy for management of ureteral calculi in children

PURPOSE: To present our experience with ureteroscopy for the treatment of pediatric ureteral calculi. PATIENTS AND METHODS: The records of 32 children with an average age of 8.7 years (range 2-15 years) treated with rigid ureteroscopy between June 1994 and July 2003 were reviewed. In 33 ureteral units, 8F rigid ureteroscopy was carried out 35 times to treat stone disease. Stones were located in the upper ureter in 2 cases, the middle ureter in 2 cases, and the lower ureter in 29 cases. Stone size ranged from 4 to 15 mm (mean 7 mm). Dilatation of the ureteral orifice was necessary in 10 procedures. RESULTS: The management of stone in 29 children (90.7%) was straightforward, and a single procedure was sufficient to clear the ureters. In 2 children (6.2%), repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%), it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 2 cases and with the holmium laser in 9; in the remaining 22 cases, the stones were removed without fragmentation. Intraoperative complications occurred in 3 children (9.3%) and consisted of extravasation (1 patient) and stone migration (2 patients). The early postoperative complications were hematuria in one patient and renal colic in another. Of the patients, 28 were followed 3 to 48 months. No stricture was detected at the site of stone impaction in any patient. CONCLUSION: In the hands of an experienced surgeon, ureteroscopy can be a safe and efficient treatment for ureteral stones in children.