医源性输尿管损伤并发上尿路梗阻的外科治疗策略

目的：研究医源性输尿管损伤后并发上尿路梗阻的病理基础。探讨处理医源性输尿管损伤后梗阻的外科治疗策略。方法：回顾性分析自2007年2月～2009年4月,上海交通大学医学院附属仁济医院泌尿外科诊治的16例输尿管腔内操作致医源性输尿管损伤并发上尿路梗阻的患者。患者平均年龄49岁。所有患者输尿管损伤后均曾成功留置D-J管4～6周。就诊时平均术后时间9．8个月（3～18个月）。通过磁共振水成像（MRU）评价输尿管梗阻累及部位、梗阻段长度及输尿管瘢痕组织厚度。以STORZF7.9。输尿管镜检查患侧输尿管。对于患侧输尿管管腔通畅者行开放输尿管梗阻段切除术,并对该段输尿管行病理检查。对于输尿管镜证实受累输尿管存在机械性梗阻,狭窄段长度〈2cm的患者行输尿管镜下钬激光输尿管内切开术。所有患者术后留置D-J管6周。术后6个月以静脉尿路造影（IVu）评价手术效果。结果：在4例患者中,STORZF7.9。输尿管硬镜成功进镜至肾盂,未发现患侧输尿管机械性梗阻。予切除瘢痕增生段输尿管,病理检查提示输尿管全层增厚伴慢性炎症,纤维组织增生,平滑肌细胞排列杂乱,但黏膜层尿路上皮完整且无明显增生。另12例患者经输尿管硬镜检查证实机械性梗阻存在,行钬激光输尿管内切开术。术后6个月随访显示,4例行开放手术患者均未出现输尿管再狭窄。12例行输尿管钬激光内切开患者中3例上尿路梗阻复发。行狭窄段切除,6个月后随访见上尿路积水消失。结论：在部分输尿管损伤后上尿路梗阻的患者,其输尿管管腔通畅,动力性梗阻可能占主导地位。对于这些患者外科手术切除输尿管狭窄段可能是最佳选择。输尿管腔内钬激光内切开术适用于狭窄段较短（〈2cm）且不伴严重输尿管增厚的患者,但远期复发率较高。尿外渗是加重输尿管损伤后纤维瘢痕形成的重要因素,在合并严重尿外渗的患者中,经皮肾穿刺（PCN）引流可能减轻局部纤维瘢痕反应,改善患者预后。     

The use of Alloderm in the closure of a giant omphalocele

Giant omphaloceles are associated with a considerable loss of abdominal domain. Early primary repair of the fascia is either not possible or poorly tolerated by the infant. Current surgical options result in a ventral hernia requiring future surgery or involve the chronic use of prosthetic patches with or without tissue expanders. This case presentation describes an alternative surgical approach that results in early fascial closure using an interposition graft of Alloderm.     

An Intraosseous Lipoma of the Calcaneus: A Case Report

Intraosseous lipomas are one of the rarest bone tumors found in the body. The incidence has been reported to be <0.1% of all primary bone tumors. The differential diagnoses of an intraosseous lipoma in the calcaneus include plantar fasciitis, retrocalcaneal bursitis, gout, stress fracture, unicameral bone cyst, aneurysmal bone cyst, osteoblastoma, enchondroma, chondromyxoid fibroma, nonossifying fibroma, giant cell tumor, chondroblastoma, fibrous dysplasia, and chondrosarcoma. It has been reported that 60% to 70% of patients with an intraosseous lipoma present with symptoms. This article describes a case of a pathologic fracture secondary to a large intraosseous lipoma, the surgical treatments, and the subsequent resolution of symptoms. The purpose of our report was 3-fold: (1) to increase awareness of intraosseous lipomas and their potential to cause pathologic fractures in the calcaneus; (2) to suggest a possible treatment protocol for intraosseous lipomas in the calcaneus; and (3) to describe a rare case of an intraosseous lipoma of the calcaneus not located exclusively in the neutral triangle.     

The surgical treatment of rhinophyma—Complete excision and single-step reconstruction by use of a collagen–elastin matrix and an autologous non-meshed split-thickness skin graft

INTRODUCTIONRhinophyma is the most common clinical manifestation of phytamous rosacea. While conservative methods (e.g. topical or systemic antibiotics, retinoids) are effective for the treatment of acne rosacea, a surgical intervention is appropriate and required in established rhinophyma. A variety of surgical techniques to reduce proliferated tissue have been reported. However, a surgical “gold standard” for treating the distorting phymatous skin alterations has not yet been established.PRESENTATION OF CASEThis case report details a novel surgical approach: the combination of a bovine collagen–elastin with simultaneous autologous non-meshed split-thickness skin grafting.DISCUSSIONOur approach was based on the following considerations: deep excision facilitates complete removal of diseased tissue that ultimately reduces the risk of recurrence in contrast to commonly applied methods relying predominantly on superficial lesion removal with subsequent spontaneous re-epithelialization. The application of a dermal substitute to create a neodermis covered by split-thickness autologous skin grafting may serve as a functionally and aesthetically appropriate model without requiring the recruitment of donor sites for full-thickness skin grafts or even local flaps.CONCLUSIONThe combination of deep excision and single-step replacement of epidermal–dermal components may ultimately avoid the recurrence of rhinophyma and contribute to a full skin repair leading to satisfactory functional and aesthetic outcome.     

Initial experience of robotic nephroureterectomy: a hybrid‐port technique

OBJECTIVE

To report a new technique of robot‐assisted laparoscopic nephroureterectomy (RANU) using a hybrid port, as RANU has recently become a minimally invasive treatment option for upper tract transitional cell carcinoma (TCC).

PATIENTS AND METHODS

Eleven consecutive patients underwent RANU by one surgeon. The first six patients were repositioned after the nephrectomy, from flank to lithotomy position, and the robot was re‐docked for excision of the distal ureter and bladder cuff. The last five patients were treated by a new RANU technique that did not require a change of position or movement of the patient cart. We analysed data obtained before, during and after RANU.

RESULTS

The total operative duration was reduced by ≈50 min in last five patients. There was no improvement in hospital stay or estimated blood loss. There were no transfusions and positive surgical margins in any patient. Maintaining the patient in a flank position allows gravity to displace the bowel away from the distal ureter, not only shortening the surgery but also improving exposure of the distal ureterectomy and closure of the bladder cuff.

CONCLUSIONS

The new RANU technique is a safe and feasible treatment option for upper tract TCC.     

Combined antegrade and retrograde endoscopic retroperitoneal bypass of ureteric strictures: a modification of the ‘rendezvous’ procedure

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

OBJECTIVE

To evaluate our experience of treating complicated iatrogenic ureteric strictures with a combined antegrade and retrograde endoscopic retroperitoneal bypass technique, a modification of the so‐called ‘rendezvous’ procedure.

PATIENTS AND METHODS

Seven patients presented to our institution between 2004 and 2008 after developing a complicated iatrogenic ureteric stricture, impassable with solitary antegrade or retrograde stenting techniques. In most cases there was a significant loss of ureteric continuity, with some strictures of up to 10–12 cm. After initial temporizing management with a percutaneous nephrostomy, each patient had a radiological ‘rendezvous’ procedure to insert a JJ stent and restore ureteric continuity. After 6 months, the JJ stents were removed and the patients evaluated by symptom assessment, serial measurements of serum creatinine and diuretic renography (F‐15 mercaptoacetyl triglycine).

RESULTS

All seven ‘rendezvous’ procedures were successful and a ureteric stent was inserted across or around the stricture in all cases. Five of seven patients whose follow‐up was >6 months had their stent removed successfully. At a median follow‐up of 21 months, all patients are alive and none has required subsequent surgery. Six of the seven patients presented with significant symptoms and they are all currently symptom‐free, which we consider to be a successful clinical outcome. No patient has developed significant renal impairment (estimated glomerular filtration rate (<30 mL/min) but we could only confirm successful unequivocal renographic drainage in one patient.

CONCLUSION

Combining antegrade radiological and retrograde endourological techniques, it is possible to restore ureteric continuity with a JJ stent, even in situations with extensive loss of the ureteric lumen. This reduces the need for morbid open surgical repair and offers a long‐term solution to patients who might otherwise be consigned to less favourable conservative measures.     

Spontaneous ureteric rupture secondary to an invasive desmoid tumour

INTRODUCTION

Spontaneous ureteric rupture is a rare entity that presents as an extravasation of urine from the ureter without previous surgery, ureteric manipulation and external trauma of the ureter. We report the case of a desmoid tumour presenting as spontaneous ureteric rupture which was managed in our institution.

PRESENTATION OF CASE

A 28 years old healthy male presented with a four day history of generalised abdominal pain secondary to spontaneous right ureteric rupture. Patient was initially managed via insertion of nephrostomy tube and antibiotics. After unsuccessful attempts of retrograde and antegrade ureteric stent insertion, patient was subsequently managed via elective surgical intervention. The excised specimen revealed desmoid tumour as cause of the ureteric rupture.

DISCUSSION

Desmoid tumours are rare benign tumours arising from fascial or musculoaponeurotic structures that do not metastasise, but tend to invade locally. It is often initially managed medically prior to undertaking a definitive surgical intervention. To our knowledge this is the first reported case of ureteric perforation secondary to a desmoid tumour of the mesentery.

CONCLUSION

Spontaneous rupture of the ureter is often misdiagnosed as other conditions. History taking and examination can be unreliable, hence a high level of suspicion and further investigations should be utilised. Once the diagnosis is made, treatment can be individualised based on aetiology.     

Skin necrosis of scrotum due to endovascular embolisation: a case report

The aim of our case report was to analyse the results obtained with the Matriderm® system and autologous skin grafting for the surgical treatment of skin necrosis of scrotum as a result of endovascular embolisation. We recruited one patient with scrotum skin necrosis as a result of endovascular embolisation admitted at the department of Plastic and Reconstructive Surgery, University of Rome ‘Tor Vergata’. The patient underwent Matriderm® system and autologous skin grafting for skin necrosis treatment. After a single treatment, reduction of the skin necrosis was obtained, after 30 days from the surgical treatment. Patient experienced a reduction in pain and a complete restoration of the loss in volume and quality of skin was noticed. Matriderm® system and autologous skin grafting is a simple, safe and feasible technique. When comparing this treatment with others, Matriderm® is a simpler, more economic and less time‐consuming method, and does not require sophisticated laboratory facilities.     

SPONTANEOUS KNOTTING OF A PIGTAIL URETERIC STENT IN THE URETER REQUIRING PERCUTANEOUS REMOVAL

Insertion of a ureteric stent is a common procedure in urologic practice. Ureteric stenting may be performed for: ureteric obstruction, benign or malignant: to prevent ureteric obstruction from stone fragments after extracorporeal shockwave lithotripsy (ESWL); or to prevent leakage from the upper urinary tract. A case of spontaneous knotting of a ureteric stent in siru is reported. Although this complication has been reported previously it is rare.     

Ureteric complications in recipients of kidneys from donation after circulatory death donors

A large increase in the use of kidneys from donation after circulatory death (DCD) donors prompted us to examine the impact of donor type on the incidence of ureteric complications (UCs; ureteric stenosis, urinary leak) after kidney transplantation. We studied 1072 consecutive kidney transplants (DCD n=494, live donor [LD] n=273, donation after brain death [DBD] n=305) performed during 2008‐2014. Overall, there was a low incidence of UCs after kidney transplantation (3.5%). Despite a trend toward higher incidence of UCs in DCD (n=22, 4.5%) compared to LD (n=10, 3.7%) and DBD (n=5, 1.6%) kidney transplants, donor type was not a significant risk factor for UCs in multivariate analysis (DCD vs DBD HR: 2.33, 95% CI: 0.77‐7.03, P=.13). There was no association between the incidence of UCs and donor, recipient, or transplant‐related characteristics. Management involved surgical reconstruction in the majority of cases, with restenosis in 2.7% requiring re‐operation. No grafts were lost secondary to UCs. Despite a significant increase in the number of kidney transplants from DCD donors, the incidence of UCs remains low. When ureteric complications do occur, they can be treated successfully with surgical reconstruction with no adverse effect on graft or patient survival.     

Reconstruction of a fulminant necrotizing fasciitis of the face and neck with a dermal regeneration template

A case of a 69-year-old woman presenting with a fulminating group A streptococcal necrotizing fasciitis of the face and neck is presented. Survival of the patient was due to early recognition of the disease and radical debridement. Integra, a dermal regeneration template, was successfully applied to cover the left hemiface and neck as well as the bony orbit. Integra provided a result that can be favorably compared to other, often much longer and complicated, surgical procedures.     

Primary megaureter: results of surgical treatment

Background: The aim of this study was to assess the clinical and radiological outcome after surgical treatment for primary ­megaureter. Methods: A retrospective analysis of 16 patients who had reimplantation of 17 primary megaureters between January 1997 and April 2001 was performed. Patients who had additional urinary tract pathology were not included in this study. The intent of the study was to focus on the complex range of data points that were used to reach the decision to operate. Results: Six of eight patients with febrile urinary tract infections prior to surgery have been without infections postoperatively. One patient who presented with daytime wetting has less wetting postoperatively, and one baby who presented with failure to thrive and postfeed vomiting, is feeding well postoperatively. On ultrasound investigation, the median diameter of the megaureter prior to operation was 11 mm (range 6?24 mm). One month after the operation, dilatation of the ureter could no longer be demonstrated in 10, was reduced in six, and increased in one of 17 ureters. Three months postoperatively, hydroureter was no longer detected in 14 and was reduced in three. In comparison, the hydronephrosis 1 month postoperatively was reduced in six, unchanged in seven and worse in four out of 17 kidneys, and 3 months after the operation, hydronephrosis was reduced in 13 and was unchanged in four compared with preoperative findings. Renograms at 3 months postoperatively showed free drainage in the 11 kidneys with impaired drainage preoperatively, and drainage continued to be normal in all six kidneys with normal drainage preoperatively. Median pre­operative renographic split function was 47% (range 39?54%), and was not significantly changed 3 months after the operation. Conclusions: When the decision to surgically intervene was made on a multifactorial basis, reimplantation of a primary mega­ureter resulted in improved clinical status, reduced dilation of the ureter and renal pelvis, and free drainage of the upper urinary tract.     

Robot-assisted laparoscopic pyeloplasty for the management of pelvi–ureteric junction obstruction in horseshoe kidneys: initial experience

Minimally invasive dismembered pyeloplasty has become the gold-standard treatment for symptomatic pelvi–ureteric junction obstruction (PUJO) in recent years. A small proportion of patients with PUJO have horseshoe kidneys. We present two cases of robot-assisted pyeloplasty in horseshoe kidneys and describe the technical modifications for success in these cases. Two patients, aged 28 and 35 years, were diagnosed with symptomatic PUJO in horseshoe kidneys. Both had a robotic-assisted laparoscopic dismembered pyeloplasty using the da Vinci^® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Three-dimensional computed tomography (CT) reconstructions were performed pre-operatively to plan surgery. The transperitoneal ports were placed more caudally than usual for improved access to the PUJ. The isthmus was not divided in either case. The procedures took 190 and 90 min, respectively, with minimal blood loss and no post-operative complications. Patients were discharged on post-operative day 2 following catheter and drain removal. Follow-up diuretic renograms showed no residual obstruction and patients were symptomatically better. Our initial experience suggests that RALP is a safe and feasible option for the treatment of PUJO in horseshoe kidneys with good short-term outcomes. These are challenging cases and robust pre-operative planning combined with technical modifications has been beneficial to our success. The enhanced suturing possible with the da Vinci^® surgical system facilitates these procedures.     

Pilot study evaluating ureteric physiological changes with a novel ‘ribbon stent’ design using electromyographic and giant magnetoresistive sensors

OBJECTIVE

To test a novel ‘ribbon stent’ (RS) design using an extraluminal bipolar electromyographic (EMG) and giant magnetoresistive (GMR) sensor system to characterize ureteric responses.

MATERIALS AND METHODS

In all, 11 female domestic pigs were divided into three groups to evaluate ureteric physiology: group 1 (two pigs) with an unstented ureter, group 2 (three) with a standard 6 F ureteric stent, and group 3 (six) with the RS. For all groups EMG/GMR evaluation was performed at baseline, immediately after stenting, and at 3 and 7 days after stenting. All pigs underwent standardized retrograde ureteropyelogram evaluation at these time points, and after the final evaluation the pigs were killed and the urinary tract was harvested for histopathological evaluation.

RESULTS

One stent in group 3 could not be deployed due to a problem with ureteric access. For groups 1, 2 and 3 the ureteric peristaltic activity was 109, 63, 72 events/h at baseline (P = 0.49); 61, 70, and 66 events/h immediately after stenting (P = 0.97); 66, 0, 8 events/h at 3 days after stenting (P = 0.002); and 61, 12, 0 events/h at 7 days after stenting, respectively (P = 0.049).

CONCLUSION

The RS was deployed easily and safely in the porcine model using a standard technique. As with a standard stent, there was significant ureteric dilation and decrease in peristalsis with the RS.     

Retroperitoneal bronchogenic cyst as a differential diagnosis of pancreatic mucinous cystic tumor

Cystic tumors of the pancreas where a pseudocyst has not been able to be excluded has been considered potentially proliferative and pre-malignant or malignant and thus aggressive surgical approach has been advocated. Retroperitoneal cystic tumors are rare and among these bronchogenic cysts are extremely infrequent. The present paper describes a case of bronchogenic cyst in association with the pancreas in which diagnostic work-up was not able to exclude a proliferative pancreatic cystic tumor.     

Parathyroid adenoma autoinfarction: a report of a case

BACKGROUND: Parathyroid adenoma autoinfarction, although uncommon, is an entity that has been previously reported in the literature; however, the influence of intraoperative parathyroid hormone (PTH) monitoring on therapeutic management has not been reported. METHODS: We present a case of parathyroid autoinfarction that is unique in that it applies a new technology to parathyroid surgery: intraoperative PTH monitoring. RESULTS: Intraoperative PTH monitoring aided in the successful surgical management of this patient. CONCLUSIONS: Intraoperative PTH monitoring can serve as a therapeutic adjunct in the surgical management of parathyroid adenoma autoinfarction.     

Case report of a Wilms' tumor and a left-sided inferior vena cava. A common tumor with a normal variant of surgical significance

We report a case of a successful surgical resection of a Wilms' tumor in the right kidney with a coincidental preoperative imaging finding of a left-sided inferior vena cava. To our knowledge, these 2 conditions occurring together has not been previously reported in literature. Diagnostic features and the value of magnetic resonance imaging are emphasized. We also review the literature of major venous anomalies and their influence on surgical procedures carried out on such patients.     

Ureteric reconstruction for the management of transplant ureteric stricture: a decade of experience from a single centre

This study was conducted to review the outcomes of patients who had undergone surgical repair of a ureteric stricture following renal transplantation. All patients who developed a ureteric stricture and underwent ureteric reconstruction following renal transplantation, between December 2003 and November 2013, were reviewed. One thousand five hundred and sixty renal transplants were performed during the study period. Forty patients required surgical repair of a ureteric stricture (2.5%, 25 male, median age 48 [14–78]). The median time to stricture was 3 [1–149] months. 19 patients were reconstructed by reimplantation to the bladder, 18 utilized a Boari flap, two were a pre‐existing ileal conduit and one was an anastomosis to a native ureter. In one patient, reconstruction was impossible and consequently an extra‐anatomic stent was used. Two patients required re‐operation for restricture and kinking. Median serum creatinine at 12 months following surgery was 148 [84–508] μmol/l. There was no 90‐day mortality. Eleven grafts were lost at the time of this study, a median time of 11 [1–103] months after reconstruction. The incidence of ureteric stricture following renal transplant is low. Surgical reconstruction of the transplant ureter is the optimal treatment and is successful in the majority of patients.     

Non-surgical management of multicystic dysplastic kidney

OBJECTIVES

To better define the outcome and association of multicystic dysplastic kidney (MCDK) with hypertension, vesico‐ureteric reflux (VUR), infection and cancer, as there is no consensus on the management of patients born with MCDK. The risk of cancer has dictated the surgical management of the disease in the past.

METHODS

The Medline database was searched for articles published between 1965 and 2006 and written in the English language, and containing the keywords ‘multicystic dysplastic kidney’.

RESULTS

The inclusion criteria were met by 105 reports that were subsequently analysed. Of MCDK, 60% regress or involute within 3 years. About 25% of patients will have VUR into the contralateral kidney, of which 90% is grade ≤3. The risk of urinary tract infection appears to be associated with VUR or coexistent abnormalities rather than the MCDK. The risk of hypertension is no greater than that in the general population and nephrectomy is usually not curative. The overall risk of Wilms’ tumour developing in a MCDK is <1 in 2000. All reported Wilms’ tumours were identified before 4 years of age and 70% presented as a palpable mass.

CONCLUSIONS

Published reports support the non‐surgical management of MCDK. Common practice has been to remove palpable or growing MCDKs, although these represent a very small fraction of MCDKs. In theory, ultrasonographic surveillance until 4 years old might allow the earlier detection of a Wilms’ tumour, and decrease the intensity of chemotherapy and improve prognosis. Previous reports do not prove or disprove this concept, and the appropriate frequency of surveillance is not evident.     

Compartment syndrome caused by a traumatized vascular hamartoma

A case report is presented of a traumatized vascular hamartoma producing a forearm flexor compartment syndrome; such a case has not been reported previously. The role of minor trauma in this case was important. There is a need for a high degree of suspicion in order to make an early, accurate diagnosis. Delayed surgical decompression and resection of the pathologic muscle resulted in a dramatic improvement in sensibility and digital mobility.