Diagnosis and management of periurethral cysts

BACKGROUND/AIMS: Periurethral cysts are a rare entity that may be confused with urethral diverticula. The protocol for diagnosis and management of these lesions is still unclear. We present our experience with six patients presenting with periurethral cysts. METHODS: From 2001 to 2005 we evaluated six patients with a paraurethral mass. History, physical examination, laboratory and radiographic findings were analyzed to determine factors helpful in mass diagnosis. Cyst excision was performed via trans-vaginal approach in all patients and outcomes of this approach were assessed. RESULTS: Six female patients, average age of 29.7 years, presented with the complaint of a paraurethral mass. Transvaginal sonography was performed in two patients to confirm the presence of a periurethral cyst. Cystourethroscopy in all patients revealed no communication between the cyst and the urethra or presence of other lesions. Pathology revealed a benign cyst in all patients. No cyst recurrence has been seen in any patient. CONCLUSION: Most periurethral cysts can be diagnosed by physical examination. The diagnosis may be confirmed with transvaginal sonography. Cystourethroscopy should be performed to rule out other pathology, but may be done in the same setting as surgical excision. Complete surgical excision is effective and is associated with minimal risk of recurrence during short-term follow-up.     

Endoscopic evacuation of Durasphere

Durasphere is a urethral bulking agent used to treat stress urinary incontinence secondary to intrinsic sphincter deficiency. Although rare, chronic outlet obstruction and urinary retention are possible complications of this "permanent" bulking agent. We describe the endoscopic evacuation of Durasphere causing bladder outlet obstruction 1 year after being injected.     

Conservative management of a transdiaphragmatic fistula

Case reports of transdiaphragmatic fistulas connecting subphrenic collections and empyemas are uncommon. We report the rare complication of a fistulous connection between a subphrenic collection and the bronchial tree.     

Triple fistula: management of a double tracheoesophageal fistula with a third H-type proximal fistula

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a relatively common congenital condition in which there have been several described anatomical variants. The most common type, EA with distal TEF, comprises more than 75% of cases in many reports. Less commonly, a smaller proximal pouch fistula (H-type) will be associated with this most common variant in 1.4% of these cases. Only 2% of all cases of EA/TEF will have 2 large fistulas between the trachea and esophagus in which the end of the upper esophageal pouch connects terminally to the midtrachea and the distal esophagus arises from the trachea near the carina. Here we describe the management of an infant with this type of EA/TEF who was also found to have an H-type TEF of the proximal trachea. The combination of this type of EA/TEF with an associated H-type TEF or “triple fistula” has been previously described in the literature in only 1 other patient.     

Antegrade ureteroscopy: a new tool in management of severe ureteral strictures

A new method is described with which ureteral strictures are visualized by antegrade ureteroscopy. Under direct vision a catheter is manipulated through the stricture, which is then dilated. This method is especially useful in patients with a ureteroenterocutaneostomy. A patient is described in whom this technique was successful after other endoscopic techniques had failed.     

Anesthetic management for a patient with renal arterio-venous fistula

Key words  anesthesia - renal arterio-venous fistula - vascular resistance     

Successful conservative management of a pyelo-duodenal fistula

Uro-intestinal fistula is a rare entity and mostly managed by means of surgical intervention. We report a case of pyelo-duodenal fistula which was treated conservatively.     

Video-thoracoscopic management of a postpneumonectomy bronchopleural fistula

Bronchopleural fistula (BPF) after pneumonectomy is a well-known, dreaded complication associated with a high mortality rate. We present a case of video-assisted thoracoscopic management of a silent, small BPF. After thoracoscopic removal of all debris and inflammatory tissues, the identified BPF was successfully sealed by thoracoscopic instillation of tissue glue. This approach may be an effective alternative and promising option for treating small bronchopleural fistulas accompanied by empyema after pneumonectomy.     

Laparoscopic management of a rare urogenital fistula

Ureteral injury is usually iatrogenic after gynecologic or obstetric surgeries. Ureterouterine fistula is a rare complication. It most commonly occurs after a caesarean section. A 24-year-old woman presented with paradoxic incontinence 1 week after caesarean section. Intravenous urography revealed a left ureterouterine fistula. She was treated successfully by laparoscopic ureteroneocystostomy.     

Anaesthetic management for a left pneumonectomy in a child with bronchopleural fistula

The anaesthetic management of a left pneumonectomy in a 18-month-old girl with a bronchopleural fistula is described. An ordinary tracheal tube was slit at the bevel to ensure upper lobe ventilation on right endobronchial intubation. A combination of a bronchial blocker, endobronchial intubation with a slit tube, and nerve blocks for these manoeuvres was used. Pain relief by a thoracic epidural block ensured good physiotherapy and a comfortable postoperative period.     

Antegrade administration of mitomycin gel for upper tract urothelial carcinoma via percutaneous nephrostomy tube: a multi-institutional retrospective cohort study

Objectives

To assess the safety profile of antegrade mitomycin gel instillation through a percutaneous nephrostomy tube (PCNT) for upper tract urothelial carcinoma (UTUC) with the aim of decreasing morbidity associated with therapy.

Patients and Methods

Patients undergoing antegrade administration of mitomycin gel via PCNT were retrospectively included for analysis from four tertiary referral centres between 2020 and 2022. The primary outcome was safety profile, as graded by Common Terminology Criteria for Adverse Events (v5.0). Post-therapy disease burden was assessed by primary disease evaluation (PDE) via ureteroscopy.

Results

Thirty-two patients received at least one dose of mitomycin gel via PCNT for UTUC, 29 of whom completed induction and underwent PDE. Thirteen patients (41%) had residual tumour present prior to induction therapy. At a median of 15.0 months following first dose of induction therapy, ureteric stenosis occurred in three patients (9%), all of whom were treated without later recurrence or chronic stenosis. Other adverse events included fatigue (27%), flank pain (19%), urinary tract infection (12%), sepsis (8%) and haematuria (8%). No patients had impaired renal function during follow-up and there were no treatment-related deaths. Seventeen patients (59%) had no evidence of disease at PDE and have not experienced recurrence at a median follow-up of 13.0 months post induction.

Conclusions

Administration of mitomycin gel via a PCNT offers a low rate of ureteric stenosis, demonstrates a favourable safety profile, and is administered without general anaesthesia.     

Anesthetic management of a patient with aortocaval fistula

Aortocaval fistula is a rare complication of ruptured abdominal aortic aneurysm (AAA), and patients with an aortocaval fistula show multiple symptoms. We report an 87-year-old man who was diagnosed as having an AAA with aortocaval fistula and who developed refractory hypotension after induction of anesthesia. Following a phenylephrine injection for slight hypotension induced by anesthetic induction, he developed severe hypotension and bradycardia, and his skin became cyanotic. Vasopressor agents had no immediate effect on the hypotension, but blood pressure gradually increased in about 30 min with continuous infusion of dopamine and noradrenaline. Transesophageal echocardiography (TEE) showed right ventricle (RV) hypokinesis and massive tricuspid regurgitation (TR). Central venous pressure (CVP) showed a remarkably high value. After the repair of the aortocaval fistula, the hemodynamics became stable, RV motion was improved, TR was reduced, and CVP became normal. Anesthetic management of the repair of an aortocaval fistula is very difficult. The hemodynamics changed dramatically throughout anesthesia in our patient with this disorder, even though low-dose anesthetics were used. For the successful treatment of this disorder, preparation for the operation is required before the induction of anesthesia, and urgent closure of the fistula is necessary after the induction of anesthesia. TEE is a useful tool for monitoring hemodynamics in such patients.     

Endoscopic management for broncholithiasis with bronchoesophageal fistula

We report a case of broncholithiasis with bronchoesophageal fistula that was successfully managed endoscopically using endoscopic laser therapy and a covered self-expandable metallic stent.     

Endovascular stent graft for management of ureteroarterial fistula: a case report

We report a case of ureteral-iliac artery fistula and its minimally invasive management with endovascular stent grafting. A 76-year-old male was admitted with massive gross hematuria from an ilial conduit. He underwent a radical cystectomy with ileal loop urinary diversion for bladder cancer 7 months ago and had undergone placement of a 7 Fr single-J ureteral catheter for repair of a partial disruption of the left ureteroileal anastomosis. Although the fistula was not confirmed radiographically, a left ureteral-common iliac artery fistula was highly suspected. The patient was treated by percutaneous placement of an autoexpandable covered stent graft across the left common iliac and left external iliac artery. After successful endovascular management of the ureteroarterial fistula, the patient's hematuria resolved and he recovered fully. During 10 months of follow up, he has been free of hemorrhagic episodes. Because open surgical repair may be difficult and associated with significant risk for complications, endovascular intervention may provide a safety treatment alternative.     

Fistulojejunostomy for the management of refractory pancreatic fistula

BACKGROUND: Pancreatic fistula (PF) formation is a known complication of pancreatic surgery, pancreatitis, and pancreatic injury. When medical or endoscopic interventions fail to resolve PF, operation remains the only viable treatment option. Unfortunately, operation for the correction of PF is often difficult and associated with significant morbidity. METHODS: Herein, we report on our experience with a previously described technique for the management of PF that is performed easily and is associated with reduced morbidity. During the period of 2003-2006, 8 patients (males = 6, female = 2) with PF were treated with prolonged percutaneous drainage. Once a mature scar tract formed around the percutaneous drain, patients underwent a fistulojejunostomy. RESULTS: The age of these patients ranged from 43 to 61 years. Of the 8 patients, 5 had fistulas secondary to necrotizing pancreatitis. The remaining 3 patients had fistulas resulting from previous pancreatic surgery. The average interval between drain placement and fistulojejunostomy was 6 months (range, 4-7 months). The average duration of operation was 2.5 h (range, 1-4.5 h). The average blood loss was 280 mL (range, 50-600 mL). Average duration of stay was 9 days (average, 4-14 days). At a mean follow-up of 17 months (range, 2-58 months), 6 of 8 patients had resolution of their pancreatic fistulas, could resume regular diet, and were free of narcotic use. One patient developed a recurrent pseudocyst and required a distal pancreatectomy, and the final patient was lost to follow-up. CONCLUSIONS: Fistulojejunostomy is an effective therapy for the definitive treatment of pancreatic fistulas.     

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.