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Query: UMLS:C0036690 (sepsis)
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The authors report on two cases of uretero-colic fistulization in the post-operative period, following surgery for infectious complications involving sigmoidal diverticulitis. In the aftermath of surgery for sigmoidal diverticula, the appearance of very liquid stools at the exact moment when the infectious and semi-occlusive picture seems to resolve, the occurrence of a uro-steraceous fistula should make one suspect a uretero-colic fistula. Air pyelography and the retrograde opacification of the ureter following a radio-opaque enema are diagnostic. The IVU does not help to establish a firm diagnosis but is useful for showing the state of the adjacent kidney and above all the state of the contralateral kidney. In regard to the sepsis which accompanies these complications (there is nearly always a pericolic abscess at the site of the utero-colic fistula) all attempts at repair are futile. Only nephrectomy may be sometimes appropriate. At the same time, nothing except treatment of the infectious focus (colic or pericolic) will safeguard the patient from the risk of further infection which might end in death. The risk of damage to the ureter which sigmoidal diverticular surgery carries, necessitates the following precautions: a pre-operative IVU, a painstaking dissecting-out and well wide of the neighbouring ureter, the systematic injections of dye to colour the urine at the time of operation in order to avoid ureteric injury and of course to ensure the repair of any injury as soon as it happens. It is only possible to save the adjacent kidney and protect the normal urinary outlet if the ureteric lesion is properly identified at operation.
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PMID:[Uretero-colic fistula. Apropos of 2 cases complicating sigmoid diverticulitis after surgery]. 716 16

Historically, most patients with a renal duplication anomaly associated with upper pole hydronephrosis underwent upper pole nephrectomy and partial ureterectomy. Prenatal sonography has resulted in increased recognition of these anomalies and, therefore, earlier urological referral and evaluation. We investigated whether as a result more upper pole moieties were preserved by performing alternative procedures, such as ureteroureterostomy. In addition, the impact on overall morbidity of the disease and its treatment is assessed. Since 1984, of 29 patients treated for ectopic ureter or ureterocele 13 presented initially with a diagnosis of prenatal hydronephrosis. Of these patients, 5 (38.5%) underwent a renal sparing procedure consisting of ureteroureterostomy in 4 and excision of ureterocele with common sheath ureteral reimplantation in 1. The remaining 8 patients underwent upper pole nephrectomy and partial ureterectomy for a nonfunctioning upper pole moiety. In contrast, of 16 patients who presented without having undergone prenatal sonography only 2 (12.5%) underwent a renal preserving procedure. Initial treatment in the remaining 14 patients was upper pole nephrectomy and partial ureterectomy. The average age at initial treatment in the prenatally detected group was 3 months, compared with 5 years in the other group. Only 1 of the 13 patients (8%) in the prenatally detected group had symptoms, whereas 14 of 16 in the other group (87.5%) presented with significant symptoms consisting of sepsis in 12, an abdominal mass in 1, urinary incontinence in 1, and an incidental diagnosis made during evaluation of an associated anomaly in 2. Although there is still controversy regarding the impact of prenatal detection of hydronephrosis on the preservation of renal function in patients with a single system, our results show a beneficial effect in patients with duplication anomalies. This was reflected in our ability to salvage the upper pole moieties 3 times more frequently than was previously possible with minimal morbidity. More importantly, the potential serious clinical manifestations of these duplication anomalies in later life were eliminated by virtue of early treatment.
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PMID:The impact of prenatal sonography on the morbidity and outcome of patients with renal duplication anomalies. 786 32

The urological complications in the first consecutive 1,000 renal transplants at our transplant center are reported with a minimum followup of 12 months. The kidney was implanted in the iliac fossa in all cases and in all but 3 the ureter was inserted into the bladder with a Politano-Leadbetter technique. Overall, there were 71 primary complications in 68 patients (7.1%), which included 36 ureteral obstructions, 25 ureteral or bladder leaks (including ureteral necrosis), 7 bladder outflow obstructions, 2 ureteral stones and 1 case of symptomatic vesicoureteral reflux. The use of high dose steroids in the early years was associated with a 10% urological complication rate, which decreased to 4% in patients receiving low dose steroids thereafter combined with azathioprine or cyclosporine. The urological complication was corrected after 1 procedure in 65 cases and after 2 procedures in 4. No grafts were lost due to urological complications. Two patients died, 1 of sepsis following transurethral resection of the prostate and subsequent ureteral necrosis, and 1 of hemorrhage following nephrostomy tube insertion. Most ureteral complications were treated by an open operation, although in recent years endoscopic techniques have become more common. Meticulous retrieval technique, low dose steroid protocols and rapid diagnosis are the crucial factors associated with a minimal incidence of urological complications after renal transplantation.
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PMID:Urological complications in 1,000 consecutive renal transplant recipients. 760 31

A total of 1016 consecutive renal transplants performed between 1976 and 1990 were analysed retrospectively to determine the incidence of urological complications and possible predisposing factors. Some 189 episodes of ureteric obstruction and/or urinary leak occurred in 143 patients (overall incidence 14.1%). The median annual rate of urinary leak was 5.1%; that of ureteric obstruction was 4.5% pre-1986 and 16.1% post-1986. Sixty-three episodes of urinary leak occurred in 54 patients from 1 day to 3 months post-transplant and 60% involved the distal ureter. Thirty were treated primarily by reconstructive surgery, ten required nephrectomy and three died of associated sepsis. A total of 126 episodes of ureteric obstruction occurred in 104 patients from 1 day to 12 years post-transplant and 86% involved the distal ureter. Prior to 1986, 10/11 patients with ureteric obstruction were treated by reconstructive surgery, but since then 88 (95%) have been treated by percutaneous nephrostomy, with or without stenting, with only one graft lost and no deaths. Children had a significantly increased incidence of ureteric obstruction (P < 0.001) whilst male recipients had an increased incidence of urinary leak (P = 0.04). More patients with ureteric obstruction than those without had two or more episodes of rejection (P = 0.03). No single cause for the increased incidence of ureteric obstruction since 1986 has been identified. Continued attention to technical detail and further study of this trend is warranted.
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PMID:Urological complications following renal transplantation. A study of 1016 consecutive transplants from a single centre. 817 99

From January 1988 to February 1992, a total of 26 patients with calculi in the middle third of the ureter underwent primary in situ ESWL in the prone position. All treatments were performed in sedoanalgesia using the Dornier HM 3 lithotriptor. During and after ESWL in the prone position, severe complications did not occur. Of the 26 patients, 10 (38%) were treated by a single application of ESWL. No auxiliary measures were necessary, and they became stone-free within 3 months following treatment. In another 9 patients (35%) auxiliary measures were required for visualization of radiolucent calculi or to relieve a urinary tract obstruction with incipient septicemia. All these auxiliary measures could be performed in sedoanalgesia. In the remaining 7 patients (27%), in whom stone disintegration following ESWL was incomplete, ureteroscopic lithotripsy techniques had to be applied. One of these 7 patients had to undergo an additional open operative procedure. The results of the present study demonstrate that a majority of patients with calculi in the middle portion of the ureter can become stone-free without invasive lithotripsy techniques following ESWL in the prone position, if necessary plus auxiliary measures, in sedoanalgesia. From these results it can be concluded that primary ESWL in the prone position should be considered for patients with calculi in the middle third of the ureter before invasive lithotripsy techniques are applied.
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PMID:[Treatment of ureteral calculi in bone coverage using in situ ESWL in prone position]. 828 60

From November, 1987 to December, 1990, 399 cases of ureteral calculi were treated by rigid ureteroscopy (URS). Our success and complication rates are presented. Of these, 99 (25%) had a calculus in the pelvis (78/99), iliac (15/99) or lumbar (6/99) ureter, and 300 (75%) had Sandstrasse in the distal ureter. The cases with Sandstrasse were submitted to ureteroscopy within the first 48-72 hours to remove the ureteral obstruction, prevent hydronephrosis or sepsis and to expedite treatment. If symptomatic, obstructive and/or 7 mm or more in diameter, a nephrostomy tube was placed first whenever there was sepsis [23/300 (7%) of those with Sandstrasse and 3/99 (3%) of those with a ureteral calculus] or marked dilatation of the renal cavities [29/300 (9%) and 6/99 (6%), respectively]. The success rate was 93% for the cases with Sandstrasse versus 85% for those with a ureteral calculus, and the complication rates were 5.7% versus 9%, respectively. The foregoing results confirm the high success rate and scant morbidity of ureteroscopy in the treatment of ureteral calculus and Sandstrasse.
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PMID:[Ureteroscopy. Our results and complications]. 834 76

Bladder reconstruction using bowel segments was advanced when intermittent catheterization proved so acceptable. Access to the reservoir by way of the urethra is often not possible in children, especially boys. Implantation of the isolated appendix into the bladder remnant or colon segment similar to a ureteral reimplant provides a continence mechanism with ready catheter access (the Mitrofanoff principle). Since 1982 we have applied this principle in 41 pediatric cases of bladder reconstruction (64% boys). Primary diagnoses included bladder exstrophy (46%) and myelomeningocele (34%). Extending the concept of a flap valve continence channel with a narrow tube into the reservoir, segments of tapered ileum and ureters were also used (appendix 61%, ileum 12%, ureter 27%). Results of continence (100%) and uncomplicated catheterization (93%) have been satisfactory. Unfortunately, the longer the experience (average 3.2 years of followup), the more stone formation we experienced (32%), which is due to mucus production and bacteriuria as the stone nidus. There were 2 deaths, including 1 from a renal stone obstructing the ureter with sepsis and 1 a likely suicide. Reoperation was required for 3 stomal revisions, 2 bowel obstructions and 7 stone removals in 3 of the 6 cases in which the bladder neck was closed. Unique aspects of these reconstructions are presented, such as our current preference to bury the stoma in the umbilicus (7 cases), placement of the ureteral segment into the perineum as a neourethra and an unusual conjoined twin reconstruction.
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PMID:Appendicovesicostomy (and variations) in bladder reconstruction. 843 67

The injuries to the ureter, whether from external trauma or iatrogenic, are rare. Some problems are common to this type of pathology, independently from the causes of injuries. It is necessary a prompt diagnosis of the lesion to avoid the urinar leakage, the infection and the fibrosis of the ureteral's stumps. If the diagnosis is not prompt, the clinical pattern may be silent for some days; after, many complications will arise up: sepsis, urinomas and fistulas. When the lesion is incomplete, and there is no devascularization, the urine drainage alone, positioned above the level of the lesion, is indicated for spontaneous repairing. When the ureteral tissue loss is extensive, it is not enough a simple anastomosis between the ureteral's stumps; in these cases is necessary a more complex repair surgery or ureteral substitution.
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PMID:[Controversies on the subject of traumatic lesions of the ureter]. 847 92

This study describes nine cases of post-transplant lymphoproliferative disease (PTLD) presenting as renal allograft dysfunction. Onset of symptoms was 34 to 265 days post-transplant, typically (in six of nine cases) after refractory rejection treated with OKT3. Diagnosis was made by histopathologic examination of needle biopsy (three of nine cases) or allograft nephrectomy (six of nine cases) specimens. Disease was confined to the allograft in three patients. The morphology was polymorphic in eight cases and monomorphic in one case. Five cases showed monotypic kappa or lambda light chain expression. Expansile lymphoid infiltrates, serpiginous necrosis, nuclear atypia, and presence of Epstein-Barr virus RNA helped to distinguish PTLD from severe rejection. Tubular damage and venulitis was common in PTLD lesions, but arterial involvement was not prominent. Infiltration of the ureter, hilar adipose tissue, and nerve twigs was frequent in nephrectomy specimens. Reduction of immunosuppression led to resolution of PTLD in two of three cases diagnosed by needle biopsy, but severe acute rejection led to graft loss in one case; the third case progressed to fatal multisystem disease. Among cases diagnosed at nephrectomy, two of six patients died of disseminated PTLD and one of six died of sepsis. The five surviving patients are alive 41 to 99 months after initial diagnosis without evidence of recurrent PTLD.
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PMID:Renal allograft involvement by Epstein-Barr virus associated post-transplant lymphoproliferative disease. 861 21

Four patients with upper urinary tract transitional cell carcinoma were treated with bacillus Calmette-Guerin (BCG) via a percutaneous nephrostomy tube or a retrograde ureteral catheter. A 68-year-old female and an 80-year-old male had carcinoma in situ (CIS) in the left upper urinary tract (cases 1 and 2). A man aged 47 had CIS in the left upper urinary tract, bladder, and prostatic urethra (case 3). CIS in the left upper urinary tract was identified in a woman aged 63 with chronic renal insufficiency (case 4). Two patients (cases 1 and 2) responded to this therapy. In the other two patients nephrectomy was performed due to residual tumor. There were extensive tuberculous granulomas in the kidneys. In one resected kidney (case 4) carcinoma had invaded the renal parenchyma. The reviewed literature showed that BCG perfusion therapy was effective in 71% (27 of 38 renal units) for the upper urinary tract tumors and that there were 5 cases of severe complication, including sepsis in 2, high fever in 2, and ureteral stricture in 1. Based on the fact that the kidney receives a profuse blood supply and that the renal pelvis and ureter have a thin wall, careful management is mandatory to prevent severe adverse effects and insidious tumor progression.
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PMID:[Intracavitary bacillus Calmette-Guerin therapy for upper tract transitional cell carcinoma]. 869 56


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