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Urothelial carcinoma of the upper urinary tract is rare but the incidence is currently increasing in western countries. Radical nephroureterectomy has long been the standard treatment; however, it can lead to chronic kidney failure and also the necessity for dialysis. Therefore, organ-preserving treatment is now recommended for selected patients with low-risk tumors. The choice of treatment depends on the tumor characteristics, comorbidities and individual risk factors. Surgical options for organ preservation include ureterorenoscopy (URS), percutaneous treatment and partial ureteral resection. The URS is the most frequently used method for organ preservation. Photodynamic diagnostics (PDD) and narrow band imaging (NBI) can potentially also be used for tumor detection in the upper urinary tract. Conservative options such as topical treatment with mitomycin C or Bacillus Calmette-Guérin (BCG) and systemic treatment options are also possible.

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Ovarian vein syndrome is a rare condition involving the compression of the ureter by the ovarian vein. Since it was first described, very few cases have been reported in literature. We present a case of a 37-year-old female with typical symptoms and common right-side involvement. The imaging findings on ultrasound, CT, and nuclear medicine imaging are classic for her condition.

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Mullerianosis is a term used to describe a pathologic entity comprised of at least 2 types of Mullerian-type epithelia (tubal, endocervical, or endometrial) at non-gynecologic sites. This is an uncommon occurrence in the urinary tract. To the best of our knowledge, only 3 instances of Mullerianosis involving the ureter have been reported. We present a fourth report and describe the clinical, radiological, and histopathologic findings. Awareness of this rare process is crucial to avoid misdiagnosis.

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Background and objective: Few studies on endoscopic management of primary obstructive megaureter (POM) in adult patients have been reported. Our objective was to describe our technique and long-term outcomes for endoscopic management of adult POM. Methods: We included 76 adult POM patients undergoing endoscopic management between September 2015 and January 2024. Under endoscopic control, the stricture was dilated to 24-30 Fr while maintaining a balloon pressure of 25-35 atm for 3 min. An additional incision of the stenotic ring using either an electrode or holmium laser was performed in 39 patients. Data for patient characteristics, intraoperative variables, surgical complications, and follow-up results were analyzed. A descriptive statistical analysis was performed. Surgical success was defined as no tubes or stents in the body, stable or improved symptoms and renal function, and the absence of reflux or obstruction during the follow-up period. Key findings and limitations: All procedures were completed without conversion to open or laparoscopic surgery. The median operative time was 45 min (range 16-165) with median estimated blood loss of 2 ml (range 0-150). The median postoperative hospital stay was 3 d (range 1-15). No intraoperative complication occurred. At median postoperative follow-up of 42 mo (range 3-100) the overall success rate was 92.1%. Restenosis of the vesicoureteral junction (Clavien-Dindo grade III) occurred in five patients (6.6%), and high-grade vesicoureteral reflux occurred in one patient (1.3%), all of whom required secondary reconstruction surgery. Conclusions and clinical implications: The results indicate that our endoscopic management for adult POM is safe and effective, with favorable long-term outcomes. This approach could potentially serve as a first-line treatment option for adult POM. Patient summary: Primary obstructive megaureter (POM) occurs when the flow of urine is blocked because of a narrow segment in the tube between the kidney and bladder (ureter), which causes widening of the ureter further up. For our minimally invasive technique, a telescope is inserted through the urethra and bladder to reach the ureter for surgical treatment. Our results show that this is a safe procedure for POM in adults.

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Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical standard of care for patients with localized prostate cancer. Although uncommon, the procedure involves a potential risk of injury to adjacent anatomical structures. We report on a unique case of iatrogenic ureteral injury during RALP that required subsequent robotic-assisted laparoscopic ureteral reimplantation for definitive repair. A 57-year-old male underwent RALP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA). The procedure was unremarkable and a 20 French Foley catheter was placed with plans for removal after one week following a negative cystogram. On postoperative day two, his creatinine level elevated to 2.69 mg/dL from a baseline of 1.40 mg/dL, left-sided flank pain increased, and non-contrast CT imaging revealed moderate left proximal hydroureteronephrosis and no other abnormalities. Aside from mild nausea on postoperative day one, he had no other symptoms. An integrated stent was unable to be placed by urology at this time. Subsequently, a left percutaneous nephrostomy tube was placed under fluoroscopic guidance. After this intervention, the patient's symptoms improved and the decision was made not to proceed with operative re-exploration at this time to attempt identification of the obstruction. Three weeks later, the patient underwent cystoscopy with attempted left retrograde ureteropyelography and left ureteroscopy due to suspected distal obstruction. This revealed complete obstruction of the intramural portion of the ureter, presumed to be secondary to suture ligation at the time of the vesicourethral anastomosis. Seven weeks postoperatively, the patient underwent robotic-assisted laparoscopic left ureteral reimplantation. Thereafter, the patient had a resolution of his left hydroureteronephrosis and acute kidney injury. This case describes an intravesical ureteral ligation during RALP. An iatrogenic intravesical ureteral ligation has far less guiding literature than a more common ureteral transection. Additionally, ureteral transection is often identified and managed intraoperatively, while the ureteral ligation presented in this case is far less likely to be apparent during surgery. Early identification will allow for rapid reoperation to manage the injury. We hypothesize that during the vesicourethral anastomosis, the left intramural ureter was ligated. Importantly, with the use of a 3-0 V-Loc stitch for the vesicourethral anastomosis, its barbed nature would not facilitate simple surgical removal. In conclusion, when performing RALP, the depth of the bladder-sided vesicourethral anastomotic stitch should be carefully considered to avoid a similar injury.

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AIM: A retrospective audit from a urological center focused on urological fistulas that directly connect with the treatment of gynecological malignancy. Ureteroarterial fistulas, i.e., pathological communication between the ureter and the artery, are discussed in more detail. MATERIALS AND METHODS: Over a period of ten years, from 2011 to 2020, a group of 47 patients with a diagnosis of urinary fistula was retrospectively evaluated. These patients, with a history of treatment for gynecological malignancy, were sent to our clinic from local and non-regional departments in the Czech Republic. We found three cases of ureteroarterial fistula in the presented analysis that focused on urological toxicity of oncogynecological treatment. RESULTS: Within the mentioned period of ten years, we recorded 64 cases of urinary fistulas, and 47 patients (73.4%) were directly related to oncogynecological treatment. In the group with gynecological tumors, we found three patients (6.4%) with a diagnosis of ureteroarterial fistula, two of whom died directly related to this complication (exsanguination). These patients were treated for cervical cancer. All of them underwent radiotherapy during the treatment. CONCLUSION: Ureteroarterial fistulas are the most severe complications that can occur in medicine. This work confirms that we have encountered these cases even recently. Management is highly demanding for patients affected in this way and requires multidisciplinary cooperation. Endovascular intervention methods can control bleeding in emergency situations with non-surgical approaches. However, they are usually the first step towards a definitive surgical solution.

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OBJECTIVE: Our objective was to propose a laparoscopic modified simple ureteroneocystostomy for repairing iatrogenic ureteral injuries. In laparoscopic modified simple ureteroneocystostomy, the highest point of the bladder was found by cystoscopy, then we implanted a "fish mouth" ureter end into the bladder, leaving at least 1 cm of ureter end in the bladder as an anti-reflux procedure. CASE REPORT: We retrospectively reviewed a case series of lower third iatrogenic ureter injury during gynecology surgery of 11 patients who received laparoscopic modified simple ureteroneocystostomy at Da Lin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, from January 2011 to December 2020. One patient needs percutaneous nephrotomy due to infection and had the ureteroneocystostomy two months later. No obstruction, ureter stenosis/stricture, bladder leakage or other renal complications were noted after repair. CONCLUSION: Laparoscopic modified simple ureteroneocystostomy is technically feasible for repairing lower third ureter injuries, with no major complications.

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BACKGROUND: Ureteral injury occurs in 0.3-1.5% of colorectal cancer surgeries. Devices to visualize the ureteral course and avoid ureteral injury are required for minimally invasive surgery (MIS). The NIRC™ fluorescent ureteral catheter (FUC) is a versatile ureteral visualization device currently available in Japan that can be used in combination with a variety of laparoscopic and robotic systems. In this study, we examined the outcomes of high-risk patients who underwent colorectal cancer surgery with FUC insertion. METHODS: One hundred forty-one patients who underwent MIS for colorectal cancer and colorectal cancer recurrence at our institute between January 2021 and May 2024 underwent preoperative FUC insertion because of the high risk of ureteral injury and surgical difficulty. For these patients, patient background data and short-term outcomes were examined. The results are expressed as the median and interquartile range. RESULTS: Age, 70 [60-78]; M:F(n), 84:57; BMI, 22.1 [19.7-24.7]; T4 (TNM classification), 52 cases (36.9%); preoperative intestinal obstruction, 45 cases (31.9%); abscess formation, 30 cases (21%); surgical history, 70 cases (50%); recurrent cancer, 14 cases (9.9%); preoperative chemo-radiotherapy, 28 cases (19.9%); time required for FUC insertion, 12 [9-19] minutes; operation time, 412 [309-552] minutes; blood loss, 10 [5-30] ml; open conversion, 0 cases; postoperative hospitalization, 12 [9-17.5]; circumferential resection margins < 1 mm (rectal surgery), 4/87 cases (4.6%); comorbidities, 0 ureteral injury, 1 urethral injury during FUC insertion (0.7%) and 16 CD Grade 3 or higher cases (11%). CONCLUSIONS: FUC may improve the safety of MIS and reduce blood loss in addition to preventing ureteral injury and is expected to have oncological advantages for ensuring the margin of the tumor without fear of ureteral injury. However, the time required for and complications associated with FUC are challenging. New methods for less invasive and easier ureteral visualization may be needed.

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Although the Boari flap technique is commonly described in the literature as a method for primarily distal and middle ureteral injuries, it can also be used for reconstructing the proximal segment of the ureter. In this case study, we present a patient who underwent gynecological surgery with subsequent damage to the proximal ureter, and who underwent ureteral reconstruction using methods such as kidney mobilization, Boari flap, and psoas hitch. The postoperative period was uncomplicated, and after a six-month follow-up, the reconstructed ureter is functioning well, and the patient is in good health.

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OBJECTIVES: Ectopic ureter and ureterocele need an adequate treatment plan and different surgical interventions. However, some cases appear as intravesical cystic lesions on ultrasound, with ectopic ureter sometimes reported as pseudoureterocele. This study aimed to describe the sonographic imaging findings of intravesical cystic lesions to differentiate between pseudoureterocele and ureterocele. METHODS: Nineteen patients with duplex collecting system and intravesical cystic lesions that were classified into pseudoureterocele and ureterocele based on the surgical findings were included. The ultrasound findings compared between the 2 groups were as follows: intravesical lesion with/without a covered muscular layer, presence/absence of notch sign within the lesion, and dynamic change in the appearance of intravesical cystic lesions using Fisher's exact test. RESULTS: The lesions in 3 patients were classified as pseudoureterocele due to ectopic ureter and the remaining 16 as ureterocele. Significant differences were observed in intravesical lesions with/without a muscular layer (pseudoureterocele versus ureterocele = 3/0 versus 3/13, P = .021) and the presence or absence of a notch sign within the vesical cystic lesion (pseudoureterocele versus ureterocele = 3/0 versus 3/13, P = .021) between the groups. Although there was a tendency for the dynamic change in the appearance of intravesical cystic lesions to be more detectable in cases with ureterocele than in pseudoureterocele, the difference was not significant (0/3 versus 11/5, P = .058). CONCLUSIONS: Sonographic findings, including bladder muscular layer location and the presence of a notch sign within the cystic lesion, were useful in differentiating pseudoureterocele and ureterocele in intravesical cystic lesions in pediatric patients with a duplex collecting system.

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We experienced a rare case in which iliopsoas abscess (IPA), caused by an Extended Spectrum ß-Lactamase (ESBL)-producing Proteus mirabilis, perforated and communicated with the ureter and caused sepsis. An 84-year-old woman, bedridden due to sequelae of a cerebral hemorrhage, was brought to our hospital with a chief complaint of fever lasting for 3 weeks. Computed tomography (CT) revealed a huge 180 × 110 × 100 mm IPA in the right iliopsoas muscle. The ureter was also found to communicate with the iliopsoas muscle abscess, ureteral stenosis was detected at the same site, and dilatation of the renal pelvis occurred above the area of the ureteral stenosis, indicating hydronephrosis. Considering the mechanism of this case, if the ureter first ruptures and urine leaks, followed by the formation of an IPA, urine will flow along the surrounding fatty tissue and cause an abscess around the ureter and kidney. However, because almost no abscess was detected around the ureter, the abscess was thought to have originated from the iliopsoas muscle located near the center of the ureter. In summary, in this case, an abscess first formed within the iliopsoas muscle, which gradually expanded and compressed the right ureter, resulting in hydronephrosis. The upper ureter, which had become dilated and thinned due to ureteral obstruction, became even more fragile because of the spread of inflammation from the IPA, and the IPA perforated and communicated with the ureter. In patients who have difficulty communicating, the diagnosis of IPA may be delayed because the only symptom is fever. As in this case, if the diagnosis is delayed, the abscess may become large and perforate the ureter; thus, IPA should always be considered as a cause of fever of unknown origin.

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Retrocaval ureter is a rare congenital anomaly. It usually occurs on the right side and cases on the left side without accompanying conditions such as situs inversus or double inferior vena cava (IVC) are uncommon. Instances of left retrocaval ureter without situs inversus or double IVC are rarely reported in the literature, and there are no cases presented sonographically. In this case, we present a demonstrative sonographic and tomographic images of a left-sided Type 1 retrocaval ureter case where situs inversus and double IVC were not present. In cases where hydronephrosis is detected on ultrasound, a medially displaced ureter should raise suspicion for retrocaval ureter.

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Small bowel obstruction is one of the most common urgent surgical conditions, caused by a variety of factors, with adhesions, malignancies, and hernias, internal and external, being the most common. Many types of internal hernias have been described in the literature; however, internal hernia caused by the ureter as a secondary complication of ureteroplasty is rare and only a few cases have been reported worldwide. This presentation discusses an interesting case of small bowel obstruction accompanied by obstruction of the urinary tract due to an internal hernia caused by the ureter. A 58-year-old female presented to the emergency department (ED) with acute pain in the abdominal and right lumbar region. Her surgical history includes hysterectomy, right ureter injury, and ureteroplasty performed 10 years ago. Clinical examination showed tenderness in the lower abdomen, positive Giordano's sign on the right, and metallic bowel sounds. A computer tomography scan revealed right-sided hydronephrosis, absence of excretion in the right urinary tract, and dilated loops of the small intestine. An exploratory laparoscopy revealed a small bowel loop strangulated by the ureter, followed by laparotomy, resection of a segment of the ileum, oblique anastomosis, and reimplantation of the right ureter. The patient was discharged eight days postoperatively without any complications. This case underscores the significance of surgical history in order to recognize even rarer causes of small bowel obstruction.

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Non-Hodgkin's lymphoma are neoplasms derived from T cells and B cells and their precursors in the lymphoid system with higher susceptibility in involvement of extra-nodal sites. Predominant ureteric involvement is an unusual presentation. We present a case of diffuse large B-cell lymphoma with secondary involvement of ureter who had symptoms of urinary tract infection in absence of positive urine culture, non-responsive to broad spectrum antibiotics and masquerading pyogenic infection leading to pyelonephritis with ureteritis. Radiological examination revealed mass like soft tissue thickening of ureter extending from renal pelvis throughout the length of ureter. FNAC as well as biopsy from the periureteric thickening revealed lymphomatous involvement of ureter. The following case report provides insight on differentials and varied symptoms of lymphomatous involvement of ureter.

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Objective: Vesicoureteral reflux (VUR) index is a simple, validated tool that reliably predicts significant improvement and spontaneous resolution of primary reflux in children. The aim of this study was to evaluate and compare the ureter diameter ratio (UDR) and VUR index (VURx) of patients treated with endoscopic injection (EI) and ureteroneocystostomy (UNC) methods in the pediatric age group due to primary VUR. Methods: Patients under the age of 18 years old who underwent EI and UNC with the diagnosis of primary VUR between January 2011 and September 2021 were determined as the participants. The UDR was assessed using voiding cystourethrography, and the VURx score was determined prior to treatment based on hospital records included in the study. Results: A total of 255 patients, 60 (23.5%) boys and 195 (76.5%) girls, with a mean age of 76.5 (range 13.0-204.0) months, were included in the study. EI was applied to 130 (51.0%) patients and UNC was applied to 125 (49.0%) patients due to primary VUR. The optimum cut-off for the distal UDR was obtained as 0.17 with sensitivity and specificity of 73.0% and 63.0%, respectively. The positive and negative predictive values were 66.0% and 70.0%, respectively. Conclusion: When the UDR and VURx score are evaluated together for the surgical treatment of primary VUR in the pediatric age group, it is thought that it may be useful in predicting the clinical course of the disease and evaluating surgical treatment options.

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OBJECTIVE: Megaureter (MU) is an uncommon condition in adults. The aim is to present a review of the current literature. MATERIALS AND METHODS: A literature search was conducted to explore the current literature including case reports on MU in adults in the period 2003-2023. Each case was characterised in terms of the eight categories: sex, age, etiology, location, symptoms, diagnostic tool used, type of treatment and follow-up. RESULTS: There was no meta-analysis but two reviews. Total, 39 case reports were included based on 35 articles. The most common observations for the first four categories were male (sex), age below 40 (age), obstructed MU (etiology) and left-sided MU (location). Almost every patient appeared with symptoms, most frequently flank pain, abdominal pain and recurrent urinary tract infections. CT scan and transabdominal ultrasonography are the most commonly used diagnostic tools. Most cases underwent either laparoscopic or open surgical treatment with ureteral reimplantation as the most performed surgical procedure. A majority of the patients had an uneventful follow-up. CONCLUSION: MU in adults is a rare condition presenting with heterogeneous symptoms. CT scan and transabdominal ultrasonography should be used as diagnostic tools. Nearly all patients underwent surgical treatment with an uneventful follow-up. Complications such as stone formation and altered function of the affected kidney are common. Surgical treatment is recommended and is determined by consideration of age, symptoms, ureteral extension and progressive loss of renal function.

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INTRODUCTION: Metastasis of malignant melanoma to urinary tract is reported to be rare. According to retrospective analysis of a single center study, improvement of overall survival was observed in patients with metastasis to the gastrointestinal tract that had undergone metastasectomy with curative intent. However, there is no significant evidence regarding resection for metastasis to urinary tract. CASE PRESENTATION: Case 1: an 86-year-old Japanese man was diagnosed with a small bladder tumor by computed tomography scan during post operative follow-up of malignant melanoma in the choroid of the left eye. Cystoscopy revealed black, nonpapillary tumors, suggesting metastatic malignant melanoma. Because no apparent invasive growth to muscle layer was observed by magnetic resonance imaging, transurethral resection was performed. Pathological appearance was compatible with metastatic malignant melanoma. No recurrence in urinary tract was observed; however, multiple liver metastasis was diagnosed at 3 months after surgery. Case 2: a 57-year-old Japanese man was diagnosed with right hydronephrosis due to ureteral tumor. He had a past history of subungual malignant melanoma to the left thumb 2 years prior to his visit. Right nephroureterectomy was performed, and pathological evaluation revealed metastatic malignant melanoma. He revisited 2 years later due to dysuria, and a large bladder tumor was revealed by ultrasound. Cystoscopy showed black-colored nonpapillary tumor, suggesting malignant melanoma. Total cystectomy was recommended; however, the patient withheld consent. Therefore, we performed transurethral resection. The resulting pathological finding was compatible with metastatic malignant melanoma without invasion to muscle layer. He remained free from local recurrence and metastasis for 22 years after surgery. CONCLUSION: We successfully performed metastasectomy for bladder and ureteral metastases without recurrence in the urinary tract. Long recurrence-free survival was observed in case 2. Complete resection for metastasis of malignant melanoma may have the potential to improve survival.

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In this study, we aimed to demonstrate the feasibility and safety of navigating the ureters, middle sacral artery (MSA), and superior hypogastric nerve (SHN) using indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during robot-assisted sacrocolpopexy (RSCP). Overall, 15 patients who underwent RSCP for apical vaginal prolapse were retrospectively enrolled. All patients underwent cystoscopic intraureteric instillation of 5 cc ICG (2.5 mg/mL) before RSCP and intravenous injection of 3 cc ICG during presacral dissection and mesh fixation. In all patients, the fluorescent right ureter was clearly identified in real time. The MSA was visualized on ICG-NIRF images in 80% (13/15) of patients. The mean time from ICG injection to MSA visualization was 43.7 s; the mean duration of the arterial phase was 104.3 s. Fluorescent SHN was detected in 73.3% (11/15) of patients. The time from ICG injection to SHN fluorescence was 48.4 s; the duration of fluorescence was 177.2 s. There was no transfusion, iatrogenic ureteral injury, or bowel or urinary dysfunction. Our results indicated that intraoperative ureter, MSA, and SHN mapping using ICG-NIRF images during RSCP is a valuable and safe technique to avoid iatrogenic ureteral, vascular, and neural injuries and to simplify surgical procedures. Nonetheless, further studies are required.

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BACKGROUND: Crossed fused renal ectopia (CFRE) is a common congenital anomaly where one kidney is positioned abnormally on the opposite side of the midline, often fused with the other kidney. However, single ureter draining crossed fused renal ectopia is a rare occurrence. CASE REPORT: Here, we report a case of crossed fused renal ectopia with a single ureter in a 46-year-old Nepali male who presented with history of lithuria. Computed tomography revealed that the left kidney was situated on the right side and fused with the right kidney. The renal pelvises of both kidneys were fused, and a single ureter, located on the right side, was draining both kidneys into the bladder. The patient was advised to have regular follow-ups. CONCLUSION: Crossed fused renal ectopia with a single ureter represents a rare renal anomaly. Asymptomatic patients can typically be managed conservatively. Regular follow-up is recommended to monitor renal function, calculus formation, infections, and malignant changes.

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