Introduction: Ureteral strictures are a significant cause of morbidity and mortality, resulting in potential kidney damage requiring several surgical procedures. Non-malignant causes include radiation, trauma from calculi impaction, pelvic surgery, or ureteroscopy (URS). We identified risk factors in our patients with ureteral strictures and the success of their treatment outcomes. Methods: A retrospective chart review of 25 patients with 29 ureteral strictures was performed to determine the success of their treatment. Results: Twenty-five (25) patients with 29 benign ureteral strictures were identified. Most cases (60%) were caused by impacted stones where the median stone size was 1.15 cm (0.37-1.8 cm). Intervention for stones prior to stricture development included shockwave lithotripsy, URS, and percutaneous nephrolithotomy. Five patients with strictures from impacted stones had ureteric complications during stone treatment including perforation +/-urinoma (n=3), fractured guidewire left in situ (n=1), and ureteric orifice resection (n=1). Other stricture etiologies included radiation (28%) and endometriosis (4%). Treatment modalities used included ureteroureterostomy (n=2), ureteral re-implant (n=3), urinary diversion (n=3), autotrasplant (n=1), laser endoureterotomy +/-balloon dilation (n=8), nephrectomy (n=2), balloon dilation +/-stent (n=3), ureterovesical junction (UVJ) resection + stent (n=1), chronic stent changes (n=4), or surveillance (n=3). Conclusions: Our evaluation highlights important principles. Patients with complicated ureteroscopies or severely impacted calculi warrant close followup with imaging after stone treatment due to possibility of rapid renal deterioration from stricture formation. Radiation-induced strictures are difficult to manage, possibly requiring subsequent urinary diversion. Finally, endoscopic management of benign ureteral strictures via balloon dilation and laser endoureterotomy is an excellent choice in properly selected patients, with opportunity for subsequent salvage treatments if needed.
Introduction and Objectives: AUA Best Practice Guidelines for uretero-scopic stone treatment recommend antibiotics coverage for less than 24 hours after the procedure. The purpose of this study was to evaluate if the rate of post-operative urinary tract infection (UTI) differed in patients receiving a single dose of antibiotics pre-operatively compared to those patients who also received post-operative antibiotics. Methods: A retrospective review was performed of consecutive patients at two institutions, University of British Columbia and Massachusetts General Hospital, Harvard. All patients were given a single dose of antibiotics prior to ureteroscopic stone treatment. A subset of patients were also given post-operative antibiotics ranging in time and selection of antibiotic. Patients who displayed symptoms of infection had a urine culture performed for speciation and antibiotic sensitivity. Results: Eighty one patients underwent ureteroscopy for renal calculi. Patients with pre and post operative antibiotics were compared to those receiving only pre-operative antibiotics. Eight (9.9%) patients in total (2 from pre-operative antibiotic and 6 from the pre and post-operative antibiotic group, P=0.219) developed UTI's in the post-operative period. Surgical factors such as ureteral access sheath, bilateral procedures, use of basket or laser was not associated with rates of infection or whether the surgeon prescribed post-operative antibiotics. Risk factors such as pre-operative stenting, nephrostomy tubes, and foley catheters did not differ between groups or predispose patients to post operative infections. Conclusions: Our data suggests that post-operative antibiotics do not decrease infection rates following ureteroscopic stone treatment, even among patients with risk factors for infection. A single pre operative dose is sufficient. Objectives: To determine predictors of Fluoroscopy Time (FT) during Percutaneous Nephrolithotomy (PCNL) and assess the impact of urology PostGraduate Trainees (PGTs) and S.T.O.N.E. Nephrolithometry Score. Methods: A prospective review of patients undergoing PCNL between 2010 and 2013 at a tertiary health care centre was performed. Patients' demographics, stone characteristics, including S.T.O.N.E. Nephrolithometry Score, and operative data were compared among PGTs. Predictors of FT were determined using univariate and multivariate models. Results: A total of 103 PCNLs were assisted by 10 PGTs from PostGraduate Years (PGY) 4 and 5 [37 (35.9%) and 66 (64.1%) cases, respectively)]. Sixty percent of patients were males with a mean age of 55.2±1.5 years and a mean BMI of 26.4±0.5 kg/m2. The mean S.T.O.N.E score was 7.7±0.1, with tubeless PCNL in 53 (51.5%) cases. The mean FT was 120±5 seconds, mean operative time was 102±3.5 minutes and mean length of hospital stay was 4.2±0.34 days. The overall stone-free rate was 72.8%. PGY-5 trainees used significantly less FT than PGY-4 trainees (115±6 vs. 130±7 sec; p=0.04). FT significantly correlated with the number of involved calyces (r= 0.24, p= ...
Ureteral stents are fraught with problems. A conditioning film attaches to the stent surface within hours of implantation; however, differences between stent types and their role in promoting encrustation and bacterial adhesion and colonization remain to be elucidated. The present work shows that the most common components do not differ between stent types or patients with the same indwelling stent, and contain components that may drive stent encrustation. Furthermore, unlike what was previously thought, the presence of a conditioning film does not increase bacterial adhesion and colonization of stents by uropathogens. Genitourinary cytokeratins are implicated in playing a significant role in conditioning film formation. Overall, stent biomaterial design to date has been unsuccessful in discovering an ideal coating to prevent encrustation and bacterial adhesion. This current study elucidates a more global understanding of urinary conditioning film components. It also supports specific focus on the importance of physical characteristics of the stent and how they can prevent encrustation and bacterial adhesion.
In this multicenter review, PCNL is confirmed to be a safe and effective means of addressing the retained and encrusted ureteral stent. PCNL without ureteroscopy or litholapaxy was sufficient in a minority of cases (21%). Adjunctive endourologic modalities are often required, and the surgeon should anticipate the need for concomitant antegrade ureteroscopic laser lithotripsy and/or cystolitholapaxy. Although complete stent removal can be anticipated, residual fragments are not uncommon.
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