Clinical Director, Boonshoft School of Medicine at Wright State University
The authors believed this helped them definitively site their endopyelotomy incision gastritis diet технополис florinef 0.1mg with visa. Different modalities were used for the endopyelotomy itself including electrocautery and holmium laser gastritis biopsy buy florinef from india. There were no significant bleeding complications gastritis gerd diet order florinef cheap, and all patients were discharged within 24 hours of the procedure. Several investigators have reported success rates of 70% to 80% with follow-up out to 5 years using ureteroscopic holmium laser endopyelotomy (Gerber and Kim, 2000; Matin et al, 2003, Elabd et al, 2009). Yanke reported on 128 retrograde ureteroscopic endopyelotomies with a 60% success rate at 20 months; Rassweiler and colleagues reported 73% success in 113 patients at 63 months (Rassweiler et al, 2007; Yanke et al, 2008). Improved results were reported by Conlin (91% success rates) with retrograde endopyelotomy in patients when culling patients with crossing vessels greater than 4 mm using preoperative ultrasonography (Conlin, 2002). Giddens and colleagues also published excellent results after culling patients with anterior and posterior crossing vessels from retrograde endopyelotomy using endoluminal ultrasound (Giddens et al, 2000). Today, endoluminal ultrasound is rarely used to identify crossing vessels because similar data can be obtained using less invasive studies (Mitterberger et al, 2008). Regardless, the best endopyelotomy success rates still lag behind those of open or laparoscopic pyeloplasty. Therefore, that series still represented a "combined" endourologic approach to endopyelotomy. Stents were routinely left in place for 6 to 8 weeks, after which diagnostic studies were performed. With a mean follow-up approaching 1 year, a success rate of 81% was achieved in 16 patients. However, two patients developed distal ureteral strictures, probably resulting from the larger-diameter rigid instrumentation. Butani and Eschghi (2008) identified 96% success rates in primary procedures with an average 5-year follow-up, although rigid ureteroscopy and preprocedure stents were necessary. Advances in instrumentation and technique now allow a ureteroscopic approach to be performed reliably at a single setting (Conlin and Bagley, 1998), and this is now considered the standard. Another advantage of the ureteroscopic approach is a decrease in cost compared with the use of the cautery wire balloon, assuming ureteroscopic equipment and electroincision or holmium laser are already available. Moreover, the risks and morbidity of percutaneous access are avoided with the ureteroscopic procedure. The indications for a ureteroscopic endopyelotomy include functionally significant obstruction, as defined earlier. Contraindications include long areas of obstruction and upper tract stones, which are best managed simultaneously with alternative approaches, usually percutaneously or laparoscopically. Another consideration is that in patients with significant hydronephrosis, the evidence indicates an antegrade endopyelotomy may be more efficacious (Lam et al, 2003b). In preparation for the endopyelotomy, a retrograde pyelogram is performed under fluoroscopic control at the outset of the procedure. A hydrophilic guidewire is passed cystoscopically under fluoroscopic control and coiled in the pyelocalyceal system. If the distal ureter is too narrow to allow easy passage of the ureteroscope, the intramural ureter can be dilated using a 5-mm balloon or a 9- or 10-Fr "introducing" catheter. If the ureter is still too narrow at any point to easily accommodate the ureteroscope, then an internal stent is placed and the procedure postponed for 5 to 10 days to allow passive ureteral dilation. Alternatively, an actively deflecting flexible ureteroscope may be used, and in most cases a ureteral access sheath is quite useful. Complications of this approach have diminished in frequency and severity with the refinement of ureteroscopic instrumentation and the introduction of small-caliber holmium laser fibers.
Congenital variants of the pelvicalyceal system are common gastritis diet oatmeal cookies purchase florinef paypal, representing approximately 4% of the population gastritis diet book purchase florinef with a visa. The renal pelvis may be completely intrarenal chronic gastritis recovery time cheap florinef master card, completely extrarenal, or a combination of both (Friedenberg and Dunbar, 1990). The infundibula insert directly into the extrarenal pelvis, giving the impression of a dilated pelvis. Receiving the tip of renal papilla, the renal calyx is a concave structure with two side projections, the fornices, which surround the papilla of the renal medulla. Multiple single calyces fail to divide completely, forming a larger compound calyx that normally can be observed in the upper and lower poles of the kidneys. Each kidney contains an average of 7 to 9 calyces, although this number may vary considerably from 4 to 19 or even more. Megacalycosis represents a nonobstructive asymptomatic congenital dilatation of some or all renal calyces while the renal pelvis and ureter are normal. It involves all calyces uniformly and usually is associated with a greater number of calyces than normal. Calyceal diverticula represent a focal extrinsic dilatation of a renal calyx that is connected to the calyceal fornix and projects into the renal cortex, not into the medulla. The renoureteral unit may show duplication anomalies, including a bifid renal pelvis and complete or incomplete ureteral duplication. Two separate pyelocalyceal collecting systems may be present in one kidney, ranging from a bifid pelvis to a bifid ureter (ureteropelvic duplication). In the retroperitoneum, the ureter is situated just lateral to the tips of the transverse processes of the lumbar vertebrae. The ureters occupy a sagittal plane that intersects the tips of the transverse processes of these lumbar vertebrae. The ureter is arbitrarily divided into proximal (upper), middle (over the sacrum), and distal (lower) segments. However, according to international anatomic terminology the ureter consists of abdominal (from renal pelvis to iliac Chapter42 Surgical,Radiologic,andEndoscopicAnatomyoftheKidneyandUreter 975 vessels), pelvic (from iliac vessels to the bladder), and intramural segments. The abdominal parts of the ureters are adherent to the retroperitoneum throughout their entire course and extend from the renal pelvis to the pelvic brim. From the back, the surface anatomy of the ureter corresponds to a line joining a point 5 cm lateral to the L1 spinous process and the posterior superior iliac spine. Posteriorly, both ureters descend anterior to the psoas major muscle and then cross the ventral surface of transverse processes of the 3rd to 5th lumbar vertebrae and enter the pelvis at the bifurcation of the common iliac vessels. The bifurcation of the common iliac vessels is used intraoperatively as a landmark to look for the ureter. The right ureter begins behind the descending part of the duodenum, where it is crossed by the gonadal vessels (testicular or ovarian), which is called "water under the bridge. The gonadal vessels cross the left ureter after running parallel to it for a small distance. The inferior mesenteric artery and its terminal branch, the superior rectal artery, follow a curved course close to the left ureter. Therefore, as the left ureter approaches the pelvis, it is crossed by the left colic vessels, the sigmoid colon, and its mesocolon. Just above the entry to the pelvis, the ureter is still covered by peritoneum by virtue of the ureteral fold. This location at the pelvic brim represents one of the most common areas of ureteral injury. Furthermore, the close relationship of the ureter with the terminal ileum, appendix, right and left colons, and sigmoid colon makes it susceptible for encroachment of inflammatory and malignant processes, resulting in clinical presentations ranging from microhematuria to ureteral obstruction or even fistulae. The pelvic segment of the ureter is approximately 15 cm long-a half of its total length.
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