Migration of varicocele coil leading to ureteral obstruction and hydronephrosis:A case report

BACKGROUND Varicocele embolization,a minimally invasive treatment for symptomatic varicoceles,carries a rare risk of complications like ureteral obstruction and hydronephrosis.This case report documents such a case to raise awareness of these potential complications and showcase minimally invasive surgical management as a successful solution.CASE SUMMARY A 35-year-old male presented with flank pain and hematuria following varicocele embolization.Imaging confirmed left ureteral obstruction and hydronephrosis.Laparoscopic ureterolysis successfully removed the embolization coil and repaired the ureter,resolving the patient's symptoms.Follow-up at six months and two years showed sustained improvement.CONCLUSION Minimally invasive surgery offers an effective treatment option for rare complications like ureteral obstruction arising from varicocele embolization.

Stents for malignant ureteral obstruction

Malignant ureteral obstruction can result in renal dysfunction or urosepsis and can limit the physician’s ability to treat the underlying cancer.There are multiple methods to deal with ureteral obstruction including regular polymeric double J stents(DJS),tandem DJS,nephrostomy tubes,and then more specialized products such as solid metal stents(e.g.,Resonance Stent,Cook Medical)and polyurethane stents reinforced with nickel-titanium(e.g.,UVENTA stents,TaeWoong Medical).In patients who require long-term stenting,a nephrostomy tube could be transformed subcutaneously into an extra-anatomic stent that is then inserted into the bladder subcutaneously.We outline the most recent developments published since 2012 and report on identifiable risk factors that predict for failure of urinary drainage.These failures are typically a sign of cancer progression and the natural history of the disease rather than the individual type of drainage device.Factors that were identified to predict drainage failure included low serum albumin,bilateral hydronephrosis,elevated C-reactive protein,and the presence of pleural effusion.Head-to-head studies show that metal stents are superior to polymeric DJS in terms of maintaining patency.Discussions with the patient should take into consideration the frequency that exchanges will be needed,the need for externalized hardware(with nephrostomy tubes),or severe urinary symptoms in the case of internal DJS.This review will highlight the current state of diversions in the setting of malignant ureteral obstruction.

Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction after failed endoscopic intervention:A technical report

Objective:Complex ureteral obstruction is refractory to conventional urological intervention.This report describes a case of laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy for treating complex ureteral obstruction.Methods:Right-side multiple ureteral stones and complicating ureteral obstruction failed an initial attempt of ureteroscopy lithotripsy with simultaneous percutaneous nephroscopy in a 23-year-old male.Laparoscopic ureterolysis with ureteroscopy and percutaneous nephroscopy was used simultaneously to dissect the periureteral adhesions with the patient placed in the Galdakao-modified supine Valdivia position.The ureter was incised to allow the insertion of a ureteral catheter through the twisted ureter,and a guide wire was advanced into the pelvis using ureteroscopy.A double-J stent was placed into the right-side ureter using antegrade percutaneous nephroscopy.Results:The laparoendoscopic procedure lasted 330 min with an estimated bleeding volume of 100 mL.The patient underwent an uneventful postoperative course,and postoperative followup radiography confirmed good positioning of the double-J stent.The double-J stent was removed 3 months after operation.The patient remained asymptomatic within a 13-month follow-up period.Conclusion:Laparoscopic ureterolysis with simultaneous ureteroscopy and percutaneous nephroscopy is an effective and safe treatment option for complex ureteral obstruction.

Acute kidney injury due to bilateral malignant ureteral obstruction:Is there an optimal mode of drainage?

There is a well-known relationship between malignancy and impairment of kidney functions,either in the form of acute kidney injury or chronic kidney disease.In the former,however,bilateral malignant ureteral obstruction is a surgically correctable factor of this complex pathology.It warrants urgent drainage of the kidneys in emergency settings.However,there are multiple controversies and debates about the optimal mode of drainage of the bilaterally obstructed kidneys in these patients.This review addressed most of the concerns and provided a comprehensive presentation of this topic from the recent literature.Also,we provided different perspectives on the management of the bilateral obstructed kidneys due to malignancy.Despite the frequent trials for improving the success rates and functions of ureteral stents,placement of a percutaneous nephrostomy tube remains the most recommended tool of drainage due to bilateral ureteral obstruction,especially in patients with advanced malignancy.However,the disturbance of the quality of life of those patients remains a major unresolved concern.Beside the unfavorable prognostic potential of the underlying malignancy and the various risk stratification models that have been proposed,the response of the kidney to initial drainage can be anticipated and evaluated by multiple renal prognostic factors,including increased urine output,serum creatinine trajectory,and time-to-nadir serum creatinine after drainage.

Peroxisome Proliferator-activated Receptor-γ Agonist Pioglitazone Fails to Attenuate Renal Fibrosis Caused by Unilateral Ureteral Obstruction in Mice

Renal tubulointerstitial fibrosis is the common ending of progressive renal disease. It is worth developing new ways to stop the progress of renal fibrosis. Peroxisome proliferator-activated receptor-γ（PPARγ） agonists have been studied to treat diabetic nephropathy, cisplatin-induced acute renal injury, ischemia reperfusion injury and adriamycin nephropathy. In this study, unilateral ureteral obstruction（UUO） was used to establish a different renal fibrosis model. PPARγ agonist pioglitazone was administrated by oral gavage and saline was used as control. At 7th and 14 th day after the operation, mice were sacrificed for fibrosis test and T lymphocytes subsets test. Unexpectedly, through MASSON staining, immunohistochemistry for α-SMA, and Western blotting for α-SMA and PDGFR-β, we found that pioglitazone failed to attenuate renal fibrosis in UUO mice. However, flow cytometry showed that pioglitazone down-regulated Th1 cells, and up-regulated Th2 cells, Th17 cells and Treg cells. But the Th17/Treg ratio had no significant change by pioglitazone. Real-time PCR results showed that TGF-β and MCP-1 had no significant changes, at the same time, CD4＋ T cells associated cytokines were partially regulated by pioglitazone pretreatment. Taken together, pioglitazone failed to suppress renal fibrosis progression caused by UUO.

Huoxue Jiedu Huayu recipe(活血解毒化瘀方)alleviates contralateral renal fibrosis in unilateral ureteral obstruction rats by inhibiting the transformation of macrophages to myofibroblast

OBJECTIVE:To investigate the action and underlying mechanisms of Huoxue Jiedu Huayu recipe(活血解毒化瘀方,HJHR)against unilateral ureteral obstruction(UUO)-induced injury in the contralateral kidney.METHODS:Forty-eight male Sprague-Dawley rats weighing(200±10)g were used in this study and randomly assigned to 4 groups:a sham group,a UUO group,a UUO+eplerenone(EPL)group,and a UUO+HJHR group.The contralateral kidneys were harvested for further study 180 d after surgery.Histological analysis,immunohistochemistry and immunofluorescence were used to study the fibrosis of the contralateral kidneys obtained from UUO rats.Contralateral kidney damagerelated pathway proteins were detected by real-time polymerase chain reaction and Western blot analysis.RESULTS:HJHR significantly inhibited fibrosis of the contralateral kidney in UUO rats by attenuating the UUOinduced macrophage-to-myofibroblast transition(MMT)in the contralateral kidney.Moreover,HJHR attenuated fibrosis in the contralateral kidney of UUO rats by preventing MMT through the aldosterone/mineralocorticoid receptor/serum/glucocorticoid regulated kinase 1 pathway.CONCLUSIONS:Our findings suggest that HJHR may be a potential treatment for renal interstitial fibrosis of obstructive nephropathy.

Ginsenoside Rb1,a Panoxadiol Saponin against Oxidative Damage and Renal Interstitial Fibrosis in Rats with Unilateral Ureteral Obstruction

Objective:To investigate the possible protective effect and mechanism of ginsenoside Rb1 against oxidative damage and renal interstitial fibrosis on rats with unilateral ureteral obstruction(UUO). Methods:In total,80 male rats were randomly divided into 4 groups,20 in each group:the sham operated group (SOR),UUO group,UUO with ginsenoside Rb1 treatment group(treated with intraperitoneal injection of 50 mg/ kg daily) and UUO with Losartan treatment group(as the positive control,treated with 20 mg/kg by gastr...

Arterially transplanted mesenchymal stem cells in a mouse reversible unilateral ureteral obstruction model： in vivo bioluminescence imaging and effects on renal fibrosis

Background Chronic kidney disease （CDK） is a worldwide health problem, but there is currently no effective treatment that can completely cure this disease. Recently, studies with mesenchymal stem cells （MSCs） on treating various renal diseases have shown breakthroughs. This study is to observe the homing features of MSCs transplanted via kidney artery and effects on renal fibrosis in a reversible unilateral ureteral obstruction （R-UUO） model. Methods Thirty-six Balb/c mice were divided into UUO group, UUO-MSC group, and sham group randomly, with 12 mice in each group. The MSCs had been infected by a lentiviral vector to express stably the luciferase reporter gene and green fluorescence protein genes （Luc-GFP-MSC）. Homing of MSCs was tracked using in vivo imaging system （IVIS） 1, 3, 14, and 28 days after transplantation. Imaging results were verified by detecting GFP expression in frozen section under a fluorescence microscope. E-cadherin, α-SMA, TGF-β1, and TNF-α mRNA expression in all groups at 1 and 4 weeks after transplantation were analyzed by quantitative PCR. Results Transplanted Luc-GFP-MSCs showed increased Luciferase expression 3 days after transplantation. The expression decreased from 7 days, weakened thereafter and could not be detected 14 days after transplantation. Quantitative PCR results showed that all gene expressions in UUO group and UUO-MSC group at 1 week had no statistical difference, while at 4 weeks, except TGF-β expression （P〉0.05）, the expression of E-cadherin, α-SMA, and TNF-α in the above two groups have statistical difference （P〈0.01）. Conclusion IVIS enables fast, noninvasive, and intuitive tracking of MSC homing in vivo. MSCs can be taken home to kidney tissues of the diseased side in R-UUO model, and renal interstitial fibrosis can be improved as well.

Ureteral reconstruction with decellularized small intestinal submucosa matrix for ureteral stricture: A preliminary report of two cases

Objective:To determine the feasibility of decellularized small intestinal submu-cosa(5IS)matrix in repairing ureteral strictures.Methods:Two patients with ureteral stenoses underwent ureteral reconstruction with SIS ma-trix at the Zhejiang Provincial Corps Hospital of Chinese People's Armed Forces between June 2014 and June 2016.The ureteral stenoses were repaired with a semi-tubular SIS matrix and the postoperative recoveries were observed.Results:Both operations were successfully completed.The average operative time was 90 min and the average length of hospital stay was 15 days.No fevers,incision infections,intestinal obstruction,graft rejection,or other serious complications were noted.After 2 months,ure-teroscopic examinations showed that the surfaces of the original patches were covered by mu-Cosa and there were no apparent stenoses in the lumens.The ureteral stents were replaced every 2 months postoperatively and removed 12 months postoperatively.No infections or uri-nary leakage occurred after removal of the stents.Intravenous urography was performed 6 and 12 months postoperatively.The results showed that the ureters were not obstructed and there was no apparent stenosis at the anastomosis sites.The average follow-up time was>12 months.Long-term follow-up is still ongoing,and computed tomography examin ations of the urinary tract have been conducted in the outpatient department of our hospital 1,3,and 6 months after removal of the double-J stents,suggesting the absence of hydronephrosis.The serum creatinine levels remained stable during the follow-up.Conclusion:SIS matrix reconstruction is a feasible method to repair ureters stenosis.

Diagnosis and management of ureteral complications following renal transplantation

When compared with maintenance dialysis,renal transplantation affords patients with end-stage renal disease better long-term survival and a better quality of life.Approximately 9% of patients will develop a major urologic complication following kidney transplantation.Ureteral complications are most common and include obstruction(intrinsic and extrinsic),urine leak and vesicoureteral reflux.Ureterovesical anastomotic strictures result from technical error or ureteral ischemia.Balloon dilation or endoureterotomy may be considered for short,low-grade strictures,but open reconstruction is associated with higher success rates.Urine leak usually occurs in the early postoperative period.Nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression(nephrostomy tube,ureteral stent,and indwelling bladder catheter).Proximal,large-volume,or leaks that persist despite urinary diversion,require open repair.Vesicoureteral reflux is common following transplantation.Patients with recurrent pyelonephritis despite antimicrobial prophylaxis require surgical treatment.Deflux injection may be considered in recipients with low-grade disease.Grade IV and V reflux are best managed with open reconstruction.

Metallic ureteral stent in restoring kidney function: Nine case reports

BACKGROUND Retroperitoneal fibrosis is an exceptionally rare disease characterized by proliferation of fibrous tissue and inflammation in the retroperitoneum.It features many symptoms in the kidneys and in other organs and usually leads to ureteral obstruction.CASE SUMMARY Here we present 9 consecutive cases of idiopathic retroperitoneal fibrosis(IRPF)in patients who presented to the Department of Nephrology or Department of Rheumatology,Xuanwu Hospital,Capital Medical University,Beijing,China,between January 2012 and June 2017 with ureteral obstruction due to external compression of the ureter that led to hydronephrosis and kidney dysfunction.Computed tomography imaging was used to identify hydronephrosis and ureteral obstruction and to evaluate kidney function.Each patient was diagnosed with IRPF based on clinical observation and computed tomography examination results.To restore kidney function,a retrograde metallic stent was placed in the ureter under X-ray guidance 2 d after each patient’s admission.No perioperative complications occurred in any patient,but postoperative complications occurred in two patients as follows:Patient 2 had stent migration and repeated metallic stent infections that resolved with treatment;and patient 4 had postoperative hematuria because he resumed normal activities too soon after stent placement(contrary to instruction).Placement of the metallic ureteral stents provided relief from ureteral obstruction and restored kidney function in all patients.CONCLUSION Our 9-case series underscores the utility and efficacy of applying the Resonance®metallic ureteral stent to treat ureteral obstruction in patients with IRPF.For all retroperitoneal fibrosis cases in our series,ureteral stents provided effective relief and were shown to reduce the incidence rate of perioperative and postoperative complications.

CTRP1 Attenuates UUO-induced Renal Fibrosis via AMPK/NOX4 Pathway in Mice

Clq/TNF-related protein 1(CTRP1),a conserved protein of the Clq family,plays a key role in cardiovascular and metabolic diseases.However,the role of CTRP1 in renal injury is unclear.The purpose of this study is to explore the role of CTRP1 in unilateral ureteral obstruction(UUO)-induced renal fibrosis and to elucidate the underlying mechanism.Using gene delivery system,CTRP1 was overexpressed in the kidney,then the mice were operated to induce UUO model after adenovirus transfection.It was found that the expression of CTRP1 in the renal tissue was decreased in mice after UUO.CTRP1 overexpression decreased the kidney function and kidney weight index.Moreover,CTRP1 reduced oxidative stress and renal collagen deposition in vivo.As expected,we found that CTRP1 activated AMP-activated kinase(AMPK)and decreased NOX4 expression,while silencing AMPKal abolished the protective effects of CTRP1 overexpression in mice after UUO.In conclusion,CTRP1 may protect against UUO-induced renal injury via AMPK/NOX4 signaling.Our results indicate that CTRP1 exhibits potential effects to treat renal fibrosis caused by UUO.

Trabecular bone deterioration at the greater trochanter ol mice with unilateral obstructive nephropathy

Our previous study showed the early molecular responses of bone in response to obstructive nephropathy in a unilateral ureteral obstruction （UUO） mouse model. Here, we addressed the changes in trabecular bone properties at greater trochanter, the proximal and the distal metaphysis of femur in UUO mice. The male mice were subjected to UUO （n= 10） or sham operation （n= 10）. All mice were killed on day 7 after the surgical operation. The micro-computed tomography （micro-CT） analysis for different femoral trabecular bone sites demonstrated pathological alterations of trabecular bone mass and micro-networks at greater trochanter as shown by decreases in bone mineral density/bone volume （P〈O.05） and trabecular number （P〈O.05） and increases in trabecular separation （P〈O.01） and bone surface/bone volume （P〈O.05） in UUO mice. The present study demonstrates that UUO-induced unilateral obstructivenephropathy has markedly detrimental effects on the trabecular trochanter of the femur.

Renovascular Morphological Changes in a Rabbit Model of Hydronephrosis

Obstructive nephropathy ultimately leads to end-stage renal failure. Renovascular lesions are involved in various nephropathies, and most renal diseases have an ischemic component that underlies the resulting renal fibrosis. The aim of this study was to investigate whether morphological changes occur in the renal vasculature in hydronephrosis and the possible mechanisms involved. A model of complete unilateral ureteral obstruction（CUUO） was used. Experimental animals were divided into five groups： a normal control group（N） and groups of animals at 1st week（O1）, 2nd week（O2）, 4th week（O4） and 8th week（O8） after CUUO. Blood pressure was measured, renal arterial trees and glomeruli were assessed quantitatively, and renovascular three-dimensional reconstruction was performed on all groups. Glomerular ultrastructural changes were examined by transmission electron microscopy. The results showed that the systolic blood pressure was significantly increased in the obstructed groups（O1, O2, O4 and O8）. Three-dimensional reconstruction showed sparse arterial trees in the O8 group, and a tortuous and sometimes ruptured glomerular basement membrane was found in the O4 and O8 groups. Furthermore, epithelial media thickness and media/lumen ratio were increased, lumen diameters were decreased, and the cross-sectional area of the media was unaltered in the segmental renal artery, interlobar artery and afferent arterioles, respectively. In conclusion, renal arterial trees and glomeruli were dramatically altered following CUUO and the changes may be partially ascribed to vascular remodeling. Elucidation of the molecular mechanisms of renovascular morphological alterations will enable the development of potential therapeutic approaches for hydronephrosis.

Role of Protease Activated Receptor-2 Expression in Renal Interstitial Fibrosis Model in Mice

Summary： The role of protease activated receptor-2 （PAR-2） in the renal tubulointerstitial lesion induced by unilateral ureteral obstruction （UUO） was explored. Mice were sacrificed on the day 1, 3, 5, 7, 10, 14 and 21 after UUO. The expression of PAR-2 mRNA and protein and a-smooth muscle actin （α-SMA） protein in tubuloin,terstitium was detected by RT-PCR and immunohistochemistry at each time point, respedtively. The results showed that the PAR-2 expression in renal tubulointerstitium was increased progressively starting from 24 h to the day 14 post-ligation, and it was significantly associated with the relative volume of interstitium and the positive area of α-SMA. PAR-2 was mainly expressed in renal tubule epithelial cells, especially in proximal tubular cells. It also located in renal capillary ansa, interstitial infiltrate cells and fibroblasts. It was concluded that PAR-2 was active in interstitial and tubular cells in the early phase of fibrotic process and played an important role in mediating the tubulointerstitial lesion after UUO.

Yishen Huoxue decoction(益肾活血方) attenuates unilateral ureteric obstruction-induced renal fibrosis and hypoxia-induced reactive oxygen species generation via adenosine monophosphate-activated protein kinase/peroxisome proliferator-activated receptor coa

OBJECTIVE:To investigate the effeicacy of Yishen Huoxue decoction(YSHX)on renal fibrosis induced by unilateral ureteric obstruction(UUO),and on reactive oxygen species(ROS)homeostasis in human umbilical vein endothelial cells(HUVECs).METHODS:Forty male mice were randomly divided into six groups,sham group,UUO group,UUO+resveratrol(RSV)(15 mg/kg)group,UUO+YSHX20 mg/kg group(UUO+YSHX-L),UUO+YSHX 40 mg/kg group(UUO+YSHX-M),UUO+YSHX 80 mg/kg group(UUO+YSHX-H).Western blotting was used to measure protein expression levels.Reverse transcription-quantitative polymerase chain reaction was used to measure the m RNA expression.Immunohistochemistry was used to examine the histopathological changes of kidney tissue sample.Cell apoptosis was measured by Annexin V/PI staining.Cell viability was measured using CCK-8/WST-8 assay.RESULTS:YSHX treatment reducedα-SMA and Col-4 expressions,and increased CD31 and VE-cadherin expressions in UUO model mice.In vitro,YSHX increased cell viability and decreased apoptosis of HUVECs under hypoxic conditions.YSHX inhibited ROS generation by activating adenosine monophosphate-activated protein kinase(AMPK)/peroxisome proliferator-activated receptor coactivator-1α(PGC-1α)/silent mating-type information regulation2 homolog 3(Sirt3)signaling.CONCLUSION:YSHX treatment reduced 109 KJ UUO-induced renal injury and fibrosis.Furthermore,YSHX treatment attenuated hypoxia-induced oxidative stress by regulating AMPK/PGC-1α/Sirt3 signaling.

MHC class Ⅱ in renal tubules plays an essential role in renal fibrosis

Immunomodulation has been considered a potential therapeutic approach for chronic kidney disease(CKD).Although it has been previously reported that CD4+T cells contribute to the development of renal fibrosis after UUO,the role of MHC class Ⅱ(MHCII)in UUO-induced renal fibrosis remains largely uncharacterized.The present study reports that the expressions of MHCII molecules in renal cortical tubules are upregulated in a mouse unilateral ureter obstruction(UUO)model.Global or renal tubule-specific ablation of MHCII significantly alleviates renal fibrosis following UUO.Additionally,renal expression of profibrotic genes showcased consistent reduction in both MHCII gene deficient mouse lines.These results demonstrate that renal tubular MHCII plays an important role in pathogenesis of renal fibrosis.