Richstone, Lee

Ureteroarterial fistulas (UAFs) are defined as an abnormal communication between one of the major arteries and the ureter. Urologists most frequently encounter iatrogenic fistulas occurring in patients with a history of pelvic extirpative surgery, chronic ureteral catheterization, and history of pelvic radiation. We present two cases of UAFs in patients with no history of prior radiation, who underwent open radical cystectomy and robot-assisted radical cystectomy with intracorporeal ileal conduit. Both patients developed postoperative ureteroileal anastomotic leaks that were managed with indwelling ureteral catheters. Furthermore, both patients were having left-sided UAF after presenting with nonlife threatening gross hematuria, which became brisk and pulsatile during ureteral stent exchange. Endovascular stenting was performed in both patients with resolution of hemorrhage and full recovery. In one patient, nephrostomy tubes were placed and ureteral catheters were removed; the second patient was managed with continued ureteral catheterization without further episodes of hematuria.

Objective To evaluate whether elective off‐clamp laparoscopic partial nephrectomy ( LPN ) affords long‐term renal functional benefit compared with the on‐clamp approach. Patients and Methods This is a retrospective review of patients who underwent elective LPN between 2006 and 2011. Patients were followed longitudinally for up to 5 years. In all, 315 patients with radiographic evidence of a solitary renal mass and normal‐appearing contralateral kidney underwent elective LPN ; 209 were performed on‐clamp vs 106 off‐clamp. One patient who required conversion from LPN to open PN was excluded from the study. Additionally, four patients in the on‐clamp cohort who underwent subsequent radical nephrectomy for local‐regional recurrence were excluded from longitudinal functional evaluation after their procedure. The primary objective was to evaluate differences in postoperative estimated glomerular filtration rate ( eGFR ) between hilar clamping groups. Subgroup analyses were performed for patients with clamp times >30 min and those with baseline renal insufficiency ( eGFR <60 mL/min/1.73m 2 ). Risk of developing worsened or new‐onset renal insufficiency was also compared. Results The mean preoperative eGFR was similar between the on‐clamp and off‐clamp cohorts (80.7 vs 84.1 mL/min/1.73m 2 , P > 0.05). Univariable and multivariable analyses did not show significant differences in postoperative eGFR between both groups among all‐comers, those with clamp times >30 min, and patients with baseline renal insufficiency. Risk of chronic kidney disease was not diminished by the off‐clamp approach with up to 5 years of follow‐up. Conclusions Progressive recovery of renal function after hilar clamping in the elective setting eclipses short‐term functional benefit achieved with off‐clamp LPN by 6 months; there was no significant difference in eGFR or the percentage incidence of chronic kidney disease between the on‐clamp and off‐clamp cohorts with up to 5 years follow‐up. As such, eliminating transient ischaemia during elective LPN does not confer clinical benefit.