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Using a four-port transperitoneal approach prostate 28 discount 5 mg proscar mastercard, a wide-base renal pelvic flap was created and tubularized to bridge the defect, using intracorporeal freehand suturing techniques. At a 2-month follow-up, excretory urography and diuretic renal scan confirmed a widely patent upper ureter. Rather than performing tedious anatomic dissection and complex ureteral reconstruction in such a scenario as required in conventional laparoscopic pyeloplasty, a nephrotomy was created at the most dependent portion of the hydronephrotic lower pole moiety and then laparoscopically anastomosed to the bladder dome vesicostomy using intracorporeal freehand suturing and knottying techniques. At the 4-month follow-up, patent calicovesicostomy was confirmed endoscopically and clinically. These variations in many cases may be performed through either open or minimally invasive approaches, depending on the skill level of the surgeon. Like other flap techniques, however, its use has generally been replaced by the more versatile dismembered pyeloplasty. As in other flap techniques, the Foley Y-V-plasty is specifically contraindicated when transposition of lower pole vessels is necessary. In situations requiring concomitant reduction of redundant renal pelvis, this technique is also of little value. In Foley Y-V-plasty, the renal pelvis and proximal ureter are first exposed, and a widely based triangular or V-shaped flap is outlined with methylene blue or fine stay sutures. The incision from the apex of the flap (the stem of the Y) is then performed along the lateral aspect of the proximal ureter. First, the apex of the pelvic flap is approximated to the apex (inferior aspect) of the ureterotomy incision using fine, absorbable suture. Interrupted technique is likely to minimize pursing or buckling of the suture line, as well as local tissue ischemia. The Culp-DeWeerd spiral flap is generally best suited for large, readily accessible extrarenal pelves, in which the ureteral insertion is already in a dependent, oblique position. Retroperitoneal laparoscopic approach and anterior extraperitoneal approach rely on creation of a working space using manual or balloon dilation. The incision from the apex of the flap, which represents the stem of the Y, is then carried along the lateral aspect of the proximal ureter well into an area of normal caliber. The apex of the pelvic flap is then brought to the most inferior aspect of the ureterotomy incision. The spiral flap is outlined with the base situated obliquely on the dependent aspect of the renal pelvis. The anatomically medial line of incision is carried down completely through the obstructed proximal ureteral segment into normal-caliber ureter.

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Hyperuricosuria has been postulated to increase urinary levels of monosodium urate prostate jewelry order proscar 5 mg, which in turn promotes calcium oxalate crystallization through heterogeneous nucleation, or epitaxial crystal growth (Coe et al. In addition, the colloidal form of sodium urate has been shown to adsorb naturally occurring macromolecular inhibitors of crystallization, thereby reducing their effectiveness and promoting nucleation of calcium oxalate (Pak et al. However, the mechanism of action of allopurinol in reducing stone recurrence rates cannot be definitively attributed to its effect in reducing urinary uric acid. Solution phase Salting out Hypocitraturia Hypocitraturia is an important and correctable abnormality associated with nephrolithiasis that exists as an isolated abnormality in up to 10% of calcium stone formers and is associated with other abnormalities in 20% to 60% of stone formers (Levy et al. Citrate is an important inhibitor that can reduce calcium stone formation by several mechanisms. First, citrate reduces urinary saturation of calcium salts by complexing with calcium (Pak et al. Second, citrate directly prevents spontaneous nucleation of calcium oxalate (Sakhaee et al. Third, citrate inhibits agglomeration and sedimentation of calcium oxalate crystals (Kok et al. Finally, normal urinary citrate levels can enhance the inhibitory effect of Tamm-Horsfall glycoprotein (Hess et al. Metabolic acidosis reduces urinary citrate levels secondary to enhanced renal tubular reabsorption and decreased synthesis of citrate in peritubular cells (Hamm, 1990). A study comparing normal subjects and stone formers noted comparable mean serum citrate levels and filtered citrate loads in the two groups; however, 24-hour urinary citrate and the fasting citrate-to-creatinine ratio were significantly reduced and mean tubular reabsorption of citrate was significantly increased in the stone formers compared with control subjects (Minisola et al. Indirect evidence for a primarily renal cause of hypocitraturia comes from a study comparing intestinal absorption of citrate in idiopathic hypocitraturic stone formers and normal subjects (Fegan et al. Oral ingestion of citrate was followed by rapid and efficient absorption in both groups, with 96% to 98% absorbed within 3 hours. As such, hypocitraturia is unlikely to arise from impaired gastrointestinal absorption of citrate in stone formers without overt bowel disease. Low urinary citrate results from a variety of pathologic states associated with acidosis. Chronic diarrheal states cause intestinal alkali loss in the stool with subsequent systemic acidosis and hypocitraturia (Rudman et al. Excessive animal protein intake can provide an acid load, reducing citrate levels (Breslau et al. Indeed, a metabolic study evaluating the effect of a high-protein, low-carbohydrate diet demonstrated a significant reduction in urinary citrate and pH, likely as a result of low citrus and high animal protein intake (Reddy et al. Diuretics such as thiazides induce hypokalemia and intracellular acidosis (Nicar et al. Angiotensin-converting enzymes can cause hypocitraturia independently of systemic acidosis or hypokalemia, perhaps as a result of intracellular acidosis (Melnick et al. However, hypocitraturia may also represent an isolated abnormality unrelated to an acidotic state.

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The effect of common urinary pathogens and endotoxin in an in vitro system prostate cancer vitamin d 5 mg proscar purchase otc, J Urol 108:700, 1972. Klaus E, Englert H, Hropot M, et al: Inhibition of the rhythmic contractions of ureters by K+ channel openers, Naunyn Schmiedebergs Arch Pharmacol 340:R59, 1989. Kobayashi M, Irisawa H: Effect of sodium deficiency on the action potential of the smooth muscle of ureter, Am J Physiol 206:205, 1964. Kobayashi M: Conduction velocity in various regions of the ureter, Tohoku J Exp Med 83:220, 1964. Hernández M, Prieto D, Simonsen U, et al: Noradrenaline modulates smooth muscle activity of the isolated intravesical ureter of the pig through different types of adrenoceptors, Br J Pharmacol 107:924, 1992. Hernández M, Simonsen U, Prieto D, et al: Different muscarinic receptor subtypes mediating the phasic activity and basal tone of pig isolated intravesical ureter, Br J Pharmacol 110:1413, 1993. Hertle L, Nawrath H: Calcium channel blockade in smooth muscle of the upper urinary tract. Hertle L, Nawrath H: Stimulation of voltage-dependent contractions by calcium channel activator Bay K 8644 in the human urinary tract in vitro, J Urol 141:1014, 1989. Holmlund D, Hassler O: A method of studying the ureteral reaction to artificial concrements, Acta Chir Scand 130:335, 1965. Hosgor M, Karaca I, Ulukus C, et al: Structural changes of smooth muscle in congenital ureteropelvic junction obstruction, J Pediatr Surg 40:1632, 2005. Hou T, Yang X, Hai B, et al: Aberrant differentiation of urothelial cells in patients with ureteropelvic junction obstruction, Int J Clin Exp Pathol 9:5837, 2014. Hua X-Y, Theodorsson-Norheim E, Brodin E, et al: Multiple tachykinins (neurokinin A, neuropeptide K and substance P) in capsaicin-sensitive sensory neurons in the guinea pig, Regul Pept 13:1, 1985. Ichikawa S, Ikeda O: Recovery curve and conduction of action potentials in the ureter of the guinea pig, Jpn J Physiol 10:1, 1960. Imaizumi Y, Muraki K, Takeda M, et al: Characteristics of transient outward currents in single smooth muscle cells from the ureter of the guinea pig, J Physiol 427:301, 1990. Imaizumi Y, Muraki K, Watanabe M: Ionic currents in single smooth muscle cells from the ureter of the guinea pig, J Physiol 411:131, 1989. Kobayashi M: Effects of Na and Ca on the generation and conduction of excitation in the ureter, Am J Physiol 208:715, 1965. Kobayashi S, Tomiyama Y, Hoyano Y, et al: Gene expressions and mechanical functions of 1 adrenoceptor subtypes in mouse ureter, World J Urol 27:775, 2009a. Kobayashi S, Tomiyama Y, Hoyano Y, et al: Mechanical function and gene expression of 1 adrenoceptor subtypes in dog intravesical ureter, Urology 74:458, 2009b. Kobayashi S, Tomiyama Y, Maruyama K, et al: Effect of four different alpha (1)-adrenoeptor antagonists on alpha-adrenoceptor agonist-induced contractions in isolated mouse and hamster ureters, J Smooth Muscle Res 45:187, 2009c. Kondo S, Latifpour J, Morita T, et al: Characterization of beta-adrenergic receptor subtypes of the upper and lower renal pelvis in rabbits, J Urol 142:1099, 1989. Kontani H, Ginkawa M, Sakai T: A simple method for measurement of ureteric peristaltic function in vivo and the effects of drugs acting on ion channels applied from the ureter lumen in anesthetized rats, Jpn J Pharmacol 62:331, 1993.

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Domenik, 65 years: Di Silverio F, Gallucci M, Alpi G: Staghorn calculi of the kidney: classification and therapy, Br J Urol 65:449­452, 1990. During cystectomy with lymph node dissection, care must be taken to avoid injury to the graft vessels or blood supply to the ureter or the ureter itself (Demirdag et al.

Innostian, 64 years: There are at least five different techniques described for distal ureterectomy, and most of these apply to open and laparoscopic surgery. On the superior aspect of the corpora cavernosa, the deep dorsal vein, paired dorsal arteries, and multiple branches of the dorsal nerves are contained within the envelope of Buck fascia.

Miguel, 61 years: Therefore, a mainstay of conservative management for kidney stone prevention is increased fluid intake to achieve a urine output of at least 2. At the present time, vein "grafts" are being widely used for replacement of defects of the tunica albuginea of the corpora cavernosa.