Chronic renal infarct simulating renal mass: diagnostic challenge

A 36-year-old male presented with symptomatic left renal mass simulating renal cell carcinoma. He underwent left radical nephrectomy and histopathology revealed chronic renal infarct with calcifications. The case description warrants the inclusion of focal chronic renal infarcts in the differential diagnosis of renal masses, especially following history of previous trauma.

Primary small cell neuroendocrine carcinoma of urinary bladder: an uncommon entity to be recognized

INTRODUCTION

To describe the clinical presentation, diagnosis and treatment outcome of neuroendocrine carcinoma of urinary bladder.

METHODS

Clinical and pathological findings of 11 patients with diagnosis of small cell neuroendocrine tumour (SCNE) of urinary bladder are reviewed between Jan. 1991 to Jan 2001. Clinical data including age, sex, presenting symptoms, clinical stage at presentation, modality of treatment and outcome were determined. Sections of the tumour were studied by immunohistochemical methods using various antibodies to determine neuroendocrine pattern.

RESULTS

Patient age ranged from 35 to 79 years (mean 60 years). The clinical presentation included, gross hematuria 6, increased urinary frequency and dysuria 3, hydroureteronephrosis with flank pain 2. 3 patients had open exploration for presumed bladder stones by suprapubic route. Undifferentiated carcinoma was the initial report in 2 and associated transitional cell carcinoma in 2 cases. Urinary cytology obtained in 4 patients showed poorly differentiated carcinoma. Immunohistochemistry showed in all cases. 7 patients had radical cystoprostatectomy with adjuvant chemotherapy and 4 patients had combination of chemotherapy and radiotherapy. The survival ranged from 6 months to 30 months (mean 16.5 months).

CONCLUSION

Primary small cell neuroendocrine carcinoma of urinary bladder is an aggressive malignancy with poor long-term outcome. Awareness of clinical presentation with free application of immunocytochemistry is emphasized to diagnose this unusual malignancy at earliest.

Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms

A 70-year old female patient presented with intractable lower abdominal pain and recurrent urinary tract infection following an endoscopic bladder neck suspension. Investigations revealed it to be a case of suture and pledget migration leading to foreign body granuloma in urinary bladder. It is being reported as an uncommon complication of endoscopic bladder neck suspension. An early endoscopic evaluation should be carried out in cases of unexplained lower urinary tract symptoms following any surgical procedure for incontinence. It is also appropriate to retrieve these foreign bodies endourologically without resorting to open surgery and thus extending safe, comfortable, and short postoperative course with good long term results.

Colovesical fistula an unusual complication of cytotoxic therapy in a case of non-Hodgkin's lymphoma

A 65-year old man, a known case of non-Hodgkin's lymphoma of base of the tongue and epiglottis presented with complaints of pneumaturia and faecaluria. He had received the first cycle of cytotoxic therapy (CHOP-regimen). At the end of the cycle he developed febrile neutropenia (circulating granulocyte count <1500/mm3). Cystogram showed air in the bladder area and a fistulous communication to a cavity behind the bladder. CT-scan showed air in the bladder, a fistulous communication between the sigmoid colon and bladder along with an intervening small abscess cavity. On exploration a fistulous communication between the sigmoid and bladder along with an intervening small abscess cavity was found. Resection of involved portion of sigmoid and end to end anastomosis along with a diverting colostomy was done. The bladder was closed in two layers with an omental interposition between it and the sigmoid along with a suprapubic cystostomy. The histopathology demonstrated only inflammatory response without any evidence of malignancy or diverticular disease.

Is infundibuloureteropelvic angle (IUPA) a significant risk factor in formation of inferior calyceal calculi?

INTRODUCTION

Many studies confirm the fact that radiographic anatomy of inferior calyx has a significant role in the clearance of a stone lodged in it [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; BJU Int. 83 (Suppl) (1999) 24; J. Urol. 132 (1984) 1085]. Acutely angled and narrow infundibular neck of a inferior calyx has a poorer stone clearance in comparison to that with a less acute angled and wider infundibular neck [Br. J. Urol. 50 (1978) 449; Invest. Urol. 18 (2) (1980) 167; Br. J. Urol. 82 (1998) 12; BJU Int. 83 (Suppl) (1999) 24]. Incidence of bilateral stones in clinical practice is significantly less than unilateral stones. This study was taken up to define the significance of radiographic anatomy of the inferior calyx as a risk factor predisposing to stone formation in a patient and compared the anatomy of inferior calyx of the stone forming and contralateral kidney. The fact that inspite of the similar known etiological factors (intrinsic and extrinsic) of stone formation, why stone forms unilaterally?

MATERIAL AND METHODS

100 consecutive cases of non-obstructed unilateral inferior calyceal calculus with non-metabolically active stones were studied. The infundibuloureteropelvic angle (IUPA) and infundibular width of the stone forming and non-stone forming contralateral side were compared.

RESULTS

IUPA of stone forming side was more acute than the non-stone forming side, in 74% of the cases, more obtuse in 18% of the cases, and same in 8% of the cases. The difference in the IUPA of the stone forming and that of non-stone forming contralateral side was statistically significant (p<0.0002). The infundibular width of the stone forming side ranged from 1 to 16 mm and that of non-stone forming side from 2 to 11 mm. There was no statistically significant difference between the infundibular width of both the sides. Exactly, how and more importantly under what influences the macromolecules in the urine transforms into a calculus in the pelvicalyceal system is still not known till date but from our observations we conclude that IUPA is a significant risk factor which predisposes to calculus formation in inferior calyx.

CONCLUSION

IUPA is a significant risk factor, which predisposes to urolithiasis in inferior calyx.

Endoscopic management of post-traumatic prostatic and supraprostatic strictures using Neodymium-YAG laser

We assessed the feasibility, efficacy and long-term results of endoscopic management using Neodymium-YAG (Nd-YAG) laser as a day care procedure in patients with post-traumatic supraprostatic and prostatic strictures. Three patients with post-traumatic prostatic and supraprostatic obliterative strictures underwent Nd-YAG laser core through urethrotomy as a day care procedure. Patient age ranged between 12 and 14 years. Mean duration of injury was 16 months. The length of stricture was assessed by bi-directional endoscopy prior to the procedure in all cases. Core through procedure was carried out using Nd-YAG laser under the guidance of a cystoscope placed antegradely. Patients were discharged on the same day with urethral catheter. Foley catheters were removed at 6 weeks. Nd-YAG laser core through procedure was carried out successfully in all cases with negligible blood loss in a mean time of 48 min. There were no intraoperative or postoperative complications. Patients were discharged on the same day. Follow-up cystogram was conducted at 6 weeks and urethroscopy at months. At a mean follow-up of 23 months, patients were asymptomatic and voiding well. Nd-YAG laser core through urethrotomy is a safe and effective procedure. It is a less invasive alternative to more complex urethroplasty procedures for patients with post-traumatic prostatic and supraprostatic strictures. It can be carried out as a day care procedure in carefully selected patients and has no complications.

Laparoscopic radical cystectomy with intracorporeal ileal conduit diversion: five cases with a 2-year follow-up

OBJECTIVE

To assess the feasibility and intermediate-term outcome of laparoscopic radical cystectomy (LRC) with ileal conduit urinary diversion in patients with organ-confined muscle-invasive carcinoma of the urinary bladder, the entire procedure undertaken intracorporeally only using laparoscopic techniques.

PATIENTS AND METHODS

Five patients (four men and one woman) underwent LRC with intracorporeal ileal conduit diversion in February 2000, using a six-port transperitoneal technique. LRC, ileal conduit exclusion, restoration of ileo-ileal continuity, and bilateral stented uretero-ileal anastomoses were completed intracorporeally in all patients. The follow-up data up to 2 years are reported.

RESULTS

All procedures were completed laparoscopically with no open conversion or intraoperative complications. The mean duration of surgery was 7.5 h; the blood loss was 360 mL and no patient required perioperative blood transfusion. The mean (range) hospital stay was 7 (6-22) days; the specimen weight was 225-400 g. The surgical margins of the bladder specimen were negative in each patient. One patient developed intestinal obstruction after surgery, requiring a diverting ileostomy for 12 weeks. At a follow-up of 2 years, two patients died, both from unrelated causes (myocardial infarction and septicaemia from pulmonary infection in one each). The three surviving patients are asymptomatic with normal upper tracts and no evidence of local recurrence or metastatic disease.

CONCLUSION

LRC with ileal conduit diversion undertaken completely intracorporeally is a feasible option for muscle-invasive organ-confined carcinoma of the urinary bladder, with good outcomes over a 2-year follow-up.

Intercostodiaphragmatic hernia secondary to a bull gore injury: a delayed detection

We report a case of a 45-year-old male presenting with asymptomatic right lower chest mass following a forgotten penetrating trauma. This case highlights a rare; delayed complication of lower chest penetrating injuries by the bull gore, involving the diaphragm. Intercostodiaphragmatic hernia should be kept as a differential diagnosis of slowly growing lower chest wall asymptomatic masses with forgotten injuries in the past.

Psoas abscess-like metastasis from transitional cell carcinoma of urinary bladder

We report a 70-year-old male who presented with gross painless total haematuria associated with persistent left hip pain of one month duration. Computerised tomography of abdomen revealed a mass on the right lateral wall of urinary and abscess like lesion in the left psoas. He underwent transurethral resection of bladder tumour and ultrasonographical guided tru-cut biopsy of psoas lesion. Histopathology confirmed transitional cell carcinoma with metastasis to left psoas muscle. The presentation highlights the clinical and radiological features along with review of literature of rare metastatic site from transitional cell carcinoma of urinary bladder.

Renal cell carcinoma presenting as acute pancreatitis

We present a 50-year-old male with renal cell carcinoma and hypercalcemia presenting as acute pancreatitis. The sudden onset of epigastralgia, acute pancreatitis and hypercalcemia with raised parathyroid-like peptide levels in this patient could not be explained except for renal cell carcinoma. This is the first report of such a complication in renal cell carcinoma. The rare presentation and management with a review of the literature is described.

Retroperitoneoscopic extirpation for adult multicystic calcified dysplastic kidneys with contralateral ureteral abnormalities mimicking genitourinary tuberculosis

PURPOSE

To identify adult multicystic calcified dysplastic kidneys (AMCDK) with contralateral ureteral abnormalities mimicking urinary tuberculosis and to evaluate the feasibility and efficacy of retroperitoneoscopic extirpation in their management.

PATIENTS AND METHODS

We retrospectively identified a group of adult patients who were referred to us as having unilateral nonfunctioning kidney containing calcified cystic masses with a contralateral normally functioning kidney along with segmental dilation of ureter. Two patients had histories of treatment elsewhere with antitubercular drugs on the basis of imaging studies, before being referred to our center for retroperitoneoscopic nephrectomy with a diagnosis of nonfunctioning left kidneys and urinary tuberculosis. The other two cases with similar findings on imaging studies were detected incidentally while the patients were undergoing investigations for vague abdominal symptoms.

RESULTS

All these patients had AMCDK on the left side and a contralateral normally functioning kidney with ureteral abnormality. Retroperitoneoscopic extirpation of the nonfunctioning left renal unit was carried out uneventfully with a mean operating time, blood loss, and hospital stay of 124 minutes, 80 mL, and 3 days, respectively. There were no complications. The dissection in these cases was difficult, as the dysplastic calcified kidney was plastered in the retroperitoneum.

CONCLUSION

Unilateral AMCDK with contralateral segmental dilation of the ureter may be separate entity or a coincidental finding, and it should not be confused with urinary tuberculosis unless there is microbiological and radiologic or histopathologic evidence of infection. Minimally invasive surgery in the form of retroperitoneoscopic extirpation is feasible, safe, and effective in such cases, although difficult, and it requires skills as well as experience.

Multiple bilateral cannon-ball lung metastases from carcinoma of the prostate: orchiedectomy induced remission

A 56-year-old man presented with lower urinary tract obstructive symptoms, hemoptysis and progressive dyspnoea. Digital rectal examination showed an enlarged nodular prostate and a tru-cut biopsy confirmed carcinoma prostate. Chest x-ray showed multiple bilateral cannon ball opacities suggestive of metastases. He underwent bilateral orchidectomy and follow up assessment showed significant clearing of the cannon-ball lesions in the lungs. He remained asymptomatic at follow up that has extended to 8 years.

Core-through urethrotomy using the neodymium: YAG laser for obliterative urethral strictures after traumatic urethral disruption and/or distraction defects: long-term outcome

PURPOSE

We assessed the feasibility, efficacy and long-term outcome of neodymium (Nd):YAG laser core-through urethrotomy for posttraumatic urethral stricture.

MATERIALS AND METHODS

Between May 1997 and April 2000, 65 patients 5 to 62 years old underwent laser core-through urethrotomy for posttraumatic urethral stricture. Most patients had been involved in a motor vehicle accident but 8 and 3 sustained trauma after tractor injury and a railroad accident, respectively. All patients underwent suprapubic cystostomy formation and 18 had previously undergone anastomotic urethroplasty, railroad or attempted cold knife core-through urethrotomy. Mean stricture length was 2.2 cm. on bi-directional uroradiography and endoscopy. All strictures were in the bulbomembranous urethra except 3, which were prostatic-supraprostatic. The procedure was technically unsuccessful in 4 cases. Core-through urethrotomy was performed using Nd:YAG a 600 mu. contact bare fiber at 15 to 20 W. on an outpatient basis. Catheter removal and voiding cystourethrography were performed at 6 weeks. Uroflowmetry and urethroscopy were done 3 months after urethral catheter removal. Followup was 9 to 44 months.

RESULTS

Nd:YAG laser core-through urethrotomy was performed on an outpatient basis successfully in all except 4 cases without any intraoperative or postoperative complications. Blood transfusion was not required. Although most patients were symptom-free, a few underwent initial optical internal urethrotomy and/or endoscopic dilation before the stricture became stable. The urethral lumen was obliterated again in 2 cases.

CONCLUSIONS

Nd:YAG laser core-through urethrotomy is feasible and effective with good long-term results for posttraumatic urethral stricture.

Endourologic management of obstetrical ureterouterine fistula: case report and review of literature

A 32-year-old woman presented to us with complaints of paradoxical incontinence for a period of 6 months following a cesarean section for obstructed labor performed elsewhere and subsequently treated elsewhere. Clinical and urographic assessment revealed an iatrogenic ureterouterine fistula, which was successfully treated endoscopically by dilatation of the ureteral stricture and ureteroscopic double-J stenting. It had been explained to the patient, and she had given consent for, ureteroneocystostomy in the event of failure. The literature regarding the management of this rare genitourinary fistula is reviewed and discussed.

Endourologic reconstruction of post-traumatic obliterated urethral stricture in a young female: a point of technique

INTRODUCTION

A simple endourologic technique for reconstruction of a post-traumatic obliterated urethra in a young unmarried woman is described as an alternative management to complex open urethral reconstruction.

TECHNICAL CONSIDERATIONS

A 20-year-old woman presented with a post-traumatic obliterated urethra after a road traffic accident. The cystogram at 6 weeks did not reveal a bladder neck or urethra. The examination under anesthesia showed just a dimple at the presumed external urethral meatus. Antegrade cystoscopy revealed a complete block just distal to the bladder neck. A puncture was made from the external urethral meatus into the bladder through the bladder neck under antegrade cystoscopic guidance. The tract was dilated up to 18F using fascial dilators over a guidewire. A 16F Foley catheter was placed for 6 weeks. The operative time was 30 minutes, with no intraoperative complications. The catheter was removed at 6 weeks. Urethroscopy showed a normal urethra. She performed self-catheterization for the initial 3 months. A micturating cystourethrogram at 3 months revealed a normal urethra. She was continent and stricture free at follow-up of 16 months.

CONCLUSION

This technique is simple and easy, with good results in selected cases of post-traumatic complete obliteration of the urethra with an intact bladder neck in young women.

Primary squamous cell carcinoma of the prostate: a rare clinicopathological entity. Report of 2 cases and review of literature

Primary squamous cell carcinoma of the prostate is an uncommon clinicopathological entity. It differs from more common adenocarcinomas in its cell of origin, biological behavior, therapeutic response to the usual hormonal manipulation and prognosis. The review shows that squamous cell carcinoma is biologically more aggressive than adenocarcinoma. Despite the agreement on its uniqueness, a controversy exists on the exact histopathogenesis, diagnostic criteria and modality of treatment. We report on 2 patients with primary squamous cell carcinoma of the prostate. One patient presented with lower urinary tract symptoms with a hard nodular prostate on digital rectal examination, and the other with acute urinary retention on normal digital rectal examination. The evaluation revealed metastasis in the pelvic and right femur in both cases. Palliative transurethral resection of the prostate with chemotherapy (Adriamycin based) was given in both the cases. However, both the patients died at 4 and 5 months of follow-up, respectively.

Solitary delayed contralateral testicular metastasis from renal cell carcinoma

We report a 60 year old male presenting with contralateral testicular metastasis 7 years following radical nephrectomy for renal cell carcinoma. Testicular metastases from renal cell carcinoma reported in literature are predominantly ipsilateral and invariably on the left side. Usually these are present simultaneously with the renal primary or precede the diagnosis of renal tumors. Delayed contralateral testicular metastatic has not been reported to the best of our knowledge. The case highlights the unique behaviour of renal cell carcinoma with an unusual site of recurrence. The clinical presentation, pathogenesis and management of this rare presentation along with review of recent literature are discussed.

Laparoscopic repair of vesicovaginal fistula and right nephrectomy for nonfunctioning kidney in a single session

We report a case of failed vesicovaginal fistula repair and nonfunctioning right kidney, which was managed by laparoscopic nephrectomy and fistula repair with omental interposition in a single session.

Laser welding of vesicovaginal fistula

The management of vesicovaginal fistula remains a source of debate, despite extensive literature on the subject. It is difficult to prove the superiority of one surgical technique over another by randomized trials, given the variabilities of fistula etiology, the location and clinician expertise. Small epithelized fistulae following conservative treatment and residual or recurrent cases following transabdominal or transvaginal repair pose a therapeutic challenge. A case of a small vesicovaginal fistula following abdominal hysterectomy is presented, in which a successful outcome was achieved using endoscopic Nd-YAG laser fulguration.

Post-cesarean cervicovesical fistula: technique of laparoscopic repair

PURPOSE

We describe the technique of laparoscopic repair of post-cesarean cervicovesical fistula.

MATERIALS AND METHODS

Two patients 30 and 35 years old, respectively, presented with urinary incontinence, amenorrhea and menouria. Both patients had undergone previously a second cesarean section. Diagnosis was post-cesarean cervicovesical fistula, which was repaired laparoscopically.

RESULTS

Laparoscopic repair was successfully completed in 1 patient. In the other case, after complete dissection of the fistula and preparation of the edges for suturing, surgery had to be converted to an open procedure due to inability to maintain a pneumoperitoneum.

CONCLUSIONS

Laparoscopy is a viable option for the repair of post-cesarean cervicovesical fistula with all its attendant advantages.

Mycotic abdominal aortic aneurysm: a fatal sequel to concomitant prostatic and renal aspergillosis. Case report and review of the literature

We report the first case of aspergillus mycotic aneurysm as a sequel to concomitant prostatic and renal aspergillosis. The patient had undergone left nephrectomy and transurethral resection of prostate for aspergillus infection one year ago. He again presented with LUTS and backache and clinical examination showed visible pulsations in the epigastrium. CT-scan abdomen showed a pseudoaneurysm of the abdominal aorta. The aneurysm was repaired in situ with homografting and omental wrap. However, the patient succumbed to septicemia on the tenth postoperative day. Adjunctive surgery is usually essential as medical management alone has been unsatisfactory. It is imperative that these cases should be followed closely to detect the disease recurrence and complications at the earliest.

Pelvic lipomatosis presenting as uraemic encephalopathy

Pelvic lipomatosis is a benign disorder of unknown aetiology, characterised by deposition of mature fat in the pelvis. It has a variable natural history, manifesting either with symptoms attributable to the lower urinary tract or varying degrees of renal failure. Owing to the mild, non-specific initial symptoms and slow progression, presentation is delayed and patients are often lost to follow-up, only to present with advanced renal failure later on. We report a case of a young patient with pelvic lipomatosis who, after an initial diagnosis, was lost to follow-up for several years and then presented with uraemic encephalopathy. The case highlights the importance of regular follow-up and an early intervention before irreversible changes occur.