Giant neonatal hydronephrosis of the upper pole of a complete duplicated renal system

Ureteropelvic junction obstruction (UPJO) in the upper pole of a complete duplicated renal system is extremely rare. We report a case that was diagnosed prenatally and we review 10 cases published in the literature. Diagnoses of adrenal hematoma and cystic neuroblastoma were suspected on prenatal ultrasound, based on the severity of dilatation and the difficulty of identifying the exact origin of this anomaly. Neonatal magnetic resonance imagery (MRI) was subsequently able to show a normal adrenal gland. Surgical management is similar to that of a single-system pyeloureteral junction obstruction. Since this situation is very rare, we believe cystoscopy can be useful to confirm diagnosis of UPJO associated with complete duplication, especially in the absence of preoperative MRI. Among the 11 surgical cases previously published, seven patients underwent pyeloplasty and four heminephrectomy.

[Endometriosis of the ureter from the standpoint of implantation theory: some aspects of pathogenesis and clinical picture]

The article describes such fundamental and applied aspects of pathogenesis and clinical manifestations of such rare disease as endometriosis of ureters. Frequent involvement of left ureter in its pelvic part, close to distal colon, associated with its inflammatory diseases followed by leaky gut syndrome with bacterial spread to the fallopian tube causing its inflammation and dysfunction, provoking menstrual reflux and predisposing to affection of left ovary, peritoneum and contact spread of endometriosis to ureteral wall. This mechanism fits to the regurgitation theory of endometriosis. Surgery is the gold standard for endometriosis treatment and more beneficial, comparing with conservative treatment and essential for prevention of such dangerous complications as hydronephrosis and renal failure. But the early and in-time diagnostic of endometriosis depend on gynecologists, not urologist, that characterizes endometriosis as significant interdisciplinary problem. In the article symptoms, that must cause concern for this rare pathology are thoroughly described.

[Surgical treatment of patients with renal tuberculosis, complicated by ureteral tuberculosis]

Late diagnosis of renal tuberculosis leads to complications that cannot be eliminated by treatment. A clinical observation of renal tuberculosis, complicated by total ureteral obliteration, in a comorbid patient is presented. He underwent planned bowel substitution of the right ureter. In the postoperative period, pyelonephritis developed, which was resolved by drug therapy. In this case, there is the correct tactics of outpatient urologists. When hydronephrosis was diagnosed, a nephrostomy tube was put, which allowed to preserve the kidney, Then the patient was immediately referred to a phthisiatrician to exclude urogenital tuberculosis. In the local TB dispensary, the patient did not have the opportunity to receive necessary treatment, and he was transferred to the TB Research Institute of Ministry of Health of Russia, where a reconstructive laparoscopic procedure was performed.

Timing urinary tract reconstruction in rats to avoid hydronephrosis and fibrosis in the transplanted fetal metanephros as assessed using imaging

Chronic kidney disease leads to high morbidity rates among humans. Kidney transplantation is often necessary for severe symptoms; however, options for new curative treatments are desired because of donor shortage. For example, it has been established that the kidneys can efficiently generate urine after transplantation of the metanephros, ureter, and bladder as a group. After transplantation, the urine can indirectly flow into the recipient's bladder using a stepwise peristaltic ureter system method where the anastomosis is created via the recipient's ureter for urinary tract reconstruction. However, the growth of the regenerated metanephros varies significantly, whereas the time window for successful completion of the stepwise peristaltic ureter system that does not cause hydronephrosis of the metanephros with bladder (ureter) is quite narrow. Therefore, this study was conducted to periodically and noninvasively evaluate the growth of the transplanted metanephros, ureter, and bladder in rats through computed tomography and ultrasonography. The ultrasonographic findings highly correlated to the computed tomography findings and clearly showed the metanephros and bladder. We found that the degree of growth of the metanephros and the bladder after transplantation differed in each case. Most of the rats were ready for urinary tract reconstruction within 21 days after transplantation. Optimizing the urinary tract reconstruction using ultrasonography allowed for interventions to reduce long-term tubular dilation of the metanephros due to inhibited overdilation of the fetal bladder, thereby decreasing the fibrosis caused possibly by transforming growth factor-β1. These results may be significantly related to the long-term maturation of the fetal metanephros and can provide new insights into the physiology of transplant regeneration of the metanephros in higher animals. Thus, this study contributes to the evidence base for the possibility of kidney regeneration in human clinical trials.

A ten-year, single institution experience with percutaneous nephrostomy during pregnancy

PURPOSE

To evaluate the safety and efficacy of percutaneous nephrostomy (PCN) in pregnancy.

MATERIALS AND METHODS

PCN tubes were placed during 52 pregnancies in 49 patients from 2008 to 2018. The medical records during pregnancies were retrospectively reviewed for imaging findings, procedural parameters, outcomes of delivery, and complications.

RESULTS

The mean gestational age on percutaneous nephrostomy placement was 27 weeks (range, 8-36 weeks). PCN catheters were placed for the following indications: 1) flank or lower abdominal pain (42%), 2) obstructing calculi (37%), 3) pyelonephritis (20%), and 4) obstructing endometrioma (2%). Prior to PCN, retrograde ureteric stenting was performed in 17 of 49 patients (34%) and attempted but failed in 4 patients (8%). Nephrostomy drainage relieved pain completely or significantly in all 12 patients without prior ureteral stenting, but in only 4 of 10 with retrograde ureteric stents. In one patient in whom the ureteral stent had been removed, PCN relieved her flank pain. The mean number of PCN catheter exchanges was 1.6, ranging from 0 to 9, with a mean time interval of 21.3 days between exchanges. There were 29 difficult exchanges due to encrustation in 15 patients with a mean of 20.5 days between exchanges.

CONCLUSIONS

PCN drainage is a safe and effective treatment for managing symptomatic hydronephrosis in pregnant patients but is less effective in treating pain when retrograde ureteral stents are in place. Rapid encrustation, seen more commonly in pregnancy, tends to recur in the same patients and requires more frequent exchanges than the general population.

A case report of hydronephrosis caused by imperforate hymen in an infant

RATIONALE

Hydronephrosis, mostly caused by ureteropelvic junction obstruction, rarely occurs in infants. However, imperforate hymen atresia in female infants may cause hydronephrosis, even though it is rare.

PATIENT CONCERNS

A 3-month-old female infant was admitted to our hospital for frequent crying. There was no significant past medical history.

DIAGNOSES

Following ultrasound imaging, the patient was diagnosed with hydronephrosis possibly caused by imperforate hymen.

INTERVENTIONS

The infant underwent hymenotomy with a cruciate incision to prevent future complications such as acute renal injury.

OUTCOMES

Hydronephrosis resolved after the operation. The outcome was very good, with no complications in the postoperative period.

CONCLUSIONS

Early ultrasound diagnosis plays a significant role in the management and treatment of infant patients. Ultrasound is the mandatory imaging technology for determining the cause of hydronephrosis.

Our experience with laparoscopic Anderson-Hynes ureteropyeloplasty

OBJECTIVE

To analyze whether the application of laparoscopic surgery in the treatment of pyeloureteral junction obstruction (PUJO) has been beneficial for pediatric patients.

MATERIALS AND METHODS

Medical records of all patients undergoing PUJO surgery from January 1997 to December 2017 were retrospectively reviewed. Patients with <6-month follow-up and patients undergoing video-assisted surgery were excluded. Open surgery was compared with laparoscopic surgery. The following data were collected: surgical approach, need for and type of urinary diversion, operating time, mean hospital stay, complications, and restenosis rate. Ultrasound and diuretic renogram parameters were also retrieved.

RESULTS

328 Anderson-Hynes pyeloplasties were analyzed, 142 of which had been performed laparoscopically. Overall success rate was 96.6%, and complication rate was 11.9%. No significant differences were noted between open and laparoscopic surgery. In 97.5% of surgeries, urine was diverted using an external nephroureteral catheter, a double J stent, or a Salle stent, with significant differences between open and laparoscopic surgery. Mean operating time was significantly longer in laparoscopic surgery. Mean hospital stay was significantly shorter in the laparoscopic surgery group.

CONCLUSION

Surgical approach does not play a role in PUJO surgery success. Therefore, in our view, laparoscopic surgery should be the technique of choice in pediatric patients.

[Surgical learning curve for top-down two-knot laparoscopic pyeloplasty in congenital hydronephrosis in children]

The aim was to evaluate the surgical learning curve and advantages of top-dow two-knot laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO).

MATERIALS AND METHODS

A retrospective analysis of medical records regarding 98 patients from Speranskij Childrens Municipal Hospital No9, Moscow and Regional Clinical Hospital No7, Volgograd, aged from 3 to 24 months with unilateral hydronephrosis of varying degrees, according to the SFU classification (Society of Fetal Urology) in the Onen modification was carried out. LP in all children was performed in accordance with the Heins-Andersen technique, with minimal resection of the pelvis. In order to compare different techniques for the formation of pyeloureteral anastomosis, patients are divided into two groups: on the first group (n=59) TDTKT was performed, and on the second (n=39) - the standart knotting technique (SKT) was performed. The patients were operated by two surgeons from different clinics. Average time of operation, learning curves, frequency of post-operative complications and post-operative assessments were included as criteria for the comparison of the two groups.

RESULTS

Using TDTKT allowed a reduction in mean time of surgery of 30%. Positive results were obtained in both groups of patients by reducing the degree of hydronephrotic transformation of the kidney during their follow-up year.

CONCLUSION

Using TDTKT not only permits an experienced surgeon to reduce his duration of operation to 67.86 minutes, it also positively affects the surgical learning curve for less experienced surgeons. In this regard, this technique can be recommended to surgeons who do not have much experience in conducting laparoscopic pyeloplasty.

Bladder-sparing treatment of nonmetastatic muscle-invasive bladder cancer

Bladder-sparing therapies for the treatment of nonmetastatic muscle-invasive bladder cancers are included in both American and European guidelines. Numerous treatment approaches have been described, including partial cystectomy, radiation monotherapy, and radical transurethral resection. However, the most oncologically favorable and well-studied regimen employs a multimodal approach that consists of maximal transurethral resection of the bladder tumor followed by concurrent radiosensitizing chemotherapy and radiotherapy. This sequence, referred to as trimodal therapy (TMT), has been evaluated with robust retrospective comparative studies and prospective series, although a randomized trial comparing TMT with radical cystectomy has not been performed. Despite promising reports of 5-year overall survival rates of 50% to 70% in well-selected patients, relatively few patients qualify as ideal candidates for TMT. Specifically, contemporary series exclude patients who have clinical stage T3 disease, multifocal tumors, coexisting carcinoma in situ, or hydronephrosis. Herein, we review all forms of bladder-preserving therapies with an emphasis on TMT, highlighting the rationale of each component, survival outcomes, and future directions.

Ureteral obstruction and hydronephrosis caused by foreign body: A case report and literature review

RATIONALE

Foreign bodies related ureteral obstruction and hydronephrosis is rare and usually cause numerous problems for clinical physicians.

PATIENT CONCERNS

We report a 36-year-old female who was referred to our hospital due to a 4-year history of dull pain on the left back.

DIAGNOSIS

X-ray and abdominal CT revealed a foreign body around the upper part of the left ureter with ureteral obstruction and hydronephrosis.

INTERVENTIONS

Laparoscopy was performed and a 3-cm sewing needle was removed successfully.

OUTCOMES

After 6 months' follow-up, the patient's ureteral obstruction and hydronephrosis were significantly reduced, and the double-J ureteral stent was removed.

LESSONS

This case indicated that ureteral obstruction and hydronephrosis caused by foreign bodies needed to be early diagnosed and located. Invasive therapies rather than conservative treatments are preferred to remove the FBs and relieve obstruction.

Detection rate of crossing vessels in pediatric hydronephrosis: Transperitoneal laparoscopy versus open lumbotomy

BACKGROUND

A bundle of crossing vessels (CV) supplying the lower pole of the kidney and causing mechanical obstruction of the ureteropelvic junction (UPJ) has been the subject of many discussions. During pyeloplasty, it is possible to overlook the CV. This may result in recurrent dilatation of the kidney and the need for re-surgery.

OBJECTIVES

To compare the detection rate of CV in UPJ obstruction (UPJO) depending on the operational access applied (transperitoneal laparoscopy (LAP) vs open lumbotomy (OPEN)). Assessment of features that could indicate the presence of CV.

MATERIAL AND METHODS

Two hundred and forty-six pediatric pyeloplasties were performed between January 2006 and July 2017 in the Department of Pediatric Surgery and Urology at the Wroclaw Medical University, Poland - 111 out of them by LAP and 135 by OPEN, on 98 girls and 148 boys. A retrospective analysis of the patient records for the detection of CV and characteristics of the CV before surgery was performed.

RESULTS

Intraoperative CV causing obstruction of the UPJ in the LAP group were recognized in 34.2% (n = 38) of the patients, and within the OPEN group in 12.5% (n = 17) (p < 0.0001); 90% (n = 27) of patients with the diagnosed CV did not show congenital hydronephrosis. In 68% (n = 21) of the patients there were cases of recurrent renal colic. The presence of CV was suspected in 7.2% of kidney ultrasounds and in 12.5% in computed tomography (CT) urograms.

CONCLUSIONS

The detection rate of CV in UPJO is statistically higher in LAP access than in open retroperitoneal lumbotomy. The distinguishing features of patients with CV are the lack of prenatal diagnosis for hydronephrosis and the presence of pain in the lumbar region.

Laparoscopic transposition of lower pole crossing vessels in children with extrinsic pelvi-ureteric junction obstruction: a worthy alternative to dismembered pyeloplasty

Pelviureteric junction obstruction (PUJO) due to intrinsic or extrinsic causes is a common problem in childhood. Extrinsic compression by a lower pole-crossing blood vessel can present symptomatically in older children. In these cases, laparoscopies Vascular Hitch can represent a valid alternative to pyeloplasty dismembered. We analyzed the data of 4 children affected by extrinsic PUJO treated at our institution with the laparoscopic Vascular Hitch procedure modified by Chapman. Surgical indications included presence of clinical symptoms, worsening of intermittent hydronephrosis, signs of obstruction on the MAG-3 scan, clear or suspected images of polar crossing vessels on CT scan or Uro-MRI. All procedures were completed laparoscopically. No complications occurred. Mean follow-up was 13 months with resolution of symptoms and PUJ obstruction and significant improvement of hydronephrosis in all cases. When blood vessels crossing lower pole represent the pure mechanical cause of UPJ obstruction the laparoscopic Vascular Hitch procedure represents an excellent alternative to dismembered pyeloplasty. It is less technically demanding then pyeloplasty and is associated with a lower complication rate. The main challenge is to intraoperatively ascertain the absence of associated intrinsic stenosis.

Robot-assisted Laparoscopic Pyeloplasty for "Huge" Hydronephrosis Causing Vena Cava Thrombus

OBJECTIVE

To present a rare case of "huge" hydronephrosis causing distortion of large vessels and formation of a thrombus in the inferior vena cava. Multidisciplinary treatment was applied with particular focus on pyeloplasty utilizing a robot-assisted laparoscopic approach.

METHODS

A 20-month-old male presented to the emergency room severely ill with abdominal pain, nausea, vomiting, and fever and was subsequently transferred to the intensive care unit, in septic shock. An abdominal ultrasound revealed a large multilobular cystic structure in the right hemiabdomen, which was initially interpreted as an infected mesenteric cyst. CT scan revealed a huge hydronephrotic kidney crossing the midline, causing a mass effect that compressed and distorted the vena cava laterally, in addition to a thrombus between the hepatic vein and right renal vein. Intravenous Ceftriaxone and Amikacin, as well as anticoagulation therapy with low molecular weight heparin (Enoxaparin) were initiated. A nephrostomy tube was inserted that drained 900 mL of purulent urine. A full hematology investigation including protein C, S, and antithrombin III was carried out, excluding factor V Leiden and prothrombin mutation. All values were in the normal range. Dimercaptosuccinic Acid (DMSA) scan showed 30% function on the affected kidney and Voiding Cystourethrogram (VCUG) excluded any bladder pathology or reflux. Subcutaneous Enoxaparin was continued for 3 months, maintaining antifactor Xa in the therapeutic range (0.7-1 IU/mL). Ultrasound Doppler of the vena cava showed full resolution of the thrombus. Robot-assisted laparoscopic pyeloplasty was performed and significant reduction of the renal pelvis was carried out, taking care to preserve the calyces. Postoperative ultrasound 4 months after surgery showed a complete resolution of the hydronephrosis.

CONCLUSION

Giant hydronephrosis is a rare finding. Distortion of adjacent veins and formation of thrombosis should be kept in mind, as they are life threatening. A multidisciplinary collaboration is mandatory to ensure optimal treatment.

[Fetal anteroposterior renal pelvic diameter for predicting antenatal hydronephrosis requiring postnatal surgery]

OBJECTIVE

To assess the value of fetal anteroposterior renal pelvic diameter (APD) in predicting antenatal hydronephrosis requiring surgical treatment after birth.

METHODS

A total of 525 cases of antenatal hydronephrosis detected by prenatal ultrasonography (ultrasound index APD ≥ 4 mm in the second trimester and APD ≥ 7 mm in the third trimester) in Zhejiang Prenatal Diagnosis Center from June 2007 to June 2018 were retrospectively analyzed. ROC curve was used to analyze the relationship between these ultrasound indicators and the requirement for surgical treatment after birth.

RESULTS

There were 162 cases (30.9%) diagnosed in the second trimester and 363 cases (69.1%) diagnosed in the third trimester; 131 cases were diagnosed pathologically after birth, of which 121 finally underwent surgical treatment. The area under ROC curve (AUC) of APD in middle pregnancy for prediction of requiring surgery 1-12 years after birth was 0.910; the cut-off value of APD was 8.45 mm with a sensitivity of 97.1%, specificity of 70.9%, positive predictive value (PPV) of 47.9%, and negative predictive value (NPV) of 98.9%. The AUC of APD in late pregnancy for prediction of requiring surgery 1-12 years after birth was 0.800; the cut-off value of APD was 12.25 mm with a sensitivity of 66.7%, specificity of 81.2%, PPV of 51.7%, and NPV of 89.1%.

CONCLUSIONS

APD in pregnancy can be used to predict whether the fetus with hydronephrosis needs surgical treatment after birth, and the prediction value of APD in the middle pregnancy is better.

Subcutaneous ureteral bypass for treatment of bilateral ureteral obstruction in a cat with retroperitoneal paraganglioma

CASE DESCRIPTION A 7-year-old female domestic shorthair cat was referred for evaluation of azotemia and unilateral hydronephrosis. CLINICAL FINDINGS Abdominal ultrasonography revealed right-sided hydronephrosis and dilation of the proximal aspect of the ureter; the left kidney was small with irregular margins. A highly vascular, irregular retroperitoneal mass, not clearly associated with the ureteral obstruction, was also visualized. Surgical exploration confirmed a retroperitoneal mass involving the caudal mesenteric artery and both ureters, with hydroureter on the right side. TREATMENT AND OUTCOME A subcutaneous ureteral bypass (SUB) device was surgically implanted to treat right ureteral obstruction, and the mass was biopsied. Shortly after surgery, progressive azotemia and hyperkalemia were detected; ultrasonographic examination revealed left-sided hydronephrosis and hydroureter, which was suspected secondary to inflammation of the mass causing a left-sided ureteral obstruction. A second surgery was performed to place an SUB device for the left kidney and remove the retroperitoneal mass; both ureters were ligated at the mid- and distal aspects and then transected and removed with the mass. A neuroendocrine paraganglioma was identified by histopathologic evaluation of the mass. Hydronephrosis improved (right kidney) or resolved (left kidney) after surgery, and azotemia improved. Chemotherapeutic intervention was declined. Markers of renal function were static during the 14-month follow-up period. At the last follow-up evaluation, the patient was reportedly doing well, and both SUB devices were patent. CLINICAL RELEVANCE This was the first report of retroperitoneal paraganglioma in a domestic cat causing bilateral ureteral obstruction. Bilateral SUB device placement enabled en bloc mass resection and provided long-term relief of ureteral obstruction.

Management of crossing vessels in children and adults: A multi-center experience with the transperitoneal laparoscopic approach

BACKGROUND

Crossing vessels (CVs) are common in older children and adults with hydronephrosis but no gold standard exists on how to treat this condition. The final decision is made intraoperatively by the surgeon.

OBJECTIVES

To assess the outcome of the laparoscopic dismembered pyeloplasty with translocation of the CVs in children and adults.

MATERIAL AND METHODS

Prospectively collected data from 3 departments was reviewed. Inclusion criteria were: 1) a transperitoneal laparoscopic approach; 2) dismembered pyeloplasty; and 3) the same operating pediatric urologist (RC) or urologist (TS). In the case of CVs, pyeloplasty with vessel transposition (children) or with cephalad translocation (adults) was performed. Forty-eight children and 41 adults met these criteria. Patients were divided into 4 groups: children with (group 1A) and without (group 1B) CVs, and adults with (group 2A) and without (group 2B) CVs. Any surgical reintervention at the uretero-pelvic junction (UPJ) was deemed a failure.

RESULTS

The overall reintervention rate was 3/48 (6.25%) in children and 2/41 (4.9%) in adults (p > 0.05), and involved the following: 4 endopyelotomies and 1 redo pyeloplasty. Crossing vessels were identified in 28/48 (58%) children and 12/41 (29%) adults. The mean operation time was 152 min in group 1A and 161 min in group 2A (p > 0.5). Reintervention was needed in 2/28 patients in group 1A and in 1/12 patients in group 2A (p > 0.05). There was no difference in the failure rate between group 1A and group 1B, nor between group 2A and group 2B (p > 0.05).

CONCLUSIONS

Crossing vessels should be meticulously looked for during pyeloplasty in older children and adults. Dismembered laparoscopic pyeloplasty (LP) with dorsal transposition or cephalad translocation are comparable methods in terms of success rate for the treatment of UPJ obstruction in these patients.

Retroperitoneoscopic nephrectomy for a horseshoe kidney with hydronephrosis and inflammation: A case report

RATIONALE

A horseshoe kidney is the most common congenital fusion abnormality in the kidney, occurring in approximately 1 in 400 live births. Several complications including renal malignancies, ureteropelvic junction obstruction, urolithiasis, vesicoureteral reflux, and hydronephrosis can occur in this patient population.

PATIENT CONCERNS

A 28-year-old woman was admitted to hospital because of chronic left low back pain. Microscopic hematuria was not seen. Computed tomography showed the horseshoe kidney and left hydronephrosis.

DIAGNOSES

On the basis of these findings and clinical manifestations, the final diagnosis was the horseshoe kidney with left renal hydronephrosis and inflammation.

INTERVENTIONS

A retroperitoneoscopic nephrectomy on the left kidney was performed.

OUTCOMES

Histopathological examination of the specimen confirmed massive dilatation of the pelvicaliceal system and chronic pyelonephritic inflammation. The patient was discharged on the 7th postoperative day with no complications and no back pain. She remained well at 3 months with normal activity and good cosmetic result.

LESSONS

Retroperitoneoscopic nephrectomy can be a safe and minimally invasive surgery for horseshoe kidney treatment.

Plasma exchange improves outcome of sepsis-associated liver failure: A case report

RATIONALE

Sepsis-associated liver failure is characterized by increased bilirubin levels and coagulation disorders, which has a significant impact on mortality due to the insufficient understanding of its complicated pathogenesis pathophysiology and a lack of standardized treatment.

PATIENT CONCERNS

A 56-year-old woman presented signs of sepsis on the 2nd day after undergoing ureteroscopy for left ureter and laparoscopy for lysis of adhesions around left ureter due to hydronephrosis. Her condition seemed to have been improved after treatment, but the bilirubin levels suddenly increased drastically with presence of coagulation disorders.

DIAGNOSIS

Laboratory tests combined with her medical history confirmed the diagnosis as sepsis-associated liver failure.

INTERVENTIONS

Plasma exchange was applied after hepatoprotective drugs, and other supportive therapies were given which did not significantly improve the condition.

OUTCOMES

Laboratory liver function tests indicated the restoration of damaged liver function after plasma exchange was performed and the patient was soon transferred from intensive care unit back to the general ward.

LESSONS

Plasma exchange might be a vital and effective therapy to improve outcome of sepsis associated liver failure especially when conventional support therapy is ineffective.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature

BACKGROUND

Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst.

CASE DESCRIPTION

A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed.

CONCLUSIONS

Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

Acute Kidney Injury Induced by Pneumoperitoneum Pressure Via a Mitochondrial Injury-dependent Mechanism in a Rabbit Model of Different Degrees of Hydronephrosis

OBJECTIVE

To clarify the effect of mitochondrial injury during laparoscopic surgery of the kidney in different degrees of hydronephrosis in rabbit model.

METHODS

A total of 90 rabbits were randomly allocated into 3 groups (groups PN, PM, and PS, ie, rabbits without, with mild and with severe hydronephrosis, respectively). The rabbits in the PM group (n = 30) and PS group (n = 30) underwent surgical procedures that induced mild and severe left hydronephrosis, respectively. The rabbits in all the groups were then allocated into 5 subgroups and were subjected to intra-abdominal pressures of 0, 6, 9, 12, and 15 mmHg. Changes in the mitochondrial membrane potential and mitochondrial electron microstructure were observed. The apoptosis proteins cytochrome C, apoptosis-inducing factor, caspase-3, and caspase-9 were measured by western blot analysis.

RESULTS

As the degrees of hydronephrosis increased, histopathological changes such as the decrease in mitochondrial membrane potential and mitochondrial vacuolization along with increased expression of apoptosis proteins, cytochrome C, apoptosis-inducing factor, caspase-3 gained statistically significance at lower intra-abdominal pressures (In PN and PM groups at 15 mmHg, and in PS group at 9 mmHg; for all P <.01).

CONCLUSION

Mitochondrial injury plays an important role during acute kidney injury induced by pneumoperitoneal pressure in different degrees of hydronephrosis in the rabbit model.

Rare case with plethora of upper urinary tract anomalies associated with pelviureteric junction obstruction: a surgical challenge managed with robot assistance

The genitourinary system for reasons unknown is more likely to have birth defects than any other system. The anomaly of collecting system draining the kidney represent mystifying subset of congenital anomalies. Pelviureteric junction obstruction (PUJO) is most common. Chronic obstruction can lead to stasis, urinary infection and stone formation in PUJO. Extrarenal calyces, which is characterised by presence of calyces and renal pelvis outside the renal parenchyma is one of the rare anomalies seen among the collecting system right gonadal vein drains into inferior vena cava. Its altered drainage into right renal vein is rarely seen and reported. Glut of these multiple anomalies in a single case is an extremely rare event. We hereby discuss a case of 40-year-old male patient with combination of all these anomalies and discuss the embryology, presentation and management.

Migration of an intrauterine device causing severe hydronephrosis progressing to renal failure: A case report

RATIONALE

Intrauterine device (IUD) is commonly used in China. Its complications include uterine perforation, IUD ectopic migration, etc. However, a migrated IUD rarely leads to renal failure.

PATIENT CONCERNS

IUD insertion in the patient was followed by unexplained pain in the left renal area, without bladder irritation or dysuresia.

DIAGNOSES

Hydronephrosis, renal failure, migrated IUD.

INTERVENTIONS

The patient underwent laparoscopic and retroperitoneoscopic left nephrectomy, partial ureterectomy, and migrated IUD extraction.

OUTCOMES

No complications were found after 1 year of follow-up.

LESSON

An IUD should be placed by an experienced doctor. If conditions permit, it is best to perform the procedure under the guidance of ultrasound. The patients should be advised to undergo regular check-ups after the procedure. If necessary, abdominal color Doppler examination should be performed. Importantly, patients with IUD pregnancy must be reviewed.

Diuretic renography in hydronephrosis: a retrospective single-center study

PURPOSE

Ureteropelvic junction obstruction (UPJO) is one of the most common causes of hydronephrosis other than transient hydronephrosis. In children with unilateral hydronephrosis, mercaptoacetyltriglycine-3 diuretic renography (MAG₃) is used to calculate differential renal function and to assess drainage. The aim of our study is to examine whether anteroposterior pelvic diameter on renal ultrasound (US) scan can predict both differential renal function (DFR) and obstruction in pediatric patients, and whether an US adequately identifies those patients who need further investigation. We also aimed to design a study with a larger sample size than previous studies investigating the relationship between MAG₃ and US.

METHODS

We retrospectively reviewed the MAG₃, US, dimercaptosuccinic acid scan (DMSA) findings, and medical records of pediatric patients with hydronephrosis and/or atrophy who were at follow-up between January 2013 and December 2016 in our center which is located in the south-east region of Turkey.

RESULTS

Two hundred and twenty-five pediatric patients (M/F = 156/69) with unilateral hydronephrosis but without VUR were enrolled in this study. The mean age of the children was 45.4 ± 48.3 months (range 2-173 months). Sixty-nine patients had obstructive pattern on ^99mTc-MAG₃. With respect to obstructive pattern, there was a significant difference between the hydronephrosis groups both with 15 and 20 mm border. An APD of greater than 20 mm had 15.8 times (95% CI 5.72-43.69) higher likelihood of having obstruction MAG3 findings. On the other hand, an APD of greater than 15 cm had 9.2 times (95% CI 3.01-28.57) higher likelihood of having obstruction MAG₃ findings. The incidence of urinary tract infections was lower than in the obstructive group than the other groups. The regression analysis showed that an APD of greater than 20 mm was a risk factor for low DRF (OR = 5.208, 95% CI 1.529-17.743, p = 0.008). However, the regression analysis showed that an APD of greater than 15 mm was not a risk factor low DRF.

CONCLUSIONS

The combination of ultrasound and MAG₃ provides the necessary anatomical and functional information to follow the degree of obstruction and to decide between surgical intervention and conservative follow-up. Our study supports a threshold of 20 mm rather than 15 mm for severe obstruction and a low DRF. An APD threshold greater than 15 mm did not have a predictive value in DRF estimation.