Spontaneous steinstrasse: A case report and literature review

IntroductionSince its introduction in 2008, endoscopic combined intrarenal surgery (ECIRS) has shown multiple advantages for complex renal stones management. ECIRS provided a higher stone-free rate with lower incidence of severe complications, including blood transfusion, than conventional percutaneous nephrolithotomy (PCNL)[1]. The simultaneous utilization of flexible ureteroscopy with PCNL is of diagnostic and therapeutic value. Ureteroscopy evaluates the upper urinary tract for abnormalities, including strictures or stones, allowing cautious planning before tackling the renal stones. Furthermore, flexible ureteroscopy evaluates the calyceal anatomy and visually supervises the calyceal puncture and dilatation of the tract, which helps minimize radiation use. in addition, flexible ureteroscopy gives access to unreachable calyces to ensure better stone clearance and minimize the number of percutaneous accesses needed[2]. Case presentationA 42-year-old gentleman with a history of recurrent stone formation and previous left open pyelolithotomy presented to our clinic with left dull aching flank pain for one week. ResultsComputed tomography scan showed a 5 mm stone in the left proximal ureter with severe back pressure changes in addition to multiple non-obstructing renal stones, with the largest group in the lower calyx measuring collectively 2.5 × 2 cm associated with a distorted renal calyceal system as a result of previous open renal surgery. Given the large renal stone burden with ureteric obstruction, ECIRS was planned. The technique of procedureThe patient was placed in Giusti's position. Examination of the left ureter using a 6.5 F semi-rigid ureteroscope showed a small stone in the left upper ureter, a guide wire was passed to the left kidney under the endoscopic vision, and the stone was grasped using a nitinol basket. A ureteric access sheath was advanced to the left pelvi-ureteric junction under fluoroscopy, followed by backloading the 8.6 WiScope® Single-Use Digital Flexible Ureteroscope. The entire pelvicalyceal system was examined, showing multiple lower calyceal and renal pelvic stones. Under fluoroscopic and endoscopic guidance, lower calyx puncture was done using the triangulation technique. The lower calyceal access was dilated using a balloon catheter up to 30 F, followed by the introduction of the 30 F Amplatz sheath. The 26 F nephroscope showed multiple stones in the lower calyx that were removed with forceps and fragmented using ultrasonic lithotripsy. Multiple stones were seen in a parallel calyx to the puncture and were grasped using a nitinol basket through the flexible ureteroscope and passed to the nephroscope. A final inspection of the renal calyces using the flexible ureteroscope showed no residual stones. A retrograde JJ stent was placed in the renal pelvis. An Argyle tube was placed as a drain before removing the Amplatz sheath. The percutaneous track was inspected using a flexible ureteroscope rough the transparent tube showing no bleeding or organ injury, and fluoroscopy showed no contrast extravasation. The nephrostomy tube was removed 48 hours after the operation, and the patient was discharged home with no perioperative complications. Stone analysis showed calcium oxalate dihydrate.

A 41-year-old male patient presented to the Emergency Department (ED) of Sultan Qaboos University Hospital (SQUH) complaining of left flank pain of one day’s duration which was colicky and increasing in intensity. There was no history of fever, nausea or vomiting or other significant medical history; however, a similar episode had occurred previously. The patient’s vital signs were stable and he was afebrile. Physical examination of the abdomen was non-contributory; routine microscopic urinalysis was normal. In view of the suspicion of left renal colic, he was referred for a non-contrast enhanced computed tomography (NCCT) scan, the gold standard at SQUH to assess urinary tract calculi in patients presenting with renal colic. The scan showed significant left perinephric fat stranding and mild left hydroureteronephrosis and evidence of periureteric fat stranding around the left ureter. No calculi could be identified in the left kidney or the left ureter. There was a direct inguinal hernia on the right side which contained part of the urinary bladder and a small radio-opaque calculus. These findings suggested the recent passage of a left ureteric stone into the bladder and the migration of this stone into the herniated part of the urinary bladder. It is also possible that the patient had passed out the ureteric stone via the urethra, and that the stone in the herniated bladder was an incidental finding. Clinically, the pain decreased over the period of observation in the ED, and the patient was discharged. At Urology Clinic follow-ups, there was no recurrence of pain, and the patient was managed conservatively. Inguinal hernias can be direct or indirect; the Hesselbach triangle is usually the site for direct inguinal hernias. On CT, the direct inguinal hernia lies medial to the inferior epigastric artery.1 A total of 1–3% of all inguinal hernias involve the bladder;2 in obese men aged 50–70 years, the incidence may reach 10%.3 Inguinal hernias generally occur on the right side.2 Urinary bladder hernias are mostly diagnosed incidentally during hernia surgeries,4 or during imaging.2 The herniated parts of the urinary bladder can contain tumors or calculi.2,5 These may migrate from upper tracts or form de novo in the hernia due to stasis. CT is the best modality for the diagnosis and evaluation of inguinoscrotal urinary bladder herniation after injection of intravenous contrast. The post-processing of the CT using 3D reconstructions can demonstrate the contents of the hernia and its relationships.6 Our patient’s calculus, could possibly have passed from the left ureter. However, it is possible that it may instead have travelled to the herniated component of the urinary bladder and been overlooked, especially as the herniated part of the bladder was small and did not significantly distort the urinary bladder in the pelvis. Therefore, we suggest that the protocol for the routine NCCT of the kidney, ureter and bladder for urolithiasis should extend below the pubic symphysis so as not to miss posterior urethral calculi or calculi in unusual areas.

Tension pneumothorax caused by the argon beam coagulator during laparoscopic partial nephrectomy.

Surgical Excision of Endometriosis in the Setting of a Congenital Pelvic Kidney

Objective: To compare the stone free rates on patients with staghorn, renal pelvic, and inferior calyx stones with stone burden < 20 mm, 21-30 mm, and > 30 mm following percutaneous nephrolithotomy (PCNL) in Cipto Mangunkusumo General Hospital Jakarta. Material & methods: The data were collected retrospectively from PCNL medical records in Cipto Mangunkusumo General Hospital Jakarta between January 2000 and March 2011. Six hundred and twenty-three patients with 651 kidney stones underwent PCNL. The inclusion criteria were staghorn stones, renal pelvic stone, and inferior calyx stone. All cases outside these three criteria and incomplete data were excluded. Stone free status was defined as no residual fragment on radiography or ultrasonography. Results: As many as 364 kidney stones from 344 patients were included, with 47.8% cases of staghorn stones, 31.9% cases of renal pelvic stones, and 20.3% cases of inferior calyx stones. Overall, 273 (75%) cases were defined as stone free. In group < 20 mm, 4 staghorn stones (100%), 18 renal pelvic stones (81.8%), and 34 inferior calyx stones (94.4%) were cleared (p = 0.811). In group 21-30 mm, 20 staghorn stones (95.2%), 52 renal pelvic stones (91.2%), and 26 inferior calyx stones (92.9%) were cleared (p = 1.000). In group > 30 mm, 83 staghorn stones (55.7%), 28 renal pelvic stones (75.7%), and 8 inferior calyx stones (80%) were cleared (p = 0.037). Conclusion: PCNL is an important tool for treating various kinds and sizes of kidney stones with high stone free rate.

Objective To evaluate the safety and efficacy of ultrasound-guided transperitoneal PCNL for treatment of renal calculi in pelvic ectopic kidney. Methods The clinical data of 4 cases of pelvic ectopic kidney treated in our hospital from June 2016 to August 2017 were retrospectively analyzed. The patient's age ranged from 30 to 67 years with an average of 47.25 years. There were two male and two female patients. 2 cases suffered with left pelvic ectopic kidney stones. One case had right pelvic horseshoe ectopic kidney stones and one case had spinal deformity left pelvic ectopic kidney stones. Multiple stones were found in 2 cases. The mainly stones located in the renal pelvis in one case. Multiple stones in the lower calyx was found in another case. The remaining 2 cases had single stones in the renal pelvis. Stone size was 3.4 cm×2.1 cm, 3.0 cm×2.1 cm, 2.8 cm×2.4 cm and 2.1 cm×1.9 cm respectively. And 1 case with renal calculi in left pelvic ectopic kidney had a history of open surgery 11 years ago because of the same situation with pelvic ectopic kidney calculi. In this study, all operation was performed under general anesthesia. The ultrasound-guided percutaneous nephrolithotomy combined with preoperative CTU and intraoperative color Doppler ultrasound was used to find the target renal calyx or renal pelvis. And a certain pressure was applied to the abdominal wall to make the intestinal canal deviate from the surface of the pelvic ectopic kidney as much as possible. Under ultrasound real-time detection, it was punctured into the target renal calyx or renal pelvis to find and break stones. And F6 double J tube and F18 nephrostomy tube were left. Operative and post-operative related details (stone free, bleeding, abdominal infection) were reviewed. Results Stone free rate were 100% (4/4). The time of operation and hospital stay were 62, 59, 55, 51 min and 6, 6, 5, 5 days, respectively. None had significant intraoperative and postoperative complications, including haemorrhage, injury of mesenteric vessels, abdominal infection and hydrops. No one left residual stones during 1 month and 3 months of follow-up. Conclusions The ultrasound-guided transperitoneal PCNL is a safe and effective procedure for the treatment of patients with renal calculi in pelvic ectopic kidney. Key words: Percutaneous nephrolithotomy; Transperitoneal; Ultrasound-guided; Pelvic ectopic renal calculi

Objective To study the efficacy and safety of the integrated flexible and rigid ureterorenoscope in the treatment of upper ureter or renal pelvis stones. Methods The clinical data of 48 patients with upper ureter or renal pelvis stones were retrospectively analyzed between January 2015 and July 2017. Twenty-five cases were treated with integrated flexible and rigid ureterorenoscope(integrated group), while 23 cases were treated with minimally invasive percutaneous nephrolithotomy lithotripsy(mPCNL group). The operative effect and safety of both groups were compared. Results In the integrated group, stone finding rate was 96% and 100% in the mPCNL group. The blood loss of the integrated group was (6.83±2.60)mL lower than that of the mPCNL group (75.57±18.85)mL (P 0.05). There was no significant difference in postoperative complications between the two groups. Conclusions The integrated flexible and rigid ureterorenoscope is safe and effective in the treatment of the upper ureter and renal pelvis stones. With a high stone clearance rate, it can achieve the similar clear stone effect of mPCNL. Compared with mPCNL, the integrated flexible and rigid ureterorenoscope has less bleeding, shorter operative time, lower cost of treatment, faster recovery after surgery, less complications, with broad prospects for the use. Key words: Ureteral Calculi; Kidney Calculi; Ureteroscopy; Lasers, Solid-State

Stone diseases that affect the urinary system include urinary tract stones. One common disorder of the urinary system is stones in the urinary tract. According to where they occur, the four different types of stones are categorized as well as urethra, bladder, kidney, and ureteral stones. The patient healed fast and was released after receiving a series of systematic and successful treatments, including completing the one-stage operation. Whole urinary calculi can be eliminated after a single therapy, and urolithiasis persisting over the entire term is uncommon. After seven days of treatment, the clinical improvement response was outstanding and considerable. After receiving Unani therapy for a month without surgical intervention, a U.S.G. finding was suggestive of the absence of any calculi in the left kidney and ureter. The formulations prevented urinary supersaturation of lithogenic chemicals and proved safe and efficient. Clinical findings: For the past four years, problems included abdomen ache, frequency, hesitation, and a burning sensation while passing pee. There was a history of blood in the urine on several occasions. He then proceeded to Rural hospital Wardha. Diagnostic evaluation: After being admitted, the patient had an abdominal computed tomography (C.T.) scan.The findings revealed right ureteric calculi and vesicle calculi. The results of a routine urinalysis indicate that the blood's WBC count is 4,578/L and that the creatinine (Cr) level is 140 mmol/L. Therapeutic intervention: Catheterization and bilateral nephrostomy were our first treatments, which resulted in grey pyuria. Simultaneously, piperacillin-tazobactam was widely utilized as an anti-inflammatory agent. Outcome: The patient's health has improved once all interventions have been completed. The patient's lower abdomen pain and burning when urinating have subsided, and she is now stable. Conclusion: Rarely occurs urolithiasis with an entire challenging course.

Ureteral atresia presenting as an abdominal cyst: A case report

To compare outcomes of the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy for lower calyceal and renal pelvic stones in preschool children. From January 2010 to December 2014, single renal pelvic or lower calyceal calculi 10-25 mm in size in children (age ≤6 years) treated by either extracorporeal shockwave lithotripsy (64 patients) or the mini-percutaneous nephrolithotripsy technique (54 patients) were included. Extracorporeal shockwave lithotripsy was carried out by using a Dornier electromagnetic lithotripter. The mini-percutaneous nephrolithotripsy technique was through 14-Fr renal access using a 9.5-Fr semirigid ureteroscope with holmium:yttrium aluminium garnet lithotripsy. The two study groups were compared using Mann-Whitney, χ(2) -test or Fisher's exact test. Stone parameters were similar in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups in all patients, and in the pelvic (39 Miniperc, 52 extracorporeal shockwave lithotripsy) and lower calyceal (15 Miniperc, 12 extracorporeal shockwave lithotripsy) subgroups. Stone-free rates in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups were 88.9% versus 43.8% (P < 0.001) and 94.4% versus 81.2% (P = 0.032) after first and last sessions, respectively. In the renal pelvis, they were 87.2% versus 50% (P < 0.001) and 94.9% versus 84.6% (P = 0.179), whereas in the lower calyx, they were 93.3% versus 16.7% (P < 0.001) and 93.3% versus 66.7% (P = 0.139) after first and last sessions, respectively. Retreatment rates in the mini-percutaneous nephrolithotripsy technique versus extracorporeal shockwave lithotripsy were 7.4% versus 50% (P < 0.001), 7.7% versus 46.2% (P < 0.001), and 6.7% versus 66.7% (P = 0.003) in all patients, renal pelvic and lower calyceal stones, respectively. No significant difference was found in complications (P = 0.521). Auxiliary procedures were required in 9.4% and 1.9% of children in the extracorporeal shockwave lithotripsy and mini-percutaneous nephrolithotripsy technique groups, respectively. The mini-percutaneous nephrolithotripsy technique has significantly higher stone-free rates than extracorporeal shockwave lithotripsy for renal pelvic and lower calyceal stones (10-25 mm), with a lower retreatment rate and without a significant increase in complications.

Cystitis cystica is a rare benign proliferative lesion of the bladder, caused by hyperplasia of the bladder submucosa, usually as a response to chronic irritation. It is considered to be premalignant, leading to adenocarcinoma of the bladder. Though cystitis cystica occurs mainly at the bladder neck and trigone region of the bladder, we report a case of cystitis cystica causing bilateral ureteric obstruction and loin pain. CASE REPORT A 46 year old gentleman presented to the urology clinic with abdominal and loin pain. An ultrasound scan revealed a leftsided hydroureteronephrosis. Following this, an IVU was performed, which demonstrated an irregular filling defect at the left VUJ. A rigid cystoscopy showed an inflamed bladder neck and trigone. Multiple bullae were seen and neither ureteric orifices were visible. Multiple biopsies were taken of the abnormal mucosa and bullae. Histopathology of these specimens confirmed cystitis cystica et glandularis with (globlet cell) metaplasia. The gentleman continued to have left sided loin pain. A repeat IVU continued to show marked hydronephrosis with clubbing of the calyces on the left side with hydroureter. The IVU also demonstrated right hydronephrosis and hydroureter without calyceal clubbing. The patient however was asymptomatic on this side. A DTPA scan was also performed to rule out any nonfunctioning kidneys. This showed divided function of 48% for the right kidney and 52% for the left kidney with the left kidney showing early PUJ obstruction. With continuing pain in the left loin, a percutaneous nephrostomy followed a week later by antegrade stent was placed in the left ureter as retrograde stenting was deemed difficult due to the inability to locate the ureteric orifices. A week following antegrade stent insertion, the patient was readmitted to hospital with fever, rigors and left loin pain. He was given broad spectrum antibiotics and e-coli were cultured from the urine specimen. We assumed that this episode of gram negative sepsis was solely due to stent insertion of the left ureter. He settled with antibiotics and was discharged home. A routine check rigid cystoscopy and biopsy three months following stent insertion showed an unchanged bladder with cystitis cystica still present. His urine at this point was sterile. It was decided at the multidisciplinary team meeting to perform a repeat rigid cystoscopy in a further six months. Over the next six months, the patient didn't complain of any stent related pain. He also didn't develop any further urinary tract infections. The rigid cystoscopy performed six months later demonstrated a much improved bladder. No cystitis cystica nodules were seen, the ureteric orifices were visible and patent. No further bladder biopsies were taken. The JJ stent in the left ureter was removed. The patient was discharged home and placed on bladder surveillance in the form of flexible cystoscopy.

We report the anatomical findings of a kidney discovered in a 92‐year‐old male during a routine dissection of the abdominal viscera performed by medical students at the Oakland University William Beaumont School of Medicine. The lower poles of the kidney are fused together, forming an isthmus anterior to the aorta and inferior vena cava at the L3‐L4 vertebral level. The right and left kidneys ascend past the isthmus, forming a “U” shape, the defining feature of a horseshoe kidney. The left kidney stops prematurely, approximately 3.2 cm below the inferior mesenteric artery at the level of the left inferior renal artery. The right kidney drains into superior, inferior, and middle renal arteries which have three, two, and one branches respectively. Due to the size and position of the hilum, five separate roots extend outside the kidney into the right ureter. The left side is supplied by a superior and inferior renal artery, each dividing into two branches. The left inferior renal artery branches off the ventral face of the descending aorta. The left renal vein notably has three prominent tributaries from the kidney and an additional branch of the left adrenal vein. Six roots extend from the left hilum and drain into the left ureter. In total, the kidney has nine veins, six arteries, and eleven ureteric branches draining into the left and right ureters. These findings will be useful in regard to research and surgery on other horseshoe kidneys.

The patient was 66 years old, had three pregnancies and two deliveries, and was menopausal at the age of 51. She had irregular bleeding and was found to have a chicken-egg-sized uterus and a thickened endometrium (23 mm). She underwent laparoscopic surgery for uterine endometrial cancer (endometrioid carcinoma G1, stage IB). Laparoscopic simple hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, para-aortic lymph node dissection, and partial omentectomy were performed using the transperitoneal approach (TPA). The patient was obese, with a height of 148 cm, a weight of 68 kg, and a body mass index of 31 kg/m2. She had a large amount of visceral fat, which made it difficult to expand the surgical field during para-aortic lymph node dissection. A laparoscopic fan retractor (EndoRetract II, Medtronic) was used to lift the intestinal tracts and expand the field of view. It broke the fat around the left kidney, and the exposed left ureter was heat-damaged using a vessel sealing device (LigaSure, Medtronic). Postoperatively, a left ureteral stent was placed, and continuous urine draining into the retroperitoneum was performed. To prevent injury to the left ureter, the left ovarian vein branching from the left renal vein should be exposed as a landmark before the left ureter running parallel to it is isolated. It is essential that the fat around the left kidney is not broken during this operation. The left iliopsoas muscle should be exposed, and using this as a base, the left ovarian vein, left ureter, and left perirenal fat should be compressed and moved to the left side using a fan retractor to ensure a safe operation.

BackgroundWe review urological procedures performed on a spinal cord injury patient during three decades.Case presentationA 23-year-old male patient sustained T-12 paraplegia in 1971. In 1972, intravenous urography showed both kidneys functioning well; division of external urethral sphincter was performed. In 1976, reimplantation of left ureter (Lich-Gregoir) was carried out for vesicoureteric reflux. As reflux persisted, left ureter was reimplanted by psoas hitch-Boari flap technique in 1978.This patient suffered from severe pain in legs; intrathecal injection of phenol was performed twice in 1979. The segment bearing the scarred spinal cord was removed in September 1982.This patient required continuous catheter drainage. Deep median sphincterotomy was performed in 1984. As the left kidney showed little function, left nephroureterectomy was performed in 1986. In an attempt to obviate the need for an indwelling catheter, bladder neck resection and tri-radiate sphincterotomy were carried out in 1989; but these procedures proved futile. UroLume prosthesis was inserted and splinted the urethra from prostatic apex to bulb in October 1990. As mucosa was apposing distal to stent, in November 1990, second UroLume stent was hitched inside distal end of first. In March 1991, urethroscopy showed the distal end of the distal stent had fragmented; loose wires were removed. In April 1991, this patient developed sweating, shivering and haematuria. Urine showed Pseudomonas. Suprapubic cystostomy was performed. Suprapubic cystostomy was done again the next day, as the catheter was pulled out accidentally during night. Subsequently, a 16 Fr Silastic catheter was passed per urethra and suprapubic catheter was removed. In July 1993, Urocoil stent was put inside UroLume stent with distal end of Urocoil stent lying free in urethra. In September 1993, this patient was struggling to pass urine. Urocoil stent had migrated to bladder; therefore, Urocoil stent was removed and a Memotherm stent was deployed. This patient continued to experience trouble with micturition; therefore, Memotherm stent was removed. Currently, wires of UroLume stent protrude in to urethra, which tend to puncture the balloon of urethral Foley catheter, especially when the patient performs manual evacuation of bowels.ConclusionWe failed to implement intermittent catheterisation along with anti-cholinergic therapy. Instead, we performed several urological procedures with unsatisfactory outcome; the patient lost his left kidney. We believe that honest review of clinical practice will help towards learning from past mistakes.

A two week-old Holstein heifer was examined for dribbling of urine and scalding of the perineum since birth. The history and clinical findings were suggestive of an ectopic ureter. Contrast radiography, endoscopic examination of the vagina and urinary bladder, and ultrasonography were supportive of a left ectopic ureter. A definitive diagnosis of a left ectopic ureter and hydronephrosis was made during abdominal exploratory surgery. The left kidney and ureter were removed. The calf recovered without complications or urinary incontinence.