Atrophic Left Kidney Research Articles

PS-R02-6: ASSOCIATION BETWEEN DE NOVO TYPICAL CLINICAL-SCENARIO-1 HEART FAILURE AND RENAL ARTERY STENOSIS

A 70-year-old man with sudden onset of dyspnea was referred to our emergency room. Over several years, he had received medical treatments for hypertension, diabetes mellitus, hypercholesterolemia, and obesity, and had a history of heavy smoking until the age of 60. In the past month, systolic blood pressure (BP) increased from around 120/- mmHg to 170/- mmHg or over and exertional dyspnea appeared. On admission, BP was 241/134 mmHg and pulse rate was 140 beats per minute. The chest X-ray showed severe pulmonary edema with butterfly shadow and blood gas analysis revealed the PO2 was 62.2 mmHg, the PCO2 57.7 mmHg, and the pH 7.208 with oxygen inhalation of 12 litters per minute. These were the typical manifestations of clinical scenario (CS) 1 of heart failure (HF). Chemical analysis showed total cholesterol of 240 mg/dl, LDL-cholesterol 159 mg/dl, triglyceride 127 mg/dl, creatinine 1.04 mg/dl, BNP 455.7 pg/ml, and plasma renin activity over 20 ng/ml/hr. Intravenous nitroglycerin, atrial natriuretic peptide and furosemide and noninvasive positive pressure ventilation with oxygen inhalation were consecutively administered. The symptom rapidly resolved thereafter. The left ventricular ejection fraction (EF) of 25–30 % on admission improved to 66 % 5 days later. Abdominal ultrasonography showed an atrophic left kidney (pole-to-pole length 77 mm, resistive index 0.61) compared with the right kidney (pole-to-pole length 96 mm, resistive index 0.71), which suggested the stenosis of the left renal artery and plain computed tomography showed severe calcification of the abdominal aorta and left renal artery. Contrast-enhanced magnetic resonance imaging and diagnostic angiography revealed severe left renal stenosis. There was no significant stenosis in any coronary arteries. After renal revascularization, BP decreased and antihypertensive agents were reduced, and there was no exacerbation of HF afterward. Renovascular hypertension (RH) is a rare disease in daily practice and is recognized as one of the causes of HF with unknown etiology. RH with recurrent exacerbation of HF is the indication for renal revascularization. However, renal artery stenosis is rarely identified even in HFpEF (HF with preserved EF) patients. We experienced a de novo HFpEF case with the typical features of CS 1 of hypertensive emergency complicated by RH with underlying multiple arteriosclerotic diseases. The association between de novo typical CS-1 heart failure of hypertensive emergency and renal artery stenosis might be closer and thus both conditions might more often coexist than expected, and once RH would be identified, the clinical course could be carefully observed thereafter.

313.3: Domino Kidney Transplant Following Nephrectomy for Renal Artery Stenosis With Arterial Reconstruction and Viability Assessment Using Ex Vivo Normothermic Perfusion: A Case Series

Introduction: Ex vivo normothermic perfusion (EVNP) is increasingly recognised as a viability tool to increase organ utilisation. We report use of EVNP to assess graft perfusion of potential domino transplants following therapeutic nephrectomy and backbench arterial reconstruction in four cases of refractory hypertension secondary to renal artery stenosis (RAS) unsuitable for endovascular treatment. Case Detail: Patient A and Patient B had isolated unilateral RAS presumed secondary to fibromuscular dysplasia. Pre-operative imaging and functional assessment revealed a split function of the affected kidneys to be 38% and 43%, for Patient A and Patient B, respectively. Patient C and Patient D had a wider distribution of vascular occlusive disease. Patient C had an occluded left renal artery with an atrophic left kidney and no evidence of function on isotope imaging. Following unsuccessful angioplasty and stenting, Patient D had developed in stent occlusion; subsequent imaging demonstrated hypo-perfused right kidney with 6% estimated split function. Outcome: Following nephrectomy, all kidneys were prepared on the backbench for EVNP. For Patient A and Patient B, a common stem was created using spatulation of the renal artery and reconstruction with collateral vessels (plus saphenous vein patch in Patient B). Both grafts perfused well with excellent global perfusion and urine output (EVNP assessment score=1). Beyond the stent stenosis, the renal artery from Patient C was short but allowed cannulation following dilatation. Patient D required separate cannulation (to renal artery and main collateral) with 14G cannula. Patient C and Patient D demonstrated high resistance and poorer perfusion (EVNP assessment score=4). The kidneys from Patient A and Patient B were successfully transplanted into two dialysis-dependent patients who achieved primary function and eGFR of 58 and 62ml/min/1.73m2, respectively. Discussion: The demonstration of adequate arterial reconstruction plus excellent graft perfusion whilst on EVNP, alongside favourable pre-operative functional imaging, provided confidence to transplant two marginal domino grafts.

632 A Rare Case of Genitourinary Tuberculosis Presenting as Occult Compensated Renal Failure

Abstract It is acknowledged in the literature that genitourinary TB is a diagnostic challenge due to its rarity and insidious presentation. We herein report a case of a 64-year-old gentleman originally from Peru with an unremarkable past medical history that attended his GP practice on multiple occasions complaining of recurrent left sided loin pain, headaches, and microscopic haematuria. Abdominal ultrasonography revealed an atrophic left kidney and dilated renal pelvis. This was interpreted to either be a complication of chronic renal calculi, or secondary to malignancy. Further investigations including CT urogram, MAG3 renogram, cystoscopy and anterograde pyelogram effectively ruled out malignancy, revealing hydronephrosis and loss of cortical thickness. And although this was initially dismissed, further deterioration prompted more robust investigations. A complication of testicular pain and swelling with an associated lack of response to prolonged courses of antibiotics and associated scrotal abscess on ultrasonography prompted rapid surgical decompression and drainage. Histopathological results reported findings of acute necrotising granulomatous inflammation with positive acid-fast bacilli on Ziehl-Neelsen staining – consistent with tuberculosis. Routine follow up since commencing anti-TB therapy showed marked improvement with no further episodes of haematuria or flank pain, and kidney function remained at baseline. By raising awareness of potential imaging features as well as more subtle clinical presentations, it is hoped that clinicians can consider genitourinary tuberculosis as a differential, if there is no improvement with conventional antimicrobial agents.

971 A Rare Case of a Reno-colic Fistula Presenting as a Retroperitoneal and Psoas Abscess

Abstract Background Fistulous connections arising between the kidney and colon are rare and develop due to multiple aetiologies. We present a rare case of a reno-colic fistula presenting unusually as a retroperitoneal and psoas abscess managed surgically with a good outcome. Case Report A 49-year-old lady presented with 5-day history of left flank pain and swelling with no significant surgical or medical history. Physical examination revealed a tender left renal angle with raised inflammatory markers (CRP and WCC). Computed tomography (CT) revealed an extensive collection extending from an atrophic left kidney through the retroperitoneum and psoas into the subcutaneous tissues with possible fistulation into the descending colon. This was initially treated with antibiotics and percutaneous drainage of the collection. A reno-colic fistula was confirmed via left retrograde pyelogram. Under the multidisciplinary care of the urology and colorectal general surgical teams she underwent a left nephrectomy, large bowel resection and defunctioning colostomy successfully and was discharged eight days later. Histology later confirmed an extensively scarred atrophic left kidney with multiple renal stones with no preserved glomeruli, focal inflammatory infiltrate and stromal calcification consistent with end stage nephropathy. With the resected 5 cm descending colon showing mucosal and serosal inflammation consistent with site of fistula. Conclusions Reno-colic fistula is rare and presentation with a retroperitoneal and psoas abscess uncommon. We report a rare case of a reno-colic fistula secondary to a chronically infected and obstructed left kidney managed surgically with a good outcome.

Primary squamous cell carcinoma of renal pelvis and kidney- Sole diagnosis by histopathology

Primary Squamous cell carcinoma of the renal pelvis is rare and accounts to only 0.5- 0.8 % of malignant renal tumours having poor prognosis. Chronic irritation, inflammation and infection induce the pathogenesis of this malignancy. A 53 year old male patient, presented with left flank pain since one month. On radiological investigation, his CT revealed atrophic shrunken left kidney measuring 7.9x5.2cms showing significant parenchymal thinning and complete loss of corticomedullary differentiation. A left upper ureteric calculus is seen measuring 7.5 mm with significant left renal hydronephrosis.Clinically, it was diagnosed as Xanthogranulomatous Pyelonephritis. Grossly the radical nephrectomy specimen measures 10.5x5.5x3.5cm. External surface is irregular & bosselated. On Cut surface renal architecture is effaced by necrotic mass measuring 9.5x5.0x3.0 cm involving pelvic ureter and most of renal parenchyma.Hematoxylin and eosin stained tissue revealed characteristic feature such as keratin pearls and intracellular bridges seen, rendering the diagnosis of well-differentiated keratinising squmaous cell carcinoma seen with 40% tumour necrosis associated with Keratinizing Squamous Dysplasia. In the present case, obstructive uropathy has triggered the event of malignancy. The radiologic differential diagnosis includes primary and secondary renal neoplasms and xanthogranulomatous pyelonephritis associated with renal calculi. XGP is commonly associated with lithiasis however, rarely causes keratinizing squamous metaplasia and its manifestations closely mimic renal neoplasm, leading to misdiagnosis of malignancy.The prognosis is dismal with a 5-year survival rate of <10%. CT and MRI play a crucial role in diagnosis and staging of these tumors, though histology always remains confirmatory and diagnostic.

Surviving Complications of Retroperitoneal Fibrosis with Intermittent Relapses over a Period of 20 years: Case report and literature Review

Idiopathic retroperitoneal fibrosis is a rare fibro-inflammatory disease of varied etiology which usually originates around aorta and spreads caudally along Iliac vessels into adjacent retroperitoneum causing ureteral obstruction as the most frequent complication. A 53-year-old male patient presented with complaint of mild pain in both the legs off and on. On investigating further, we found that he had been struggling with intermittent relapses every 3-4 years for last 20 years since he was first diagnosed with Idiopathic Retroperitoneal Fibrosis. He was 33-year-old when he first developed the symptoms of anuria for 48 hours and was diagnosed with Idiopathic retroperitoneal fibrosis. This was followed by atrophy of left kidney and hypertension 6 years later, then hypothyroidism after another 3years and finally involvement of Inferior Vena Cava and acute Deep Vein Thrombosis of lower limbs after another 3-4 years. His deep vein thrombosis was well managed in time. He was put on glucocorticoids everytime he had a relapse and a complication. We did a review of literature to understand recent advances about its pathogenesis, diagnosis, investigations and management. We searched in PubMed using terms like retroperitoneal fibrosis alone and in combination with related terms such as Inferior Vena Cava thrombosis, Deep Vein Thrombosis, Tamoxifen, Methotrexate. This case is unique as it is very rare to find acute Deep Vein Thrombosis in Idiopathic retroperitoneal fibrosis without development of any collaterals when Inferior Vena Cava lumen is compromised to almost complete obstruction. After a follow up of 20 years patient is doing well in terms of physical activity and psychological wellbeing with anti-hypertensives, thyroxine and anti-coagulants. Is the disease-free interval actually free of the disease or it just subsided with immunosuppressants to become active after some time?

Donepezil markedly prevents the progression of chronic heart failure and renal dysfunction in renal artery stenosis-induced hypertensive rats

Abstract Introduction Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension. Methods RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). In the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology. Results Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05) and kidney fibrosis (left: −64%, P<0.001; right: −55%, P<0.01). DT also significantly prevented the progression of CHF, through suppressing cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac fibrosis (−70%, P<0.01), and cardiac dysfunction [cardiac index: 102±3 vs. 86±3 ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05), BNP (360±13 vs. 460±39 pg/ml, P<0.05), angiotensin II and aldosteron, and suppressed the systemic inflammation. Conclusions Donepezil treatment markedly prevented the progression of CHF and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension. Funding Acknowledgement Type of funding source: None

Application of contrast-enhanced ultrasonography in the diagnosis of post-kidney transplant lymphoproliferative disorder in native kidney- a case report

BackgroundPost-transplant lymphoproliferative disorders (PTLDs) represent a spectrum of heterogenetic lymphoid proliferations. PTLD is a serious complication that affects the long-term survival of kidney transplant patients. Imaging examination is an important method for detecting and diagnosing PTLD. Contrast-enhanced ultrasonography (CEUS) and CEUS-guided biopsy are important modalities for tumor detection and diagnosis. In this case, we describe a 69 years old man in whom a native kidney PTLD was confirmed by CEUS.Case presentationA 69-year-old male patient who had a kidney transplant 1 year earlier presented with 3 months of progressive myasthenia of both lower limbs associated with amyotrophy and weight loss. Although positron emission tomography/computed tomography (PET-CT) showed a high metabolic lesion in the untransplanted kidney, abdominal contrast enhanced computed tomography cannot detect the lesion in the atrophic left kidney. The above examinations showed that the transplanted kidney was normal. CEUS can detect a homogeneously enhanced lesion in the same location as PET-CT. Subsequently, a biopsy was performed under CEUS guidance, and the final pathological diagnosis was diffuse large B-cell lymphoma. The patient then received the R-CHOP treatment. Unfortunately, pulmonary thromboembolism occurred 2 weeks later, and the patient’s condition was not alleviated through active treatment. Finally, the patient’s family gave up treatment, and the patient was discharged.ConclusionThe case suggested that CEUS was a valuable imaging method for patient with renal transplantation to detect and diagnose of PTLD.

Nefrectomía laparoscópica unipuerto con Colecistectomía concomitante: Reporte de un caso

La cirugía laparoscópica por puerto único (LESS), ofrece ciertas ventajas, como la disminución del trauma quirúrgico, menor dolor postoperatorio, menor necesidad de analgésicos y excelentes resultados estéticos. El empleo de un único puerto quirúrgico otorga la oportunidad de combinar procedimientos en una sola sesión.
 Presentamos el caso de una paciente de 59 años con antecedente de cólico renal izquierdo e infecciones de vías urinarias de repetición, así como cuadros de cólico biliar de larga evolución, ambos tratados de forma sintomática. El estudio tomográfico demuestra la presencia de riñón izquierdo atrófico, sin captación de medio de contraste, así como patología biliar concomitante. Es sometida a Nefrectomía y Colecistectomía laparoscópica con técnica LESS, con adecuados resultados quirúrgicos y estéticos.
 La técnica LESS, es una opción viable en el manejo mínimamente invasivo de diferentes patologías. Realizar procedimientos quirúrgicos simultáneos por un mismo abordaje, podría evitar la necesidad de otra hospitalización y otra cirugía; hacerlo por un único puerto proporciona adecuados resultados estéticos, así como, permitir el abordaje de sitios anatómicos distantes entre sí a través de una sola incisión.

P3501Oral administration of donepezil markedly prevents the progression of chronic heart failure in renal artery stenosis-induced hypertensive rats

Abstract Introduction Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension. Methods RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). At the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology. Results Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05). DT also significantly improved cardiac remodeling, through suppressing the progression of cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac dysfunction [cardiac index: 102±3 vs. 86±3ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), angiotensin II (17±2 vs. 23±2 pg/ml, P<0.05), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05) and BNP (360±13 vs. 460±39 pg/ml, P<0.05), and suppressed the systemic inflammation (CRP: 190±12 vs. 382±58 mg/ml, P<0.01). Conclusions Donepezil treatment markedly prevented the progression of cardiac remodeling and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

Pogorszenie kontroli ciśnienia tętniczego skojarzone ze znaczną progresją przewlekłej choroby nerek u 68-letniej kobiety z przewlekłym zamknięciem lewej tętnicy nerkowej — opis przypadku

Atherosclerotic renal artery stenosis is important etiology of secondary hypertension. Optimal treatment in this disease has been widely discussed for the recent 30 years. Authors present a case of a patient with a history of arterial hypertension, chronic closure of left renal artery, left kidney atrophy and chronic kidney disease with significant blood pressure control and kidney function deterioration in a short period of time.

A case of IgG4-related kidney disease with predominantly unilateral renal atrophy

A 73-year-old Japanese woman was diagnosed with type 1 autoimmune pancreatitis (AIP) without kidney lesions. She was treated with prednisolone (PSL) 30 mg/day, and her AIP symptoms promptly improved, after which the PSL dose was gradually tapered to 5 mg/day. Her renal function had remained normal (serum creatinine 0.7 mg/dL) until 1 year before the current admission without any imaging abnormalities in the kidney. However, during this past year her renal function gradually declined (serum creatinine 1.1 mg/dL). Follow-up computed tomography incidentally revealed unilateral renal atrophy, which rapidly progressed during the subsequent 10-month period without left kidney atrophy. A diagnosis of IgG4-RKD probably due to TIN was made, and we increased the dose of prednisolone to 30 mg/day. 1 month after administration, multiple low-density lesions on both kidneys were improved slightly but almost all lesions persisted as atrophic scars. Our case suggested that unilateral renal atrophy can develop in patients with IgG4-related tubulointerstitial nephritis without hydronephrosis caused by retroperitoneal fibrosis, and that monitoring the serum creatinine levels is not always sufficient, thereby highlighting the importance of regular imaging monitoring to detect newly developing kidney lesions.

PC176. Delayed Renal Artery Revascularization Can Be Associated With Complete Renal Recovery and Freedom From Dialysis

Acute renal ischemia can progress to irreversible loss of renal function if untreated and is considered time sensitive. Increased duration of warm ischemic time is associated with diminished long-term renal recovery. The usefulness of delayed renal artery revascularization (>48 hours) in patients with acute renal failure leading to dialysis dependence is controversial. Clinical case 1 describes a 73-year-old woman with a history of abdominal aortic aneurysm, atrophic left kidney, and right renal artery stent with a baseline creatinine of 2.3 mg/dL had presented with acute on chronic renal failure. She was severely hypertensive and hyperkalemic, with a creatinine of 9 mg/dL. She required urgent hemodialysis. On renal angiography, she was found to have a total occlusion of the right renal artery and deemed end stage renal disease. She presented 2 weeks later with a contained rupture of her abdominal aortic aneurysm. Her computed tomography scan also demonstrated opacification of the mid-right renal artery (Fig 1). She underwent open abdominal aortic aneurysm repair and right renal artery bypass. Upon discharge 12 days later, she was no longer dialysis dependent, making adequate urine, and her creatinine had returned to baseline. Clinical case 2 describes a 48-year-old woman with a history of Takayasus arteritis, prior proximal descending thoracic aorta to infrarenal abdominal aortic bypass and bypass to the left renal artery for mid-aortic syndrome, and atrophic right kidney presented with severe hypertension, fluid overload, and hyperkalemia, and a creatinine of 5.8 mg/dL requiring urgent dialysis. She was anuric and dialysis dependent. Magnetic resonance angiography revealed occlusion of the left renal artery bypass which originated from the aortic bypass graft and collateral filling of the left kidney with differential areas of perfusion (Fig 2). She underwent redo aortic graft to left renal artery bypass 18 days after her initial presentation. Upon discharge, she was no longer dialysis dependent and her creatinine has normalized. Two patients presenting with dialysis dependent acute renal failure underwent delayed renal artery revascularization, greater than 14 days from their presentation. Complete renal recovery with return to baseline renal function was observed in these patients. In select patients, delayed renal artery revascularization (>48 hours of warm ischemic time) is controversial, but can be associated with complete renal recovery and freedom from dialysis.Fig 2Case 2.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

V06-07 ROBOTIC NEPHROURETERECTOMY FOR COMPLEX RENAL ANATOMY

You have accessJournal of UrologyAdrenal, Testis, UTUC Oncology & More1 Apr 2018V06-07 ROBOTIC NEPHROURETERECTOMY FOR COMPLEX RENAL ANATOMY Tom Feng and James Porter Tom FengTom Feng More articles by this author and James PorterJames Porter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1586AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic nephroureterectomy (RNU) has demonstrated the ability to provide decreased morbidity associated with minimal invasive surgery but facilities the complete excision of the distal ureter and bladder cuff which is the standard for open surgery. We present our technique in two cases of upper tract transitional cell carcinoma (UT-TCC) in patients with complex renal anatomy. These cases required the application of principles from both partial nephrectomy and nephroureterectomy. METHODS Case 1 depicts a 54 year old male with a horseshoe kidney and renal insufficiency (GFR 42) and left high grade UT-TCC confirmed by endoscopic biopsy. Case 2 is of a 61 year old male with atrophic left kidney (GFR 65) and high grade T1 TCC in the upper moiety of a duplicated right system treated with neoadjuvant chemotherapy. Both patients had negative metastatic workup and opted for RNU given their decreased renal function. Both cases are complicated by variant renal anatomy (horseshoe kidney vs duplicated kidney) and anomalous renal vasculature. We employed a 4 arm robotic technique with the Xi platform using a linear port configuration to facilitate dissection of the kidney and distal ureter without the need for redocking or additional port placement. Unique to our technique, the ureter and bladder cuff were addressed prior to nephrectomy which we find facilitates complete dissection of the ureter. For case 1, port position was more medial and caudad given the location of horseshoe kidney. The ureter was identified and dissected down to the bladder detrusor. Prior to excising the bladder cuff completely, a 3-0 V-loc suture was placed in the detrusor muscle to provide a handle of the bladder and ensure complete, watertight closure of the bladder. Bladder closure was then tested to 240 cc. For case 2 a double-J stent was placed endoscopically in the lower moiety ureter to allow differentiation between the two ureters prior to ureteral dissection and removal. Indocyanine green (ICG) with Near Infrared imaging (NIF) was utilized in both cases to allow vessel identification and ensure selective clamping of the arterial supply of both the left moiety of horseshoe kidney (case 1) or the upper moiety of the duplicated system (case 2). Intraoperative ultrasound was used to define the margin of resection in both cases allowing division of the isthmus (case 1) or the junction between upper/lower pole moieties (case 2). Renorrhapy was performed using a two layer closure technique with an inner layer and an outer layer using the sliding clip renorrhaphy technique. Retroperitoneal lymph node dissection was then performed with meticulous use of Hemo-lock clips to prevent lymphatic leak. RESULTS There were no complications for either case. Discharge was on POD1 and POD2 for patients 1 and 2, respectively. Pathology for case 1 was pT3N0 invasive papillary TCC with negative margins and case 2 was pTis/TaN0 high grade TCC with negative margins. Both patients are disease free and have good residual GFR after surgery (GFR 32 for patient 1 and GFR 33 for patient 2). CONCLUSIONS Robotic nephroureterectomy is a safe and feasible alternative to open or laparoscopic approach for management of UT-TCC. It allows complete removal of the distal ureter with bladder cuff in keeping with established oncologic principles. With surgeon experience, RNU can be applied to cases with complex renal anatomy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e662-e663 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Tom Feng More articles by this author James Porter More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of Endovascular Repair of Ascending Aortic Dissection in Patients Unsuitable for Direct Surgical Repair

BackgroundStent grafting is a therapeutic option for patients who are unable to undergo urgent surgical repair of ascending aortic dissections. However, follow-up regarding outcomes is limited. ObjectivesThis study reports mid-term outcomes with endovascular repair for ascending aortic dissections in patients deemed high risk for open repair. MethodsBetween May 1, 2009 and January 31, 2011, 15 ascending aortic dissection patients (ages 45 to 78 years) ineligible for direct surgical repair underwent endovascular repair (1 acute dissection, 7 subacute dissections, and 7 chronic dissections) and were closely followed up for a median of 72 months (range 61 to 81 months). ResultsThe mean interval between aortic dissection onset and treatment was 25.5 (range 6 to 353) days. Technical success was achieved in all patients. No major morbidity or deaths occurred perioperatively. During the follow-up period, there were no deaths, 8 complications occurred, and there were 4 reinterventions. A new dissection in the aortic arch was treated with a branched endograft. One patient developed retrograde aortic dissection and a left ventricular pseudoaneurysm was successfully treated with open surgery. One cardiovascular ischemia was treated with stenting and 1 supraventricular tachycardia was treated with radiofrequency ablation. Other morbidities included perigraft endoleak, a bird-beak sign, a temporary pericardial effusion, and a left kidney atrophy. Significant enlargements of true lumens and shrinkage of false lumens and overall thoracic aorta were observed at 12 months. No significant changes were detected subsequently. Minimal impact on aortic valve function was recorded over time. ConclusionsOur results with the novel endovascular procedure appear acceptable. Additional evidence and studies with larger sample size and longer follow-up are needed to support the durability of this new technique.

Genitourinary tuberculosis in North America: A rare clinical entity.

Although tuberculosis (TB) is the most common cause of mortality from infectious diseases worldwide, genitourinary TB in North America is rare. We review 3 cases of genitourinary TB diagnosed within the last 5 years. The first case is that of a 76-year-old African-Canadian woman who was referred for percutaneous nephrolithotomy of right lower pole renal stones. Although renal TB was suspected, her initial urinary TB culture was negative. On follow-up imaging, she developed bilateral ureteral thickening and ureteroscopic biopsy confirmed necrotizing granulomata. Repeat urine cultures were positive for M. tuberculosis. The second case is a 73-year-old Italian-Canadian woman who was referred for ureteroscopic biopsy of left thickened ureter to rule out urothelial carcinoma. Initial urine TB cultures were negative, despite biopsies confirming granulomatous inflammation. She was closely followed with urine cytologies and TB cultures. Repeat urine culture was positive for M. tuberculosis. Both patients were treated with a course of anti-tuberculous agents and indwelling ureteral stents to relieve ureteral obstruction. The third case is a 70-year-old Cree woman who was referred for percutaneous nephrolithotomy of a left "staghorn stone" in an atrophic left kidney. Thirty years earlier she had been treated for pulmonary TB in addition to ileocystoplasty for a "thimble" bladder. A computed tomography scan showed autonephrectomized left kidney. Her urine TB cultures were negative. She was placed on prophylactic antibiotics for her recurrent bacterial urinary tract infections. Genitourinary TB may present in various subtle ways, and the astute clinician must have a high index of suspicion for this disease in patients with atypical clinical and radiologic findings. In addition, TB urine cultures should be repeated when there is high index of suspicion.

Deep Venous Thrombosis of the Leg, Associated with Agenesis of the Infrarenal Inferior Vena Cava and Hypoplastic Left Kidney (KILT Syndrome) in a 14-Year-Old Child.

Agenesis of the inferior vena cava (IVC) is a rare anomaly which can be identified as incidental finding or can be associated with iliofemoral vein thrombosis. IVC agenesis has a known association with renal anomalies which are mainly confined to the right kidney. We describe a case of a 14-year-old male who presented with left leg swelling and pain. Ultrasonography confirmed the presence of left leg deep vein thrombosis (DVT). No underlying hematologic risk factors were identified. A CT scan was obtained which demonstrated absent infrarenal IVC and extensive thrombosis in the left deep venous system and development of collateral venous flow into the azygous/hemiazygous system, with extension of thrombus into paraspinal collaterals. An additional finding in the patient was an atrophic left kidney and stenosis of an accessory left renal artery. Agenesis of the IVC should be considered in a young patient presenting with lower extremity DVT, especially in patients with no risk factors for thrombosis. As agenesis of the IVC cannot be corrected, one should be aware that there is a lifelong risk of lower extremity DVT.

Laparo-Endoscopic Single Site Surgery of Concomitant Left Adrenalectomy, Leftc, and Bilateral Partial Oophorectomy in a Woman

Aim: We reported one case who received laparo-endoscopic single site (LESS) surgery for the left adrenal gland, left kidney, and bilateral ovarian cysts. Method: The patient was a 43 year-old female who had a left adrenal tumor, atrophic left kidney with severe hydronephrosis, and bilateral ovarian cysts. We placed a LESS device with 4 working ports through a para-umbilical wound of 3 cm in length. We concomitantly performed a left adrenalectomy, left nephroureterectomy, and bilateral partial oophrectomy with the patient lying on her right side. Results: There were no peri-operative and post-operative complications, and an extra incision was unnecessary. The patient was discharged 5 days after the operation. Discussion: LESS surgery for three concomitant operations with an un-changed position is feasible and safe. Conclusion: This is the first report of three concomitant procedures through one incision, which greatly decreases the number of wounds.

Retrovesical hydatid cyst presenting with urinary retention and left kidney atrophy

Hydatid disease of the urinary tract is uncommon, accounting for only 2-3% of cases. There are very few reported cases in the literature of pelvic hydatid cysts causing obstructive uropathy and renal failure. We report a case of pelvic hydatid cyst in a patient presenting with urinary retention and secondary complete atrophy of one kidney. The patient was treated with surgical excision of this large retrovesical cyst, along with a simple left nephroureterectomy, with rapid improvement of symptoms. Hydatid disease should be taken into consideration in the differential diagnosis of a cystic mass in any anatomic localization, especially in patients from endemic areas.

Retrovesical hydatid cyst presenting with urinary retention and left kidney atrophy

Retrovesical hydatid cyst presenting with urinary retention and left kidney atrophy