Left Flank Pain Research Articles

SAT-184 Silent Pheochromocytoma Complicated by Adrenal Insufficiency After Unilateral Adrenalectomy

Background: Adrenal insufficiency (AI) following unilateral adrenalectomy for pheochromocytoma (PCC) is an exceedingly rare occurrence described previously in 1 study in only 4 out of 13 patients with unilateral PCC. We discuss an unusual case of a patient with incidentally discovered PCC who underwent unilateral adrenalectomy and subsequently developed AI. Clinical Case: 61-year-old male in overall good health taking no medications presented with left flank and groin pain after a handlebar injury in a bicycle crash. CT angiogram Abdomen & Pelvis revealed a complex enhancing left adrenal mass with internal necrosis measuring 13 x 12 cm. He denied history of headaches, diaphoresis, chest pain or hypertensive crisis. He did endorse palpitations which had resolved with reduced caffeine intake. Labs showed plasma free metanephrine 3,295 pg/mL (ref range <57) and normetanephrine 68,472 pg/mL (<148), 24hr urine metanephrine 192,677 ug (52-341), 24hr urine normetanephrine 171,880 ug (88-444), 24hr urine vanillylmandelic acid (VMA) 182 mg (1.8-6.7), serum aldosterone 8.1 ng/dL (<39.2), serum free cortisol 0.47 ug/dL (0.07-0.93), 24hr urine cortisol 41.6 ug (<60), DHEA sulfate 37 ug/dL (42-290). He was started on phenoxybenzamine and underwent left adrenalectomy. Of note patient remained only minimally hypertensive with tumor manipulation intraoperatively. Pathology was consistent with PCC with no evidence of regional or distant metastases. Postop-labs showed plasma free metanephrine <25 pg/mL and normetanephrine 122 pg/mL. Calcitonin and parathyroid hormone levels were normal. Patient was evaluated in endocrinology clinic 4 weeks after surgery for complaint of severe fatigue, weight loss, anorexia and myalgias. Adrenocorticotropic hormone (ACTH) level was 31 pg/mL (7.2-63) with AM cortisol of 2.1 ug/dL (5-23) which increased to 7.4 ug/dL 1 hour after Cosyntoprin 250 mcg stimulation. He was started on prednisone 10 mg once daily with significant improvement in his symptoms. Conclusion: PCCs typically manifest as sustained or paroxysmal hypertension, episodic headaches, palpitations or diaphoresis. Our patient was found to have a PCC with strikingly elevated levels of catecholamines without typical signs and symptoms of PCC. To the best of our knowledge this is the 5th reported case where a patient developed AI after unilateral adrenalectomy for PCC. There are case reports describing PCCs which secrete both catecholamines and ACTH. However, our patient lacked clinical or biochemical evidence of hypercortisolism preoperatively and his tumor cells in path sample stained negative for ACTH. Other possible pathophysiologic mechanisms include ectopic corticotropin releasing factor production leading to subclinical Cushing syndrome (SCS). Clinicians should have a high suspicion for SCS in the setting of PCC to promptly diagnose and treat AI after unilateral adrenalectomy.

SUN-179 Oncocytic Adrenocortical Carcinoma: A Case Report

Adrenocortical carcinoma (ACC) is a rare tumor with a poor prognosis. Oncocytic variant of adrenocortical carcinoma is considered to be an even more rare malignancy with four reported in the literature in 2002 and thirty-six documented in 2015 i ii. This case report illustrates the case of oncocytic ACC.A 40-year-old woman post-hysterectomy from cervical cancer presented to the ER with severe left flank and back pain for two weeks. There was no weight loss or early satiety. CT scan revealed a large left adrenal mass measuring 12x9x13 cm, displacing the left kidney inferiorly with no metastasis to nearby structures. We ruled out functional adrenal mass through a 24-hour urine collection and blood work, then performed open left adrenalectomy.Grossly, it was a large, tan-colored mass, weighing approximately 2,500 grams. On biopsy, we incidentally found the mass to be oncocytic adrenocortical carcinoma. Using the Lin-Weiss-Bisceglia criteria, it met two major and one minor criteria, when only one major criterion is required to indicate malignancy. Immunohistochemical stains showed that the tumor cells were positive for Mart-1, inhibin, and synaptophysin. Quantitative Ki-67 showed a proliferation index of 10% in average (>5% is considered malignant). Even though adrenocortical carcinoma, specifically the oncocytic variant of ACC, is a very rare occurrence, it should be on the differential diagnosis for a chief complaint of unilateral flank pain with a large adrenal mass on CT due to its poor prognosis.Endnotes i Hoang, M., Ayala, A. & Albores-Saavedra, J. Oncocytic Adrenocortical Carcinoma: A Morphologic, Immunohistochemical and Ultrastructural Study of Four Cases. Mod Pathol 15, 973-978 (2002) doi:10.1038/modpathol.3880638 ii Kalra S, Manikandan R, Srinivas BH. Oncocytic adrenocortical carcinoma--a rare pathological variant. BMJ Case Rep. 2015;2015:bcr2014208818. Published 2015 Apr 24. doi:10.1136/bcr-2014-208818

SUN-154 Resistant Hypertension After Shockwave Lithotripsy: The Rude Awakening of an Adrenal Incidentaloma

BACKGROUNDThe National Institutes of Health defines adrenal incidentalomas (AIs) as clinically inapparent adrenal masses discovered inadvertently in diagnostic testing or treatment for conditions not related to the adrenal glands. Non-functional adenoma remains the most frequent (60–85%) cause, while functional adenomas at 5–16%.CLINICAL CASEA previously healthy 41 year-old female consulted for a 2-month history of left flank pain. Computed tomography (CT) scan of the kidneys revealed left calculi and incidental right adrenal mass. She was asymptomatic at this time. She then underwent shockwave lithotripsy for the renal calculi. However, post-operatively, she had elevated blood pressure and was started on anti-hypertensives. She remained hypertensive despite being on four different medications. Pertinent physical examination findings: plethora of the face and extremities, Moon facies, Buffalo Hump, and pendulous abdomen with grayish striae. Further work-up revealed the AI to be cortisol-secreting. Pertinent laboratories: 1 mg dexamethasone suppression test - 800 nmol/L (<50 nmol/L), 24-hr urine free cortisol - 1014.86 ug/24 hr (20–90 ug/24 hr), Adrenocorticotropic Hormone (ACTH) - 5.0 pg/ml (9–52 pg/ml). She then underwent a right laparoscopic adrenalectomy. Post-operatively, her blood pressure normalized without her anti-hypertensive medications. Tissue biopsy of the mass was consistent with an adrenocortical adenoma. On her follow-up after one month, signs of Cushing’s Syndrome were clinically improving.CONCLUSIONThis is the first case that demonstrated shockwave lithotripsy converting a non-functioning adrenal incidentaloma into a functioning one. It also shows how internists and surgeons (i.e. Urologists) can manage various aspects of patient care through the facilitation of medical treatments, surgical interventions, and ensuring a proper multidisciplinary approach based on the endocrinology clinical guidelines. So as not to delay the delivery of proper management to the patient.REFERENCES(1) Grumbach M, Biller B, Braunstein G. et al. “Management of the clinically inapparent adrenal mass (“incidentaloma”).” Annals of internal medicine 2003; 138:424–4292 Herrera M, Grant C, van Heerden J. et al. “Incidentally discovered adrenal tumors: an institutional perspective.” Surgery 1991; 110:1014.

Remember the “Putty Kidney”—A Reminder of Days Gone by

The term ‘‘putty kidney’’ was first used in 1906 by Dr. F. Tilden Brown, a genitourinary surgeon, to describe a well-defined density seen in kidney region on standard radiograph which is caused by a ‘‘putty-like’’ substance that had formed a cast inside a tuberculous kidney. The putty kidney is a classic imaging sign, rarely seen nowadays which represents a nonfunctioning autonephrectomized kidney seen in end stage renal tuberculosis.1-5 Here, we describe a 45-year-old female with left flank pain who on imaging had a classic putty kidney which led to an evaluation and later confirmation of a diagnosis of renal tuberculosis.

Nutcracker Syndrome—A Rare but Important Cause of Varicocele in Adolescent Boys

Nutcracker syndrome is a complex of clinical symptoms due to compression of the left renal vein between abdominal aorta and superior mesenteric artery. Hematuria and pelvic or back pain are the most common presenting symptoms with varicocele being an uncommon clinical finding in these patients especially in children. Doppler ultrasound, computed tomography and selective left renal vein phlebography are useful to confirm the diagnosis. Treatment can be conservative or surgical depending on the severity of symptoms. Here, we report a 13-year-old boy with left flank pain and varicocele on examination who on evaluation was found to have nutcracker syndrome as the etiology.

A patient with colitis-associated cancer who developed clinically manifest Crohn\u2019s disease only after surgery

BackgroundPatients with prolonged inflammatory bowel disease have a greater risk of colorectal cancer, known as colitis-associated cancer. Here we describe an unusual case of colitis-associated cancer.Case presentationThe subject is a 41-year-old male who has not presented digestive symptoms and has an appreciable medical history. He consulted a nearby doctor with left flank pain. A colonoscopy revealed a lateral spreading tumor (granular-type) in his descending colon. With a clinical diagnosis of cancer, D3 left hemicolectomy was performed and a small intestine stoma was constructed. The pathological diagnosis of the tumor was mucinous adenocarcinoma, pT4a(SE), pN2a, which was associated with dysplasia in the surface area. Post-operative ileus was prolonged and the endoscopic examination revealed longitudinal ulcers in the ileum. These ulcers responded quite well to the administration of infliximab, confirming the final diagnosis of Crohn’s disease. Pathological re-examination revealed that the tumor was dysplasia-associated type, and another dysplasia was confirmed near the tumor. Furthermore, mural scars and sporadic lymphoid aggregates were noted in the colon tissues, which suggested pre-existing Crohn’s disease. The patient died of peritoneal dissemination of cancer on day 207 after surgery.ConclusionThe present case was diagnosed as colitis-associated cancer with clinically latent Crohn’s disease, who developed clinically manifest Crohn’s disease only after surgery. Our review of literature revealed no cases comparable to ours.

Rare Unilateral Spontaneous Adrenal Hemorrhage

Bleeding in the adrenal glands can be bilateral or unilateral. While it is most common in infants, it can also be observed in young adults and adults and is seven times more common in adolescents than in adults. Idiopathic unilateral hemorrhage is a very rare condition that occurs due to an idiopathic spontaneous rupture or an undetected adrenal mass. The main signs of adrenal bleeding are hemorrhagic shock, flank pain, and fever. Adrenal bleeding is rarely reported, and the ideal treatment is not clear. We present a patient with unilateral idiopathic adrenal bleeding who presented to the hospital with left flank pain and hemorrhagic shock.

V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME

You have accessJournal of UrologyUpper-Tract Reconstruction (V05)1 Apr 2020V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME Buddima Ranasinghe*, Sohrab Arora, Amit Patel, Judith Lin, and Craig Rogers Buddima Ranasinghe*Buddima Ranasinghe* More articles by this author , Sohrab AroraSohrab Arora More articles by this author , Amit PatelAmit Patel More articles by this author , Judith LinJudith Lin More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000874.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal nutcracker syndrome (NCS) is a venous entrapment caused by compression of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA). Surgical options for treatment of NCS include LRV transposition, gonadal vein transposition, renocaval bypass, and renal autotransplantation. Endovascular left renal vein stenting may lead to stent migration and fracture. Thus, we present an alternative, unique, minimally invasive treatment option. METHODS: A 20-year-old man presents with intermittent, debilitating left flank pain for 6 months. He developed an episode of gross hematuria without hypertension, oliguria, dysuria, or fever. CT venogram showed compression of the LRV between the aorta and SMA with an acute, aortomesenteric angle of 25 degrees. Venogram with pressure measurement showed a gradient of 3 mmHg across the compression. Intravascular ultrasound showed 94.4% luminal compression of the LRV. After discussion of all surgical and endovascular options, the patient decided to proceed with robotic-assisted laparoscopic resection of fibrous ring and placement of extravascular graft. The patient was positioned with right lateral decubitus. Six ports were used via transperitoneal technique. After the retroperitoneal space was incised along the inner margin of the descending colon, the LRV was mobilized. The pancreas and the left adrenal vein was identified. Tissue surrounding the left gonadal vein was excised. The fibrous bundles were excised around the outflow end between the aorta and SMA to release the renal vein compression. An externally reinforced, expanded PTFE, 16 mm in diameter, was introduced and bound to the surface of the renal vein along the long axis to prevent blood vessel compression. The PTFE cuff was sutured and tacked to the surface of the aorta and retroperitoneal tissues. SMA was lowered and stabilized over the graft. RESULTS: The operative time was 3 hours. Estimated blood loss of 10 ml. Length of stay was 1 day with no complications. At 4-week postop visit, he was doing well with full resolution of the left flank pain. Post-op intravascular ultrasound showed patent left renal vein with no evidence of elevated flow velocities. Renal vein cuff visualized at SMA with PSV of 67 cm/sec. Left gonadal vein patent with retrograde flow noted. CONCLUSIONS: Robotic-assisted laparoscopic resection of a fibrous ring and placement of an extravascular cuff around the left renal vein is an effective, minimally invasive approach for treatment of nutcracker syndrome with no warm ischemic injury and no venous anastomosis. Magnification and stability of the dual-lens robotic camera offer excellent visibility and substantially lower blood loss compared to open surgery. Source of Funding: NONE © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e470-e470 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Buddima Ranasinghe* More articles by this author Sohrab Arora More articles by this author Amit Patel More articles by this author Judith Lin More articles by this author Craig Rogers More articles by this author Expand All Advertisement PDF downloadLoading ...

V05-04 RENAL HYDATID: LAPAROSCOPIC PERICYSTECTOMY AND OMENTOPLASTY USING PALANIVELU HYDATID SYSTEM

You have accessJournal of UrologyUpper-Tract Reconstruction (V05)1 Apr 2020V05-04 RENAL HYDATID: LAPAROSCOPIC PERICYSTECTOMY AND OMENTOPLASTY USING PALANIVELU HYDATID SYSTEM Prashant mulawkar*, Abhishek Bhagwat, Parag Tapre, Giridhar Panpaliya, Amol Khandelwal, and Sumeet Agrawal Prashant mulawkar*Prashant mulawkar* More articles by this author , Abhishek BhagwatAbhishek Bhagwat More articles by this author , Parag TapreParag Tapre More articles by this author , Giridhar PanpaliyaGiridhar Panpaliya More articles by this author , Amol KhandelwalAmol Khandelwal More articles by this author , and Sumeet AgrawalSumeet Agrawal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000874.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hydatid disease is endemic in Mediterranean countries and Indian subcontinent. But renal Hydatid is a rare disease. We present a case of primary left renal hydatid cyst managed laparoscopically. METHODS: Forty one year male patient presented with left flank pain and passage of grape like material in urine. His left kidney was palpable. Computed tomography showed a 17x12 cm cystic lesion at the lower pole of left kidney. Left kidney showed delayed excretion of the contrast, moderate hydronephrosis. On delayed CT spots, there was pooling of excreted contrast and multiple daughter cysts which were seen as filling defects. He was put on albendazole and scheduled for laparoscopic surgery after two weeks. The challenges in laparoscopic hydatid surgery are avoidance of spillage and minimizing the incision for specimen retrieval. Both these issues are taken care of by Palanivelu hydatid system (PHS). The PHS consists of a 12 mm laparoscopy trocar and canula. The trocar is fenestrated at tip and hollow throughout. Each facet of the pyramidal tip is fenestrated to allow suction of the hydatid fluid leaking on the insertion. The shaft of the trocar also bears two fenestrations. There are two side channels, smaller for irrigation and the larger for suction. Preliminary left ureteric catheterization was done. Three laparoscopic ports were used for the access to the peritoneal cavity. The cyst was isolated with gauze soaked in scolicidal 1.6% NaCl. The renal hydatid cyst was approached with PHS through a separate port. A separate camera, telescope, light source and monitor was used for the PHS system and primary laparoscopy. All daughter cysts were sucked out through PHS. The cavity was irrigated thrice with scolicidal NaCl. Pericyst was excised partly. Communication with the collecting system was sutured. Omentoplasty was done. Drain was kept in the cavity. RESULTS: The lap operating time was 97 minutes. Blood loss was less than 100 ml. Total 2 liters of hydatid material was removed. Patient was orally allowed on Day 2 and discharged on Day 5. CONCLUSIONS: We demonstrate laparoscopic management of renal hydatid cyst without spillage using the PHS System. Source of Funding: Nil © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e471-e471 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Prashant mulawkar* More articles by this author Abhishek Bhagwat More articles by this author Parag Tapre More articles by this author Giridhar Panpaliya More articles by this author Amol Khandelwal More articles by this author Sumeet Agrawal More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-05 RENAL VEIN TRANSPOSITION WITHOUT VENOUS OUTFLOW OCCLUSION

You have accessJournal of UrologyTransplant, Misc GU Cancers & Bladder Reconstruction (non-cancer) (V11)1 Apr 2020V11-05 RENAL VEIN TRANSPOSITION WITHOUT VENOUS OUTFLOW OCCLUSION Kyle Rose*, Matthew Breite, Victor Davila, and Erik Castle Kyle Rose*Kyle Rose* More articles by this author , Matthew BreiteMatthew Breite More articles by this author , Victor DavilaVictor Davila More articles by this author , and Erik CastleErik Castle More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000945.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot assisted transposition of the renal vein has been described for Nutcracker Syndrome. Unfortunately, surgical repair requires clamping of the venous outflow of the kidney via the left renal vein, which may cause renal parenchymal injury. Our objective was to perform transposition of the renal vein while providing continuous venous outflow from the kidney to avoid venous congestion and renal parenchymal injury. METHODS: A thirty-two year old female with one-year history of left flank pain and inability to walk upright due to this pain. Her computed tomography scan revealed compression of the left renal vein under the superior mesenteric artery. She underwent a venogram with intravenous ultrasound, which demonstrated >90% narrowing of the left renal vein under the SMA, diagnostic for Nutcracker Syndrome. RESULTS: After positioning in Trendelenburg position and obtaining pneumoperitoneum, ports were placed similar to a robot assisted retroperitoneal lymphadenectomy procedure. The retroperitoneum was exposed by incising the posterior peritoneum and tacking this to the anterior abdominal wall. The inferior vena cava (IVC) was identified and skeletonized, with emphasis on identification and dissection of the left renal vein. Vascular control was obtained using modified Rummell tourniquets. During our dissection, we identified a dilated and prominent left gonadal vein. We anastomosed the distal aspect of the left gonadal vein to the IVC, to provide constant venous outflow from the left kidney during transposition of the left renal vein. With the left kidney draining through both the left renal and gonadal vein, the left renal vein was stapled flush with the IVC. We then performed left renal vein transposition by anastomosing the left renal vein to the IVC below the left of the previous insertion with Gore-Tex suture. Vascular clamps were removed to assess the integrity of the anastomoses, and hemostasis was excellent. Total estimated blood loss was 50mL, and total operative time was 3 hours and 19 minutes. Postoperative creatinine improved to 0.57 mg/dL from 0.75 mg/dL preoperatively. The patient was discharged on postoperative day one. At 6 weeks follow up, her flank/abdominal pain had completely resolved. CONCLUSIONS: Robot assisted renal vein transposition is a feasible and safe alternative to open transposition for Nutcracker Syndrome. Transposition of the left renal vein without venous outflow obstruction is possible when utilizing the native gonadal vein as a conduit to the IVC. Using this approach, adequate venous outflow can avoid nephron injury. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1015-e1016 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Rose* More articles by this author Matthew Breite More articles by this author Victor Davila More articles by this author Erik Castle More articles by this author Expand All Advertisement PDF downloadLoading ...

SAT-104 A rare drug toxicity as an unexpected finding on kidney biopsy

Renal biopsy in cases of unexplained renal failure can occasionally show findings which may not be directly relevant to the clinical scenario, but which nonetheless has a bearing on the long term follow up and management, in the form of addition of a therapeutic regimen, or preventing further exposure to an offending drug. A 35 year old Emirati gentleman was admitted to the hospital on 25th of April 2019 with complaints of left flank pain, dysuria, increased urination, headache and mildly confused state. Past history was significant for bipolar affective disorder for which he was on therapy from a different hospital with Risperidone, Clonazepam and Procyclidine. There was no history of renal disease. Clinical examination revealed an individual who was disoriented in time and place, and hypertension, with rest of the examination findings being unremarkable. Investigations revealed anemia, bland urine sediments, azotemia, hyponatremia, low serum and urine osmolality and normal sized kidneys on ultrasound with mild increase in cortical echogenicity. He was diagnosed with hyponatremia and unexplained renal failure. The serum sodium was corrected with 3% saline and water restriction, and a renal biopsy was performed The biopsy returned a picture of mild mesangial expansion (Image 1), foci of acute kidney injury, chronic interstitial nephritis and microcystic dilatation of the tubules ( Image 2), one of the lesions seen in chronic lithium toxicity. On further enquiry with the patient, a remote history of Lithium consumption was obtained but the duration was unknown. It was stopped completely 3 years ago. During clinic follow up, urine output and Sodium was maintained normal with fluid restriction alone. The renal functions showed an improvement from the time of admission, and since has remained stable.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Lithium nephrotoxicity spans a spectrum, from concentration defects to nephrogenic diabetes insipidus, chronic interstitial nephritis and rare glomerular involvement. Duration of treatment and cumulative dose are the determinants of renal toxicity. Careful monitoring and early withdrawal are the key to limiting damage, as a creatinine more than 2.5mg/dl at biopsy is a risk for progression to ESRD. In those with early signs of toxicity, but in whom Lithium would be necessary, a concurrent use of Amiloride could limit the damage.

Thoracolumbar Junction Syndrome Accompanying Renal Artery Stenosis: A Case Repor

Flank pain is a common reason for visits to the emergency room. The most common reason warranting hospital visits are urology-related problems. However, there are many other causes, such as musculoskeletal lesions, that difficult to achieve a correct diagnosis. Here, we describe a rare case of flank pain caused by thoracolumbar junction syndrome, accompanying renal artery stenosis. A 54-year-old male with hypertension presented with severe left flank pain for 1 week. Initially, he was diagnosed with left renal artery stenosis by computed tomography and decreased renal function on renal scan (Tc-99m DTPA). Although a stent was inserted into the left renal artery, flank pain persisted with only minor improvement. Through detailed physical examination, he was finally diagnosed with thoracolumbar junction syndrome. After three injections in the left deep paravertebral muscles at the T10–T12 levels, flank pain completely ceased. Clinicians must consider thoracolumbar junction syndrome, when treating patients with flank pain.

PRIMARY EWING’S SARCOMA OF THE KIDNEY: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE

Ewing’s sarcoma is a highly malignant tumor that usually arises from the bone and soft tissue of the extremity. Primary Ewing’s sarcoma of the kidney is extremely rare. Here, we present the case of primary Ewing’s sarcoma of the kidney in a 30-year-old man, presented with the left flank pain, and treated with the left radical nephrectomy with adjuvant chemotherapy. Despite the treatment options, the overall survival of the disease is poor. The relevant literature of this rare entity was reviewed.

Nephron sparing surgery for giant renal angiomyolipoma; a viable option?

Angiomyolipomas (AML) are most common benign tumors of the Kidney. It may be an incidental diagnosis or in symptomatic patients it may cause flank pain,hematuria or renal mass. Also, sometimes renal AML may present initially as spontaneous retroperitoneal hemorrhage secondary to rupture (Wunderlich syndrome). AML &gt;10 cm in size is known as giant AML and the data available on this entity is sparse. Herein, we report a case of a 28-year-old homemaker who had left flank pain for 3 months, on evaluation elsewhere, Ultrasonography, and Contrast Computed Tomography Scan - Kidney Ureter Bladder showed a left giant renal AML. This patient came to our centre for further management. Subsequently, this patient underwent left open Partial Nephrectomy; specimen was 21.5 cm x 16 cm x 14 cm in size and weighed 1330 g. Histopathological analysis showed AML. It is important to contemplate a primary nephron sparing approach even in a case of giant renal AML, as it may turn out to be a correct choice with a positive outcome.

Collecting Duct Carcinoma: A Rare Entity

ABSTRACTCollecting duct carcinoma is a rare and highly aggressive subtype of renal cell carcinoma. The incidence rate is less than 1-2% of all renal tumors and usually, affect middle-aged adult, commonly in men. We reported a 76-year-old man complains of an intermittent painless gross hematuria, abdominal mass and left flank pain for approximately three months. The CT abdomen showed a slightly enhancing solid mass in the left kidney and para-aorta lymphadenopathy. Cut surfaces of the kidney showed a solid-cystic and ill-defined greyish-white tumor. Microscopically, tumor formed solid sheets and tubulopapillary structures lined by neoplastic cells, hobnailing nuclei, abnormal mitotic, and a desmoplastic stroma with lymphoplasmacytic infiltration, and the immunochemical profile were PAX8 (+) /p63 (-). Based on these findings, the diagnosis was a collecting duct carcinoma. This tumor arising from the collecting duct of Bellini in the renal medulla, accounts for less than 1-2% of all renal masses and important to be distinguished from other tumors due to differences in prognosis and therapeutic. Histopathological examination is needed to establish the diagnosis. A case of collecting duct carcinoma that occurred in a 76-year-old man has been reported. A definitive diagnosis can only be done with a detailed histopathological examination for patient management benefits.Keywords : renal cell carcinoma, collecting duct carcinoma, urothelial carcinoma, PAX8, p63

Intraoperative Cardiogenic Shock Caused by Intracardiac Tumor Thrombi Obstruction

A 60-year-old man presented with left flank pain, a palpable abdominal mass, and hematuria for months. Computed tomography revealed a large tumor in the left kidney (approximately 17.7 cm in diameter) with evidence of left adrenal, left renal vein, and inferior vena cava (IVC) invasion. He underwent left nephrectomy with IVC thrombectomy. Transesophageal echocardiography (TEE) was used during the whole procedure and the tumor was found in the IVC (Fig-1) before resection.

Spontaneous retrograde migration of mid ureteric calculus into the kidney: First ever report from India

We present a case of spontaneous retrograde migration of mid ureteric calculus into the kidney. A 55 year old male, who presented with left flank pain, was diagnosed with a left mid ureteric calculus on ultrasound abdomen. X ray KUB and CT KUB confirmed the same. Intervention was planned as he did not respond to Medical Expulsive Therapy. On day three, he developed urinary intermittency followed by pain relief. We suspected the calculus to have spontaneously passed out and an X ray KUB was done to confirm it. To our surprise, the same calculus was seen in the kidney instead of ureter. A repeat CT KUB confirmed that the calculus has up migrated into the lower calyx of the kidney.

Successful non-operative management of extensive pneumomediastinum and pneumoperitoneum

Background: A 70 year old male presented with acute left flank pain and was found to have extensive free air in both the mediastinal and peritoneal cavities. He was managed successfully without surgery. Case: A 70 year old male presented with left flank pain that began an hour prior to arrival. He had a history of obstructive sleep apnea that had been treated with continuous positive airway pressure therapy (CPAP) at home for many years. His vital signs, physical exam, and laboratory testing were all unremarkable. However, imaging findings were impressive for massive pneumoperitoneum and pneumomediastinum. Given his clinical stability, operative exploration was deferred, and he was admitted for observation and bowel rest. He was discharged less than 48 hours after admission without incident. His history of home CPAP therapy was the only attributable cause for the ominous findings seen on his imaging. Recognizing that this was a case of benign free air saved this patient from the morbidity and potential for death that comes with an unnecessary operative exploration. Conclusion: Continuous positive airway pressure therapy can result in benign free air within the mediastinal and peritoneal cavities. Evaluating the complete clinical scenario will allow for recognition of similar cases in which these grim findings are not indicative of surgical disease, thus avoiding the iatrogenesis of unnecessary surgery.

Catheter-directed thrombolysis for acute renal infarction

Acute renal infarction is an uncommon disease, which is frequently misdiagnosed or diagnosed late because of its nonspecific clinical presentation, and may result in irreversible damage to the renal parenchyma. Here, we present a case of acute renal infarction in a 51-year-old male, presenting with left flank pain and being diagnosed through computed tomography. We successfully performed catheter-directed thrombolysis to rescue the ischemic renal tissue and preserve the renal function.

An Unusual Case of Mucinous Cystic Neoplasms of the Pancreas at Pregnancy

A mucinous cystic neoplasm (MCNs) of the pancreas is an uncommon tumor that occurs mostly in females and are potentially sex hormone-sensitive. However, a MCN occurring during pregnancy is quite rare. A 25-year-old woman in the 35 week of gestation was referred to us because of a left flank pain. After unsuccessful treatment for pyelonephritis, a MRI revealed a large intra-abdominal cystic lesion. The patient subsequently underwent cesarean delivery and latter had tumor resection with distal pancreatectomy and splenectomy. Histopathological revealed a pancreatic MCN with low grade dysplasia. Our case strongly indicates the importance of further evaluation for uncommon causes for left flank pain.