Left Flank Pain Research Articles

HEART FAILURE WITH RELAPSING ATRIAL FIBRILLATION: BELOW THE SURFACE

Abstract Advances in pharmacologic and device therapy have greatly improved prognosis of patients with HFrEF. However, the typical clinical course is still characterized by recurring symptoms, worsening functional status and risk of frequent hospitalizations. A 72–years–old male patient with arterial hypertension, poorly controlled T2DM, TIA and chronic kidney disease presented to Cardiology service in 2018 with dyspnoea on effort and first evidence of EF 35% at echocardiography. He was admitted for elective coronary angiography, which demonstrated limited coronary heart disease of circumflex artery and its first marginal branch, treated by PTCA and stenting. CMR confirmed severe LV dysfunction, but also revealed extensive fibrotic areas with ischaemic and non–ischaemic patterns beyond revascularized regions. With such evidences, HF treatments were intensified, with titration of disease– modifying therapies and DOAC was added for asymptomatic paroxysmal AF. CRT–D was implanted for QRS of 160 msec, which was narrowed to 130 msec. Nevertheless, in one–year time the patient presented worsening of symptoms with several hospital admissions for acute HF and AF with fast rate. A switch to rhythm–control strategy was hence chosen. DCCV was performed, after an initial deferral for thrombosis of LAA due to poor adherence to DOAC. However, three–days after DCCV, the patient presented again to emergency services for dyspnoea, left upper flank pain and AF with fast rate. He was admitted to Acute Medicine Unit and treated with high flow O2, iv Furosemide and Digoxin, analgesics. CT chest and abdomen with contrast was performed in the suspicion of systemic venous thromboembolism for persistent type 1 respiratory failure, raised D–dimer and elevated liver function tests, despite appropriate anticoagulation. CT revealed an unexpected left superior pulmonary vein thrombosis, splenic and small left renal infarcts. The patient was discharged after recovery on subcutaneous heparin. At 15–day review, the patient was in stable conditions and awaiting completion of coagulation screening tests. This case study addresses some important aspects in the care of HF. An accurate assessment of HF aetiology and recurrent triggers, a timely planning of pharmacologic and device treatments, alongside with management of co–morbidities, therapeutic adherence and appropriate anticoagulation, can provide the clinician powerful tools to accomplish the difficult task of managing HF below the surface.

Is Open Ureterolithotomy Finished? : A Case of Giant Ureteral Stone and Screening of the Literature

INTRODUCTION: Open surgery is an old method of urology in the treatment of ureteral stones. With the development of new technologies; Indications for open surgery in the treatment of stone disease have decreased to 1-5.4 %. In this case, we aimed to remove 4 stones with a diameter of 22 mm at the lower end of the left ureter by open ureterolithotomy and to report similar cases in the literature. CASE: In the direct urinary system X-ray and abdominal computed tomography of the patient who applied to us with the complaint of left flank pain, 4 stones with a diameter of 22 mm in the lower end of the left ureter, grade 4 hydroureteronephrosis in the left ureter and kidney were observed. Left open ureterolithotomy was planned. The patient's stones were removed using the left Gibson incision technique, and the ureteral incision area was sutured by placing a 6f double j catheter into the ureter. A drain was placed in the left ureteral tracing and the procedure was terminated by suturing the Gibson incision. The patient's foley catheter was removed on the 1st day and the drain was removed on the 2nd day, and he was discharged. No postoperative complications were encountered. Six weeks later, the patient's 6f double j catheter was removed and the surgical procedure was completed. DISCUSSION: Ureteral stones usually form in the primary kidney and then descend into the ureter. Ureteral stones usually pass spontaneously, but stones larger than 1 cm have fewer spontaneous passages. Ureteral stones are usually single and smaller than 2 cm. For stones larger than 5 cm, the term giant ureteral stone is used. Paik et al. reported a mean blood loss of 144 cc and a mean hospital stay of 6.5 days in seven patients with open ureterolithotomy. All patients in the series were stone-free and had no complications. In another study, open ureterolithotomy was performed in 56 patients, and 46.4% of the patients had stones in the distalureter. While the hospital stay was 4.2 days, no complications were encountered. CONCLUSION: Open ureterolithotomy has lost its status as the gold standard with the development of ureterorenoscopy, but as in our case, it is a surgical technique that should be considered in large ureteral stones.

Rare presentations of Wilms tumor in children: A case report

Wilms tumor (WT) is the most common malignant tumor (neoplasm) of the urinary tract in early childhood. The median age at WT diagnosis is 3-4 years, and 90% of cases are diagnosed before the age of 7 years. In this report, three adolescent patients with WT, aged 12, 17 and 16, are investigated. Left kidney involvement was observed in these three cases. The clinical presentation in case one was the complaint of abdominal pain with a palpable abdominal mass. The second case was presented with hematuria and an abdominal mass. The clinical symptoms in case three included left flank pain and weight loss. Although WT is usually observed in children under 7 years of age, its diagnosis should also be expected in older children with abdominal pain, palpable mass and gross hematuria.

Large renal stone with ureteral stone caused by 15 years of forgotten stent

Introduction: Ureteral stents are commonly placed in urologic surgeries, and are especially indispensable in endourologic surgeries. But if it remains for more than 6 months, the probability of migration and calculus formation of the stent increases substantially. Case description: A 57-year-old female came to the urology outpatient clinic due to left flank pain. She had a history of open left nephrolithotomy 15 years ago and had ureteral stent placed. She also had a history of open vesicolithotomy surgery 4 years ago and was told to have a follow-up surgery for the remaining kidney stone but she didn’t come because of the limited level of local medical services and her pain tolerance. NCCT study showed moderate left hydronephrosis with a high volume renal stone measuring 60x35x20 mm (HU 1.021), two proximal ureteral stones measuring 40x10x10 mm (HU 1.021) and 60x5x5 mm (HU 1.021) with ureteral stent shadow in the center. She had elevated urea nitrogen and creatinine levels, microscopic hematuria, leukocyturia, and positive urine bacteria. The patient underwent percutaneous nephrolithotomy (PCNL) with endoscopic combined intra-renal surgery (ECIRS) for stone removal. Postoperative recovery was successful with no residual stones and significant pain relief. Conclusion: The case underscores the need for patient compliance, adequate practitioner counseling, and timely medical attention. The prevention of complications is the best treatment, and multimodal endourologic approaches can safely remove forgotten, encrusted double J stents.

Successful management of a mixed epithelial and stromal renal tumor masquerading as lower pole renal cyst: A laparoscopic deroofing approach

AbstractBackgroundRenal cysts are common in clinical practice, but some may harbor rare pathological entities such as mixed epithelial and stromal tumors (MEST). Imaging studies are crucial for accurate diagnosis. While laparoscopic deroofing is an established approach for symptomatic renal cysts, encountering MEST within a cyst is uncommon.Case PresentationWe present the case of a 37‐year‐old female who presented with persistent left flank pain. Imaging revealed a large renal cyst in the lower pole of the left kidney, classified as Bosniak 2. Despite analgesia, the patient's symptoms persisted, leading to a laparoscopic deroofing procedure. Histopathological examination postprocedure revealed a MEST. The patient reported complete resolution of symptoms at the 3‐month follow‐up.ConclusionThis unique case presents the successful identification and surgical management of a MEST masquerading as a lower pole renal cyst through laparoscopic deroofing. It also contributes to the existing literature by highlighting the importance of considering rare pathological entities in the evaluation of renal cysts and the value of laparoscopic techniques in their management.

Invasive Urothelial Carcinoma of the Ureter with Associated Obstructive Uropathy and Chronic Pyelonephritis: A Case Report and Literature Review

Introduction: urothelial carcinomas can develop from any urothelium lined surface in the body and they are the seventh most common cancers seen globally. Urothelial carcinoma of the upper urinary tract (involving the renal pelvis and ureter) is not common.
 Case Presentation: A 66-year-old male presented with recurrent left flank pain, recurrent urinary tract infection and occasional haematuria of six month's duration. Abdominal Computerized Tomography (CT) done showed moderate left hydro-ureter and hydro-nephrosis and a mass was seen in the lower one-third of the left ureter. Features seen at CT was suggestive of urothelial carcinoma of the distal left ureter. No mass lesion or tumour was seen in the urinary bladder. Radical nephroureterectomy with excision of the bladder cuff was performed and the diagnosis was confirmed after histopathologic evaluation.
 Discussion: This case report highlights the rare presentation of invasive urothelial carcinoma of the ureter with associated obstructive uropathy and the role of radiologic imaging in diagnosis and thorough histopathologic evaluation in the determination of tumour grade and tumour stage and ultimate prognosis of patients.
 Conclusion: A high index of suspicion is needed for diagnosis based on presenting symptoms, and examination findings. Tumour grade and stage in upper urinary tract urothelial carcinoma are good predictors of clinical outcomes and prognosis.

Conservative management by embolization of a ruptured renal arterio-venous malformation (AVM) in Hereditary Hemorrhagic Telangiectasia (HHT)

BackgroundRenal arteriovenous malformation (AVM) in Hereditary Hemorrhagic Telangiectasia (HHT) is uncommon and only few cases have been described, mainly with surgical management because of uncontrolled hematuria.Case presentationWe managed a 70-year-old patient with HHT who presented with hematuria and left flank pain. Computed Tomography and ultrasound showed left renal AVM of 18 mm with clotting in the urinary tract. An external ureteral catheter was placed during 3 days to allow rinsing and facilitate elimination of clots.Given the patient's hemodynamic stability, a non-surgical management was chosen. Treatment of the AVM was performed by trans-arterial embolization using micro-coils and ethylene–vinyl alcohol copolymer.ConclusionsOur case study shows a conservative management by embolization of ruptured left renal AVM revealed by hematuria in a 70-year-old patient with HHT.

Primary splenic abscess in an adult female patient: a case report

BackgroundPrimary splenic abscess is rare and typically presents in patients who are immunocompromised. We present a case of a 47-year-old apparently immunocompetent female patient who was diagnosed with primary splenic abscess from a Salmonella Typhimurium infection following emergency laparotomy.Case presentationA 47-year-old female patient presented with subjective fever and severe epigastric and left flank pain. She was treated empirically with intravenous piperacillin/tazobactam and gentamicin and was resuscitated with intravenous crystalloid infusion. A radiological diagnosis of splenic infarct secondary to splenic artery aneurysm superimposed with splenic abscess was presumed, however at emergency laparotomy, primary splenic abscess was identified. This abscess had eroded the left hemidiaphragm and had ruptured the splenic capsule leading to intra-abdominal pus in the pelvis which on culture grew Salmonella Typhimurium. A splenectomy and primary repair of the left hemidiaphragm were performed, with postoperative pancreatitis diagnosed following the procedure. After intensive care treatment, this patient made a full recovery.ConclusionThis case of primary splenic abscess was treated successfully with a combination of surgery (i.e.: splenectomy and surgical drainage), prolonged antimicrobial therapy, and intensive care in the perioperative period.

IgG4-related retroperitoneal fibrosis mimicking renal pelvis tumor: a case report and literature review

BackgroundRetroperitoneal fibrosis (RPF) is a rare disease characterized by the development of a fibroinflammatory mass in the retroperitoneum. Immunoglobulin-G4 related RPF was suggested as a secondary form of RPF and thought to be part of the spectrum of Immunoglobulin-G4 related diseases (IgG4-RD). Patients often present to the clinic because of flank pain. Ranging from mild to end-stage renal failure can be observed. The main purpose of treatment is to preserve renal function. As it is a rare condition, there is no definite treatment strategy. We report a case of 39-year-old man with left flank pain and diagnosis of IgG4-related RPF mimicking a renal pelvis tumor.Case presentationA 39-year-old male patient presented with left flank pain. MRI suggested solid retroperitoneal mass associated with hydronephrosis in the left kidney collecting system. Upon identifying the retroperitoneal origin of the mass during nephroureterectomy, the procedure was concluded following the acquisition of frozen section and routine pathological samples from the lesion. In the histopathological examination, inflammatory cells were observed and specific immunohistochemistry for IgG-4 was detected focally positive. Following the placement of a DJ stent, immunosuppressive therapy was initiated with Prednol and Azathioprine. After a one-year follow-up period, during which the patient received immunosuppressive treatment and underwent tri-monthly DJ stent replacements, the DJ stent was subsequently removed, revealing complete regression of hydronephrosis.ConclusionsWith the correct diagnosis and treatment of IgG4-related RPF, it is possible to prevent irreversible complications of the disease. Because it is a rare disease, case reports in the literature will be useful for treatment.

Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting

Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n=5) and LRV transposition (n=14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n=19), proteinuria 88% (n=15), and hematuria 47% (n=9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n=17), 57.8% (n=11), and 82.3% (n=15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n=2; stenosis, n=1), and 1 patient after stenting (occlusion, n=1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.

P-04 Adrenocortical carcinoma case with long-term follow-up

Abstract Description Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy with an incidence of 0.7–2.0 cases/million/year. We present a case of ACC that we followed for a long period of approximately 5.5 years. Clinical Case A 50-year-old female patient was referred to our hospital because of a left adrenal mass. She had no complaints except left flank pain. There were no features on her resume. There were no findings related to hypercortisolemia on physical examination. Hormone levels were examined (Table 1). In the upper abdomen tomography, a 9×13×10.8 cm sized, sharply defined, lobulated contoured, heterogeneous-enhancing mass lesion with central cystic components was observed in the left adrenal region (Figure 1). The patient underwent left adrenalectomy and left partial nephrectomy. Pathology was reported as adrenocortical carcinoma. Weis score was 6/9, and the Ki-67 index was 15-20%. She was evaluated as a stage 2 disease according to ENSAT staging and followed up with thoracoabdominal CT. A 30*15 mm recurrent mass lesion was detected in the first-year postoperative follow-up. The patient underwent implant excision, left nephrectomy, and left paraaortic lymphadenectomy. Then the patient was given 6 cycles of Cisplatin-Etoposide-Adriamycin chemotherapy. On follow-up imaging after chemotherapy, a mass of approximately 13 mm in diameter was detected adjacent to the small intestine. Bridectomy and malignant soft tissue resection were performed on the patient. Mitotane treatment was started after the operation. After 6 weeks, the target mitotane level was reached. The patient was followed closely for glucocorticoid needs. Oral hydrocortisone treatment was started in the patient who complained of fatigue and nausea in the 8th month of mitotan. Since there was no hyponatremia/hyperkalemia and clinically no hypotension/orthostatic hypotension, mineralocorticoid therapy was not initiated. While under mitotane treatment, liver function tests, thyroid function tests, complete blood count and lipid parameters were evaluated intermittently. She was hospitalized 4 times in total with the clinic of infection and adrenal insufficiency. At that time, mitotane treatment was interrupted and parenteral steroid treatment was started. The patient received 4.5 years of mitotane therapy. No recurrence was detected in the follow-up scans during mitotane treatment and 6 months after the treatment was discontinued. PET-CT imaging was performed in the 1st year while the patient was in the follow-up without treatment. In the retroperitoneal region, 38×21 mm focal increased activity involvement was observed (SUV Max: 17.82). Left hemicolectomy operation was performed on the patient and chemotherapy was planned. Conclusion In conclusion, we presented a case that we followed for a long time without recurrence under mitotane treatment. It can be thought that mitotane treatment keeps ACC disease under control. Figure 1. 9×13×10.8 cm left adrenal mass. Table 1

Autosomal dominant polycystic kidney disease with ectopic unilateral multicystic kidney: a case report

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disorder and the fourth cause of death of end-stage renal disease. The disease has a prevalence of 1:400–1:1000 accounting for 10% of patients on dialysis. In most ADPKD patients, bilateral kidneys are similarly affected, with numerous fluid-filled cysts arising from different nephron segments. Only a few cases of ADPKD with ectopic unilateral multicystic kidney have been reported. It has been observed that the deterioration of their kidney function seemed to be quicker than their age- and sex-matched controls and siblings especially when the ectopic kidney is dysplastic.Case presentationWe report a case of a 46-year-old Ghanaian male patient who presented with left flank pain and hematuria with high BP and deranged renal function. Abdominal ultrasonography showed both kidneys to be larger than normal and had multiple cysts of varying sizes with the right kidney located in the right iliac fossa. Follow up Abdominopelvic computer tomographic scan (CT–Scan) without contrast showed enlarged kidneys with the renal parenchyma replaced by innumerable cyst of varying sizes. The right kidney was ectopically located in the right aspect of the pelvis. A diagnosis of ADPKD with right pelvic ectopic multicystic kidney was made. He was put on antihypertensives, analgesia for the left flank pain and to have follow up at the urology and nephrology departments.ConclusionIn most ADPKD patients, bilateral kidneys are similarly affected. Only a few cases of ADPKD with ectopic unilateral multicystic kidney have been reported. It has been observed that the deterioration of their kidney function seemed to be quicker than their age- and sex-matched controls and siblings especially when the ectopic kidney is dysplastic.

A Case of Fibrillary Glomerulonephritis – When You Least Expect It

ABSTRACT Malignancies can be associated with a wide range of glomerular diseases, with each malignancy having a predilection for a particular glomerular disease. Fibrillary glomerulonephritis (FGN) is usually associated with paraproteinemia and commonly presents as nephrotic range proteinuria with or without the full-blown nephrotic syndrome. Here, we report the case of a young male with left flank pain, found to have left adrenal adenoma, incidentally detected to have microscopic hematuria and nonnephrotic proteinuria whose renal biopsy done during adrenalectomy showed FGN. Indeed, this case demonstrates an unexpected diagnosis with an unusual presentation in the background of an uncommon malignancy. Although difficult to establish causation, it can be considered a unique case of adrenal adenoma-associated FGN.

Efficacy of Ayurveda medicine in renal calculi (Ashmari) with hydronephrosis: a case study

Abstract Introduction: Renal stone (Mutrashmari) is one of the most common diseases of Mutravaha Srotas (urinary system). It occurs when the formation of crystals, such as calcium, oxalate, uric acid, etc., takes place due to improper functioning of the filtration in the kidney. Case Study: The present study deals with a 20-year-old female patient having complaints of burning micturition, acute left flank pain in the abdomen and back which was radiating from the loin to the groin region, nausea, vomiting, dysuria. She was already diagnosed with renal calculi and was taking allopathic medications since for the last 1 month. Later she encountered the same problem and consulted an Ayurvedic physician. Ayurveda management primarily focuses on Samprapti Vighattana (breaking down the pathogenesis). Diagnosis: It was done on the basis of symptoms and USG reports. Intervention: By considering the Nidana, Dosha, and Dushya, a judicial combination of Ayurveda drugs-Gokshuradi Guggulu, Varunadi Kwatha, Tab. Cystone, Syp Neeri and Pasanbhedadi Churna were advised to take orally in morning and evening with lukewarm water. Outcomes: At the time of consultation her USG finding showed 8 mm calculus with nephrosis. After taking the prescribed formulation for 2 months, her USG report came to normal. Conclusion: The prescribed Ayurvedic herbal medicines are seen to be effective in managing the day-to-day life of an Ashmari patient.

Management of Metastatic Primary Renal Synovial Sarcoma with Inferior Vena Cava Thrombus: A Rare Case Report

Synovial sarcomas constitute 5-10% of all soft-tissue sarcomas and tend to occur in the extremities, particularly the lower extremity. Renal sarcoma is a rare entity, constituting approximately 1-5% of all malignant renal tumours. Metastatic large renal synovial sarcoma with Inferior Vena Cava (IVC) thrombus is a rare surgical challenge that demands thorough preoperative evaluation and planning for its management. A 31-year-old young male presented with symptoms of left flank pain for 10 days, with a past history of similar complaints two years prior. On examination, a massively large renal mass was palpable. A Computed Tomography (CT) scan showed an IVC thrombus and metastatic deposits. The patient underwent a radical nephrectomy with ileal segment resection, followed by chemotherapy, which showed near-complete resolution of the metastatic deposits. Renal synovial sarcoma should be considered as a differential diagnosis in young patients presenting with a metastatic, exceptionally large renal mass complicated by an IVC thrombus, necessitating thorough preoperative evaluation for effective management.

Successful management of a giant retroperitoneal ancient schwannoma mimicking malignant tumors: A case report and literature review

Introduction and Importance: Schwannomas, originating from Schwann cells surrounding nerve sheaths, tend to be slow-growing. Among these, giant ancient schwannomas are remarkable for their rare occurrence and their capacity for substantial growth and regressive changes. Furthermore, the expansiveness and flexibility of the retroperitoneal space often conceal the symptoms of retroperitoneal schwannomas, leading to delayed diagnosis and allowing these tumors to grow significantly and become large and long-standing before detection. Case Presentation: A 24-year-old man presented with left flank pain and a growing abdominal bulge in the left upper quadrant. Computed tomography scan revealed a 15×15×10 cm lytic expansile lesion. Consequently, the encapsulated mass was surgically excised and diagnosed as an ancient retroperitoneal schwannoma through histological and immunohistochemical studies. Clinical Discussion: Comprehensive preoperative planning and a multidisciplinary strategy are imperative for the complete excision of schwannomas. These tumors can present diagnostic complexities, particularly due to nuclear atypia and pleomorphism, which might lead to misinterpretation regarding malignancy. Despite the risks associated with percutaneous biopsies, the low mitotic count is a critical diagnostic factor. Our study underscores the consensus that the definitive diagnosis should rely on postoperative histopathological findings, highlighting the importance of accurate assessment. Conclusion: Rare giant retroperitoneal ancient schwannomas pose diagnostic challenges due to their rarity, lack of distinct symptoms, and atypical locations. This study presents a successful case and management.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report

BackgroundEctopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions.Case presentationWe report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient’s condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic.ConclusionWe present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

A rare presentation of bilateral emphysematous pyelonephritis with concurrent lung abscess: A case report

Bilateral emphysematous pyelonephritis (EPN) is a rare complication in uncontrolled diabetes mellitus patients and linked to a high patient mortality rate [1]. We present a case of a 62-year-old female patient with bilateral EPN who also developed a concurrent lung abscess. She came with high-grade fever, lethargy, and left flank pain. She had left lumbar tenderness and right-sided chest crepitations. Upon hospitalization, the patient developed septic shock. However, severity of her clinical presentation does not correlate with chest X-ray of right sided pneumonic changes and cavitation of the lungs on admission. Abdominopelvic computed tomography (CT) imaging revealed extensive left EPN (Huang-Tseng CT classification: class 4), early right EPN (Huang-Tseng CT classification: class 2), and right middle lobe lung abscess, which was treated with intravenous antibiotics, drainage, and optimal glycaemic management. This was followed by the resolution of sepsis and improvement in clinical status.

Rare giant renal artery aneurysm in neurofibromatosis type 1 patient: a case report

Introduction and importance: Neurofibromatosis type 1 (NF1) is a genetic disorder characterised by multiple neurofibromas, café-au-lait spots, and iris hamartomas. The variety of vasculopathies that can occur in NF1 make it difficult for clinicians to accurately follow-up patients. Most cases of vasculopathies are stenotic, and, in few cases, aneurysms may form. Case presentation: A 35-year-old male presented with extreme left flank pain for the past 2 days. His physical examination revealed whole-body several café-au-lait skin macules, a subcutaneous lesion, and a palpable abdominal mass in the left flank. His laboratory workup was within normal ranges. A multi-slice computed tomography and computed tomography angiogram with contrast outlined a giant left renal artery aneurysm (RAA). A kidney salvage surgery was planned. However, due to ectatic dilatation and large extension of the aneurysm, the affected renal artery branches and renal vein were found unfit for auto-transplantation during the surgical procedure and a total nephrectomy was necessary. Symptoms improved significantly postoperatively and no complications developed. Clinical discussion: RAA is an uncommon finding in NF1 patients. Diagnosis is often dependent on computed tomography angiogram. Management techniques are conservative, endovascular, or surgical. In few surgical cases, a total nephrectomy may be necessary if auto-transplantation is not feasible. Conclusion: Despite its rarity, the diagnosis of RAA should be considered in patients with NF1 presenting with flank pain. Moreover, early screening for renal vasculopathies can evade critical surgical outcomes including a total nephrectomy. Hence, the authors recommend a total vascular workup for these patients, consisting of doppler ultrasound and, if necessary, a multi-slice computed tomography with contrast.

Surgical treatment of nutcracker syndrome results in improved pain and quality of life

BackgroundLeft renal vein (LRV) compression, or nutcracker phenomenon, describes the compression of the LRV, most commonly between the aorta and the superior mesenteric artery. The outflow obstruction that occurs from the compression causes venous hypertension leading to the development of pelvic collaterals, lumbar vein engorgement and gonadal vein reflux. The symptoms associated with LRV compression include abdominal pain, left flank pain, back pain, headache, pelvic pain/pressure, and hematuria. Symptomatic LRV compression can cause chronic pain and disability that impedes activities of daily living. Left renal auto transplantation (LR-AT) is one mode of treatment, leading to decreased pain with no significant vascular or urological complications. Herein we present a five patient case series with symptomatic LRV compression who underwent LR-AT with improved pain and quality of life after surgery. MethodsFive patients underwent LR-AT between June 2020-December 2020 to resolve their symptomatic LRV compression. These patients were given three validated surveys pre- and post- intervention, then again at their three month follow up visit to assess their pain and health-related quality of life. ResultsThe five patients were all female with the average age of 36.8 years old (36–41) and underwent LR-AT to treat their symptomatic LRV compression. The average Numeric Rating Scale (NRS) pain score pre intervention was 8.3 (range 6.7 to 10) which improved to pain rating 5.22 (range 2.7 to 6) post intervention, p-value = 0.013. The average pain NRS score at 3 month follow up was 3.86 (range 1.3–6), p-value = 0.006 when compared to pre-intervention pain scores. The average pain intensity pre intervention was 4.5 (4 to 5) and 2.7 (1 to 4.3) post intervention, p-value = 0.024. The average pain intensity score at 3 month follow up was 2.24 (range 1.3–3.3), p-value = 0.002 when compared to pre-intervention. The VascuQoL-6 survey score pre intervention averaged score of 9.6 (range 7–12) which improved to an average score of 20.6 (range 18–24), p-value = 0.001. The average VascuQoL score at 3 month follow up was 22.6 (range 22–24), p-value = < 0.001 when compared to pre intervention QoL scores all showing a statistically significant improvement of health-related quality of life. ConclusionThe diagnosis of LRV compression can be challenging due to the non-descript symptoms and overall lack of awareness. Understanding venous tributary pathways and drainage can help clarify why patients present with unusual symptoms. Surgical treatment of LRV compression through LR-AT can improve patients’ pain and improve vascular quality of life.