Left Pelvis Research Articles

Case report: Radical robotic nephroureterectomy after chemotherapy followed by avelumab in a patient with node-positive UTUC

IntroductionPlatinum-based chemotherapy followed by the immune checkpoint inhibitor avelumab represents an intensified upfront therapy regimen that may result in significant downstaging and, subsequently, potentially radical robotic nephroureterectomy with a lymph node dissection, an uncommon approach with an unexpectedly favorable outcome.Case presentationWe report a case of a 70-year-old female presented with a sizeable cN2+ tumor of the left renal pelvis and achieved deep partial radiologic response after systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance therapy and subsequent robotic resection of the tumor. The patient continued with adjuvant nivolumab therapy once recovered after surgery and remained tumor-free on the subsequent follow-up. The systemic treatment was without any severe adverse reaction.ConclusionWe highlight the feasibility of the upfront systemic therapy with four cycles of gemcitabine-cisplatin chemotherapy followed by avelumab maintenance, robotic-assisted removal of the tumor, and adjuvant immunotherapy with nivolumab. This intensification of the upfront systemic therapy, and the actual treatment sequence significantly increase the chances of prolonged survival or even a cure. This type of personalized therapeutic approach can accelerate future advanced immunotherapeutic strategies.

Epithelioid solitary fibrous tumors from CNS and soft tissues: an unusual morphologic variant

BackgroundSolitary fibroous tumors (SFTs) are distinctive soft tissue tumors characterized by rearrangements of NAB2-STAT6 gene, which are associated with thin-walled, branching, “staghorn”-shaped vessels. SFTs are originally classified as a type of hemangiopericytoma (HPC). Classical SFTs are composed of spindle to ovoid cells arranged haphazardly or in fascicles. Rarely, SFTs exhibit unusual morphological variants such as fat formation, giant cells, dedifferentiation, or epithelioid variant. The epithelioid cell variant, which is composed almost entirely of epithelioid cells and arranged in solid or nest patterns, is extremely rare and frequently malignant.Case presentationIn this study, we reported three cases of epithelioid SFTs (ESFTs) located in extrathoracic sites (right lateral ventricle, right lumbar, left pelvis). All the subjects in this study were elderly, with a predominance of female patients, accounting for two out of the three cases, and only one case involved a male patient. The tumor cells were entirely composed of epithelioid cells and exhibited positive for CD34 and STAT-6 markers. Ultimately, the majority of cases (two out of three) were diagnosed as malignant SFTs.ConclusionThis study aims to enhance the awareness of ESFTs. In these cases, irrespective of the onset location, the arrangement patterns of tumor cells, such as papillary structures and the morphology of epithelial-like cells, conspicuously lack the hallmark histological characteristics of Solitary Fibrous Tumors (SFTs). Consequently, it requires differential diagnosis from a plethora of malignant neoplasms. Moreover, the elevated malignancy level of this cohort of cases poses substantial diagnostic challenges to pathologists, compounding the complexity of accurate interpretation.

9182 Metastatic Extra-Gastrointestinal Stromal Tumor Presenting As Hypoglycemia

Abstract Disclosure: O. faour: None. D. John: None. S.K. Suryanarayanan: None. A.A. Rizvi: None. Introduction: Non islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome seen in association with solid abdominal tumors of mesenchymal and epithelial origin. We report a case of metastatic extra-gastrointestinal stromal tumor (E-GIST) presenting with severe hypoglycemia as its initial manifestation. CASE DESCRIPTION: A 46-year-old patient was found to have a blood glucose of <45 mg/dl during a routine clinic visit with her primary care physician. Although she was asymptomatic, she was sent to the emergency room (ER) for further evaluation. She had a history of prediabetes managed by lifestyle modification. She has been experiencing multiple episodes of hypoglycemia previously which fulfilled the Whipple’s triad in the preceding months. These hypoglycemic episodes included loss of unconsciousness, falls in the shower with head injury, and several hospital visits. Serum glucose in the ER was 14 mg/dl and hypoglycemia persisted despite continuous dextrose solution. Physical examination was notable for a distended, non-tender abdomen and cervical lymphadenopathy. CT scan showed a 15 cm mass in the liver, multiple large masses in the mesentery, and a 11 cm lesion in the left pelvis. There were enlarged lymph nodes in the abdomen, chest, and neck. Serum chemistries drawn when the patient was hypoglycemic revealed potassium level of 2.7 mg/dl (3.5-5.5) an insulin level of <1.0 mIU/L (5-25), C-peptide <0.1 ng/mL (0.5-2), cortisol 13.8 mcg/dL (5-25), and insulin-like growth factor-2 (IGF-2) was 270 ng/mL (38-267). The IGF-2/IGF-1 molar ratio was 3.4 (normal <3:1). The sulfonylurea drug screen came back negative. Upper and lower endoscopies were unrevealing. Biopsy of the liver lesion showed cytology and immunohistochemical findings consistent with a epithelioid metastatic extra-gastrointestinal stromal tumor. A provisional diagnosis of NICTH was made. The patient responded well to intravenous glucose, oral carbohydrate intake and high-dose corticosteroids. She was subsequently started on therapy with the tyrosine kinase inhibitor (TKI) imatinib. Discussion: Paraneoplastic hypoglycemia is often seen in association with metastatic epithelial and mesenchymal tumors. IGF-2 and incompletely processed pro-IGF-2 activates autocrine, paracrine, and endocrine pathways that lead to tumor growth, fasting hypoglycemia, rarely of acromegalic features. Treatment with octreotide, diazoxide, and glucagon is generally ineffective, while glucocorticoid use and surgical intervention are helpful in ameliorating the hypoglycemia. Tumor-directed therapy with TKIs, primarily imatinib, appears promising in achieving remission. Our case is a clinical reminder that hypoglycemia secondary to NICTH can be the predominant presenting feature in patients with underlying E-GIST. Presentation: 6/3/2024

Deep-learning-based method for the segmentation of ureter and renal pelvis on non-enhanced CT scans

This study aimed to develop a deep-learning (DL) based method for three-dimensional (3D) segmentation of the upper urinary tract (UUT), including ureter and renal pelvis, on non-enhanced computed tomography (NECT) scans. A total of 150 NECT scans with normal appearance of the left UUT were chosen for this study. The dataset was divided into training (n = 130) and validation sets (n = 20). The test set contained 29 randomly chosen cases with computed tomography urography (CTU) and NECT scans, all with normal appearance of the left UUT. An experienced radiologist marked out the left renal pelvis and ureter on each scan. Two types of frameworks (entire and sectional) with three types of DL models (basic UNet, UNet3 + and ViT-UNet) were developed, and evaluated. The sectional framework with basic UNet model achieved the highest mean precision (85.5%) and mean recall (71.9%) on the test set compared to all other tested methods. Compared with CTU scans, this method had higher axial UUT recall than CTU (82.5% vs 69.1%, P < 0.01). This method achieved similar or better visualization of UUT than CTU in many cases, however, in some cases, it exhibited a non-ignorable false-positive rate. The proposed DL method demonstrates promising potential in automated 3D UUT segmentation on NECT scans. The proposed DL models could remarkably improve the efficiency of UUT reconstruction, and have the potential to save many patients from invasive examinations such as CTU. DL models could also serve as a valuable complement to CTU.

Aggressive Synchronous Papillary and Likely Follicular Thyroid Carcinomas in a Patient with Graves’ Disease

We report a case of an uncommonly aggressive presentation of the rare entity of synchronous papillary (PTC) and follicular thyroid carcinomas (FTC) in a 67-year-old woman initially presenting with thyrotoxicosis from Graves’ disease. She was found to have two thyroid nodules with extensive intra-cardiac tumour thrombus, symptomatic left pelvis bony metastasis with pathological fracture, pulmonary metastases and mediastinal lymph node metastases. Further investigations suggested a diagnosis of synchronous papillary and metastatic follicular thyroid cancer. Treatment with radical surgery followed by adjuvant therapeutic radioiodine ablation was proposed, but the patient declined all forms of cancer-specific therapy and was elected solely for a palliative approach to treatment. We discuss the diagnostic considerations in arriving at the diagnosis of synchronous thyroid malignancy – in this case the clear features of PTC and the strong probability of FTC due to invasiveness and metastatic follicular lesions. This case underscores potential limitations of the ACR TI-RADS system, notably with certain ultrasonographic features suggesting malignancy that might not be adequately captured. Notably, the aggressive presentation of DTC in this case may be contributed by the concurrent presence of Graves’ Disease, suggesting heightened vigilance when assessing potential thyroid malignancies in such patients.

Regional Anaesthesia with Non Invasive Ventilation and Conscious Sedation: An Alternative to General Anaesthesia in Morbidly Obese Patients with Obstructive Sleep Apnea in Retrograde Intrarenal Surgery

Obstructive sleep apnea(OSA) is a syndrome characterized by obstruction in the upper airway during sleep. OSA patients undergoing procedures under GA are at increased risk for hypoxemia, pneumonia, difficult intubation, atelactasis, myocardial infarction making it a challenge for anesthesiologist. Retrograde intrarenal surgery(RIRS) is normally performed under GA to prevent respiratory embaracement. There are very few studies focusing on Regional anesthesia in RIRS procedure. A Sixty-three-year-old male known case of morbid obesity (BMI- 35 kg/meter square), OSA (on CPAP support at night) presented with left renal pelvis calculus, STOP BANG score (=5) therefore making it a case of difficult airway. Respiratory discomfort improved at 30-35-degree head up due to existing OSA considering the severe OSA and anticipated difficult airway, the surgery was planned under Lumbar subarachnoid block with preparation for management of difficult airway if conversion to GA required. 3 ml of 0.5 percent Bupivacaine heavy and 25 mcg fentanyl injected into subarachnoid space. T6 level block acheived after 3 minutes. The patient was put on his home CPAP machine with 5cm H2O PEEP. The patient was maintained on sponatneous ventilation and monitored using Etco2 at aliquot of 1mg midazolam given to mimic natural sleep pattern. The surgery was uneventful and the risk of induction of GA and difficult intubation was succesfully avoided. Patient with regional anaesthesia who are prone to converted to GA due to multiple risk factors, i.e., OSA with anticipated difficult airway can create a chaotic situation. So as a preliminary step NIV can be used, and along with it, mild sedation can be supplemented to improve acceptance and to avoid asynchrony. In this case NIV was used as a preemptive ventilation strategy even before actual requirement of BiPAP by mimicing the natural sleep pattern and make patient comfortable while a smooth conductance of the procedure.

#1270 Exploring the shift in gut microbiota due to renal ischemia/reperfusion injury in rats

Abstract Background and Aims Acute kidney injury (AKI) due to renal ischemia/reperfusion (I/R) is a major clinical problem in renal transplantation and partial nephrectomy, which is associated with morbidity and mortality and substantial healthcare expenditures, but there is no effective and specific treatment. Recently, the clinical impact of the interaction between gut bacteria and the kidney function has become increasingly clear. Experimental evidence has highlighted a bidirectional relationship between gut microbiota and kidney disease. Therefore, we investigated the possibility that I/R can ameliorate AKI by studying gut-renal interactions and gut microbiota in AKI. Method We induced varying degrees of renal I/R injury in adult male Wistar rats by clamping the left renal pelvis for 30 and 45 minutes, simulating mild and severe conditions, respectively. These samples were subjected to extensive histologic examination using standard techniques such as hematoxylin and eosin (HE), Sirius Red, and F4/80 staining. In addition, we performed a quantitative analysis of the mRNA expression levels of fibrotic and inflammatory markers in both kidney and colon tissues using real-time PCR. Gut microbiota genomic DNA was extracted from rat feces and microbial 16S ribosomal RNA (rRNA) gene sequencing was performed. Results Renal function deteriorated with increasing ischemia time and fibrosis progressed, as confirmed by Sirius Red staining and qPCR of fibrosis genes such as TGFB. The expression of inflammatory genes such as IL-1B and IL-6 was also increased. The expression of inflammatory genes such as Toll-like receptor, C3, and IL-1B in the intestine also increased with ischemia time. In the fecal microbiota, the total read percentage of Bacteroides acidifaciens at the species level increased with increasing ischemia time. Conclusion The observed shifts in gut microbiota composition may serve as a critical indicator of chronic kidney disease (CKD)-induced gut dysbiosis secondary to AKI. This finding highlights the need for further research into the identification and migration patterns of the gut microbiota, which represents a promising avenue for early detection, prevention, and therapeutic intervention in AKI. Future investigations elucidating the mechanisms by which the microbiota influence IRI-induced AKI and the development of practical therapeutic strategies have the potential to significantly improve clinical outcomes in patients suffering from IRI-induced AKI.

#829 Renoprotective effects of laxative linaclotide: inhibition of acute kidney injury and fibrosis in a rat model of renal ischemia-reperfusion

Abstract Background and Aims Acute kidney injury caused by renal ischemia/reperfusion (I/R) is a major clinical problem in many aspects of urology fields such as kidney transplantation and partial nephrectomy, but there is no effective treatment. Linaclotide, a guanylate cyclase C agonist clinically approved as a laxative, has recently been shown to be renoprotective in a chronic kidney disease (CKD) model. Therefore, the present study investigated the possibility that the renoprotective effects of linaclotide in renal I/R may extend beyond its gastrointestinal effects. Method The left renal pelvis of adult male Wistar rats was clamped for 45 minutes to induce renal I/R injury. Kidney tissue, colon, and blood were collected 24 hours and 14 days later. Linaclotide was administered for 14 days preoperatively and until postoperative tissue collection. Tissue sections were stained with standard histologic techniques such as HE, Sirius Red, F4/80, etc. As genes associated with I/R, TGF-β and related fibrosis markers α-SMA, MMP2, TIMP1 and inflammatory cytokines TNF, IL-1β and IL-6 were analyzed by quantitative PCR analysis. Results Serum creatinine levels decreased significantly after linaclotide administration, indicating improved renal function. Histologic examination showed less tubular damage and less collagen deposition on Sirius Red staining. Further analysis showed decreased expression of TGF-β and related fibrosis markers α-SMA, MMP2 and TIMP1, suggesting downregulation of the fibrotic TGF-β pathway by linaclotide. Furthermore, 1 day after I/R injury, linaclotide significantly reduced macrophage infiltration and suppressed key proinflammatory cytokines such as TNF, IL-1β, and IL-6. Conclusion These results suggest that linaclotide, with its established safety profile, could extend its benefits beyond gastrointestinal issues and potentially serve as a therapeutic intervention in many aspects of kidney surgeries. In addition, it could provide immediate and practical insights into the selection of laxatives for the management of patients with AKI or CKD, regardless of cause, and for those receiving dialysis or transplant therapy.

Aortic Angiosarcoma Manifesting as Multiple Musculoskeletal Metastases: A Case Report.

Aortic angiosarcomas are rare. Due to its rarity and metastatic presentation, it is difficult to diagnose metastatic aortic angiosarcoma. We describe the clinicopathological and radiologic features of a metastatic aortic angiosarcoma presenting as musculoskeletal metastases. A 59-year-old male patient presented with left thigh pain. Plain radiographs revealed multifocal osteolytic lesions in the left femur shaft. Abdominopelvic computed tomography showed a lobulated osteolytic lesion in the left iliac bone. Magnetic resonance images revealed multifocal soft tissue lesions in the thigh musculature. A positron emission tomography/computed tomography (PET/CT) scan demonstrated multiple foci of increased uptake in the left femur bone, pelvis, left thigh, and calf musculature. Focal increased uptake in the lower abdominal aorta was newly detected. Pelvis biopsy showed tumor cell nests of epithelioid cells. The tumor cells showed vasoformative features. Immunohistochemically, the tumor cells showed positivity for vimentin, CD31, and ERG. The pathologic diagnosis of epithelioid angiosarcoma was established. The origin of the tumor was presumed to be the aorta. This case underscores the importance of PET scans in identifying primary lesions. In terms of the histopathologic diagnosis of biopsy samples with tumor cells exhibiting epithelioid neoplastic morphology, employing appropriate ancillary techniques such as immunocytochemistry with vascular markers may assist in accurately diagnosing metastatic angiosarcoma.

Modified Ileal Conduit for Pelvic Lipomatosis: Technique Description and Outcome

Introduction: The aim of this study was to present the surgical technique and clinical outcomes of modified ileal conduit for pelvic lipomatosis (PL). Methods: From 2020 to 2022, we prospectively enrolled 9 patients with PL undergoing modified ileal conduit. The patient characteristics, perioperative variables, and follow-up outcomes as well as the description of surgical technique were reported. Results: All 9 patients successfully completed the operation. Two patients had perioperative complications of Clavien-Dindo grade I. The mean operation time and bleeding volumes were 253 ± 51.4 min and 238.9 ± 196.9 mL, with a mean postoperative follow-up time of 13.0 ± 5.6 months. The postoperative 3-month and 1-year creatinine values were significantly decreased versus the preoperative (p = 0.006 and p = 0.024). The postoperative 3-month and 1-year estimated glomerular filtration rate values were significantly increased compared with those before operation (p = 0.0002 and p = 0.018). The separation value of left renal pelvis collection system after operation was significantly reduced compared with preoperative evaluation (p = 0.023 at 3 months and p = 0.042 at 1 year) and so was the right side (p = 0.019 and p = 0.023). Conclusion: Modified ileal conduit is safe and feasible for PL. A large sample cohort with long-term follow-up is needed to evaluate the clinical outcomes of PL.

Clear cell renal cell carcinoma with small intestine invasion mimicking intestinal tumor.

A 65-year-old man presented with asymptomatic retroperitoneal mass that had been detected on ultrasonography performed during a physical screening. He had no hematochezia, hematuria or any other symptoms. Tumor markers were normal, including alpha fetoprotein, carcinoembryonic antigen, neuron-specific enolase and cancer antigen 199. Abdominal CT demonstrated a retroperitoneal mass (white arrow) accompanied by significant thickening of the jejunal wall, involving the left kidney. After enhancement, the mass showed rapid enhancement at arterial phase and venous phase, showed washout at delayed phase. Multi-planar reformation revealed the mass involving the pancreatic tail and the left renal pelvis. Surgical resection was performed and pathological examination confirmed clear cell renal cell carcinoma involving pancreas and jejunum, with immunohistochemical results as follows: CK (partly +), Vimentin (partly +), Pax-8 (+), CD10 (+), P505s (partly +), CA-IX (+), TFE-3 (-), Syn (-), CgA (-), CD56 (+), S-100 (-), SOX-10 (-), HMB-45 (-), Desmin (-),CD117 (-), DOG-1 (-), Melan-A (-), SMA (-), CD34 (+), CD31 (+), CD68 (+), Ki67 (5%+). Discussion.

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.

EOLP-04. EXTRA-NEURAL DISSEMINATION OF MYC-ACTIVATED INFANT MEDULLOBLASTOMA DESPITE MULTIMODAL THERAPY

Abstract Extra neural metastases of infant medulloblastoma portend poor prognosis. Previous reports were in patients receiving treatment with radiation alone or patients with ventriculoperitoneal shunt (VPS). Recently with multimodal therapy, reports of extra-neural medulloblastoma are rarely reported. We report two patients with stage M3 MYC-Activated Infant Medulloblastoma who received aggressive therapy yet developed extra-neural relapses. The first case was a 2-year-old male who underwent gross total resection, which was complicated by hydrocephalus requiring VPS placement. He completed treatment as per ACNS0334 and achieved a near-complete response. Next, he received four cycles of five drug anti-angiogenic therapy followed by 2 cycles of expanded access therapy with I-3F8 antibody. He progressed both in brain and spinal cord, then received palliative craniospinal irradiation with boost. Two months following radiation, he died of disease with significant pancytopenia and hypoechoic nodules throughout the liver, suggestive of disseminated disease. Our second patient is a five-year-old girl, who was diagnosed at age two. She achieved a CR after treatment as per ACNS0334. She then enrolled on a clinical trial with Difluoromethylornithine (DFMO) for three months. On initial disease evaluation, she had progression in brain and spine. She underwent palliative radiation with craniospinal irradiation and boost with concurrent Indoximod on phase 2 clinical trial. Following radiation, she received compassionate use indoximod and temadar for 24 months and remained in CR. Three months after stopping therapy, she progressed to left orbit, pelvis and ribs. She is currently receiving palliative care. MYC-activated medulloblastoma has a very poor outcome and requires multimodal including radiation to achieve remission. Despite aggressive therapy, disease is highly evasive and can spread extracranially to multiple areas including bones, bone marrow, liver, and abdomen. Novel therapies and more exhaustive surveillance regiments need to be developed to limit extracranial dissemination and achieve more durable remissions.

Physico-Mechanical Properties of Dupska Pramenka Wool as Breed Characterization Descriptors

Summary The characterization of animal genetic resources includes morphometric, production and genetic characterization. This paper aims to determine the annual yield, staple length, and physico-mechanical properties of the wool of the Dupska Pramenka sheep. The average annual wool yields of a total of 130 ewes and 14 rams enrolled in the study were 2.120 kg and 3.340 kg, respectively. Wool samples were taken from the left shoulder, posterior rib, and pelvis of a total of 50 sheep (36 ewes and 14 rams). The lengths of wool staples collected from three body sites of the ewes were 20.92 cm, 21.75 cm, and 22.25 cm, respectively. The lengths of wool staples collected from three body sites of rams were 23.50 cm, 22.14 cm, and 23.64 cm, respectively. The height and length of wool fibers of the ewes were 21.97 cm and 22.85 cm on the shoulder, 22.38 cm and 23.10 cm on the posterior rib, and 23.06 cm and 23.77 cm on the pelvis. The height and length of wool fibers of the rams were 22.00 cm and 22.89 cm on the shoulder, 22.54 cm and 23.26 cm on the posterior rib, and 22.61 cm and 23.40 cm on the pelvis. The average fineness of wool fibers of the ewes was 43.08 µ, whereas the fineness of wool fibers of the rams was 45.43 µ. The Dupska Pramenka sheep were found to have mixed fibers: axillary (over 45µ), accounting for51.64% in the ewes and 54.91% in the rams, and transitional (30–45µ), accounting for 28.76% in the ewes and 32.80% in the rams. Fiber fluff (10–30µ) accounted for 19.83% and 12.98% in the fleeces of ewes and rams considered, respectively.

CD20 Negative Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type with Rapidly Progressing Skin Lesions

A 95-year-old man came with violaceous nodular skin lesions of the left shin. The lesions were not painful or pruritic but progressed rapidly over the 3 months. Fever, night sweats, weight loss, and other systemic symptoms were absent. Shave biopsy of the lesion revealed the cells negative for CD20 but positive for BCL2, BCL6, FOX-P1, and CD10. PET/CT showed high uptake in the left leg and a sizeable hypermetabolic lymph node in the left pelvis. The patient was started on rituximab treatment as a single agent. This report highlights some of the diagnostic and treatment difficulties in CD20 negative lymphomas and the importance of a multidisciplinary approach in those cases.

A Case Report: High-Grade Urothelial Carcinoma in the Renal Pelvis with Complete Kidney and Ureter Duplication Featuring Heterologous Differentiation

This report describes a considerably rare case of high-grade urothelial carcinoma of the renal pelvis and ureter, presenting with heterologous differentiation, in a patient with bilateral duplicated kidneys. A 73-year-old male experienced intermittent gross hematuria for 5 months, accompanied by lower back and abdominal pain. Ultrasound and computed tomography scans revealed bilateral renal and ureteral duplication with multiple tumors in the left renal pelvis. A total nephroterectomy and bladder cuff resection were performed on the left two nephrons. Multiple space-occupying lesions were identified in the left renal pelvis and ureter. Histopathological examination showed poorly differentiated and diverse tumor cells, manifesting as sarcomatoid carcinoma, papillary adenocarcinoma, and infiltrating high-grade urothelial carcinoma. The tumor infiltrated the subcutaneous fibrous connective tissue of the renal pelvis and the full thickness of the ureter. Given the rarity of recurrent renal urothelial carcinoma with heterogeneous differentiation, comprehensive imaging and pathological assessments are vital to delineate the nature of the lesion and the direction of tissue pathological heterologous differentiation. These evaluations guide early radical surgical interventions, improving survival rates.

997 Traumatic Jejunal Rupture Following Gaelic Football Game. Case Report

Abstract Aim Abdominal injury accounts for just 6.3% of injuries in sport. The most common mechanisms are contacts with a player (74.5%), a surface (8.1%) or equipment (0.6%). Only twelve cases of Jejunal rupture are described in the literature. Method This case involves a young Gaelic football player who had significant abdominal contact with other players’ knees. He experienced nausea and left flank pain radiating to the groin. At the Emergency Department the heart rate was 95 beats per minute and blood pressure was 120/70 mmHg. There was bruising in the left flank at the impact site and some guarding. Initial investigations showed normal inflammatory markers and a normal Chest X-ray. Nine hours later the white cell count had increased to 17.85x10^9 and CRP to 106mg/L. Abdominal and Pelvic CT scanning suggested a bowel injury with free fluid in the left flank and pelvis. Management Exploratory laparotomy identified a jejunal rupture 10cm distal to the duodenal-jejunal flexure. A primary two-layer repair was performed. Antibiotic and anti-fungal cover were prescribed, and he was discharged well on day 5. Conclusions Owing to the rarity of bowel injury after blunt trauma, soft peritoneal signs and radiological insensitivity, the diagnosis of small bowel perforation is often delayed and can be associated with marked morbidity and mortality. Serial examinations and a high index of suspicion is required to detect bowel injuries in the case of blunt abdominal trauma in contact sports.

Endoscopic stent placement with laparoscopic stent fixation in a patient with obstruction at a gastrojejunostomy anastomosis site

BackgroundPalliative endoscopic stent placement may be considered in patients with malignant gastrointestinal obstruction. Stent migration is a potential complication, particularly for those placed at a surgical anastomosis or across a stricture caused by extra-alimentary tract factors. We report a patient with left renal pelvis cancer and gastrojejunostomy obstruction who underwent endoscopic stent placement and laparoscopic stent fixation.Case presentationA 60-year-old male with peritoneal dissemination of a left renal pelvis cancer was admitted for treatment of upper gastrointestinal obstruction. A laparoscopic gastrojejunostomy had been previously performed for cancer invasion of the duodenum. Imaging showed gastroduodenal dilation and impaired passage of contrast medium through the efferent loop of the gastrojejunostomy. Gastrojejunostomy anastomosis site obstruction due to dissemination of left renal pelvis cancer was diagnosed. Conservative treatment failed and endoscopic stent placement with laparoscopic stent fixation was performed. After surgery, the patient was able to tolerate oral intake and he was discharged without complications. The patient gained weight and was able to resume chemotherapy, indicating the procedure was effective.ConclusionsEndoscopic stent placement with laparoscopic stent fixation for malignant upper gastrointestinal obstruction appears effective in patients with a high risk of stent migration.

Success Rate and Complications of Extracorporeal Shock Wave Lithotripsy in Patients Referring to the Kowsar Hospital in Semnan

Background and Objective: Treatment with Extracorporeal Shock Wave Lithotripsy (ESWL) is a low-cost method with a short hospitalization period. However, several complications have been reported for this method. This study was designed to investigate the efficiency and side effects of ESWL. Materials and Methods: In a cross-sectional study, all available files of cases in the stone crusher unit were evaluated according to the inclusion and exclusion criteria from April 2013 to April 2016. Preliminary information before lithotripsy, including patients' demographic characteristics and also treatment success, and complications, was assessed. Results: The success rate of ESWL was 81.4%, which had no significant relationship with gender, age, and body mass index. The mean size of the stones was 10.9±5.4 mm, which was associated with the success rate. In terms of stone location, the highest frequency was observed in the right lower calyx, followed by the left pelvis. The most common complications were ecchymosis (84.3%), hematuria (20.6%), and severe pain (15.3%). There was a significant difference in the incidence of complications in patients with different stone sizes (p&lt;0.01). The occurrence of complications had a significant relationship with the location of the stone (p&lt;0.01). Stones located in the pelvis and lower calyces caused the most complications. Conclusion: The results showed that ESWL had a high success rate and was a suitable method for the treatment of urinary stones. The success rate was associated with the stone size, which, therefore, is an important factor in choosing this approach.

A retroperitoneal cystic lymphangioma involving the spleen and pancreas: a case report.

In the present case, the girl complained of abdominal pain and dysuria. Clinical examinations showed a palpitated mass in her left pelvis; a radiology exam revealed a cystic mass infiltrating the spleen and pancreatic tail, reaching the pelvis. The mass, including the spleen and pancreatic tail, among the cystic compound was removed. The final diagnosis of benign CL was done based on a histopathology exam. A one-year follow-up showed no signs of recurrence. CL is usually asymptomatic. The retroperitoneal location of the mass delayed the diagnosis and allowed the mass to grow to a large size and compress nearby structures. The typical presentation of CL is usually a substantial, multichambers cystic mass. However, it could be easily misdiagnosed with other cystic tumors of the pancreas. Age-based differential diagnosis should be taken into consideration in children as abdominal mass can originate from gastrointestinal or genitourinary systems. The imaging features of CL are insufficient, and the final diagnosis depends on the histopathology exam. Furthermore, CL can mimic pancreatic cysts in its presentation and cite; therefore, it must be included in the diagnosing strategy whenever a retroperitoneal cyst is being investigated, as imaging features can be misleading. Surgical treatment of CL should be associated with long-term ultrasound follow-up to identify and manage recurrence early.