Left Renal Fossa Research Articles

Cystic Renal Dysplasia with Supernumerary Kidney

The supernumerary kidney is a rare anomaly characterized by the presence of an extra kidney. Obstructive cystic dysplasia occurs secondary to outflow tract obstruction. We present the case of a 10-year-old girl with recurrent urinary tract infection in whom evaluation revealed obstructive cystic dysplasia of the left kidney with ipsilateral vesicoureteric reflux and right supernumerary kidney. The history was significant for surgery for Ladd bands and spontaneous closure of an atrial septal defect. While ultrasound showed an empty left renal fossa, dimercaptosuccinic acid scan showed solitary right kidney with focal photopenic areas in the lower pole suggesting pyelonephritis. Contrast-enhanced computed tomography revealed right fused supernumerary kidney with focal nephronia and shrunken left kidney. The left ureter inserted ectopically into the urinary bladder; micturating cystourethrography confirmed grade 2 vesicoureteric reflux. The child was managed conservatively with antibiotics. Cystic renal dysplasia and supernumerary kidneys are a rare association that requires clinical and radiological monitoring. Screening of the contralateral functioning kidney and surgical correction of any anomalies is imperative. This case highlights the need for systematic evaluation for coexisting anomalies in patients with abnormal renal ultrasonography.

Compliance Issues in Managing 21 Hydroxylase Deficiency and their Short/Long-Term Consequences.

ObjectiveTo report a case of untreated classic 21 hydroxylase (OH) deficiency congenital adrenal hyperplasia (CAH) in a transgender patient resulting in pulmonary embolisms (PEs) and bilateral adrenal masses.MethodsA 36-year-old male (birth sex: female) presenting with bilateral PEs in the setting of long-standing, untreated classic 21OH CAH was also found to have bilateral adrenal masses (unconfirmed myelolipomas).ResultsFurther history revealed a known diagnosis of CAH. The patient had been treated with glucocorticoid and mineralocorticoid replacement in childhood but stopped taking these medications against medical advice. During his hospital admission, he was noted to have elevated 17-hydroxyprogesterone, low cortisol with elevated ACTH levels, and male-level testosterone measurements. CT of the abdomen/pelvis revealed a 23 cm mass in the left renal fossa and a 2.5 cm mass in the right renal fossa consistent with bilateral adrenal myelolipomas. The patient attended follow-up in clinic, but declined any further hormonal treatment as he identified as male and felt further treatment was unnecessary.ConclusionThis case demonstrated the unique long-term effects of untreated classic CAH due to 21OH deficiency, including bilateral adrenal myelolipoma, adrenal compensation to the point of producing male-level androgens, and possibly PEs. Treatment with hydrocortisone was recommended to suppress ACTH and it was planned that the patient would eventually start on testosterone (although this would have been complicated by his bilateral PEs). Potential aetiologies for the PEs included vascular compression of the renal artery (which could explain the elevated EPO/erythrocytosis contributing to hypercoagulability) or the renal vein by the adrenal mass.LEARNING POINTSGender dysphoria in patients with congenital adrenal hyperplasia (CAH) is not uncommon.Adrenal enlargement can allow untreated CAH patients to compensate.Pulmonary embolisms can be a consequence of treating as well as untreated CAH.

S1917 Complicated Diverticulitis of the Sigmoid Flexure in a Patient with Left Nephrolithiasis

Introduction: Complicated diverticulitis is defined as diverticular inflammation associated with hemorrhage, abscess, phlegmon, perforation or obstruction. There are currently no reported cases of complicated diverticulitis occurring secondary to obstructive nephrolithiasis. We report a patient admitted for a left ureteral stone, whose significant perinephric inflammation was suspected to play a role in the development of complicated diverticulitis. Case description/methods: A 76 year old woman with history of recurrent nephrolithiasis presented with acute left flank pain. On arrival, she was mildly tachycardic. Physical exam was notable for left costovertebral angle tenderness. Labs were notable for an elevated blood urea nitrogen of 25 mg/dL. Computed tomography (CT) abdomen showed a 6 mm obstructing calculus within the left proximal ureter causing moderate hydronephrosis and significant peri-nephric inflammation. The patient was started on ceftriaxone. The next day, she had a worsening leukocytosis and an acute kidney injury, so she was taken urgently for left ureteral stent placement. Postoperatively, she had significant abdominal pain, so a repeat CT abdomen was obtained. It revealed inflamed diverticulum at the splenic flexure with an associated abscess abutting the spleen, consistent with complicated diverticulitis. She was managed supportively with nasogastric tube decompression, pain control, and broadened antibiotics. On hospital day 8, her abdominal pain worsened. Repeat CT abdomen showed enlargement of the perisplenic abscess and multiple new small abscesses anterior to the spleen. The patient was taken for laparoscopic splenectomy, which was complicated by iatrogenic perforation of the stomach, peritonitis, and septic shock. After a prolonged and complicated hospital stay in the surgical intensive care unit, the patient was discharged to a long term care facility. Discussion: Our patient's complicated diverticulitis was suspected to be secondary to her left ureteral stone. While most cases of diverticulitis occur at the sigmoid colon, our patient’s was at the splenic flexure, in close proximity to the left renal fossa where significant inflammation was noted on initial imaging. It is also possible that her diverticulitis was a consequence of iatrogenic ureteral injury during cystoscopy. Clinicians should be aware that complicated diverticulitis may occur in relation to nephrolithiasis.Figure 1.: a: Synaptophysin positive tumor cells b: Chromogranin A positive tumor cells c: Colonoscopy showing 2 cm mass at Hepatic flexure. d: High grade adenocarcinoma arising in a background of sessile serrated adenoma e: CK7 positive immunohistochemical staining.

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

OEIS Syndrome: Omphalocele, Exstrophy of the Cloaca, Imperforate Anus, and Spinal Defects

A case of solitary kidney with duplex collecting systems and renal vascular variants in an adult male cadaver

We describe a unique solitary kidney with duplex collecting system and vascular variation observed in an 86-year-old white male formaldehyde- and phenol-fixed cadaver during routine academic dissection. The left renal fossa was empty with an intact adrenal gland, and the right renal fossa contained a fused renal mass with apparent polarity between the superior and inferior regions and two renal pelves converging into a single ureter. There were three right renal arteries supplying the renal mass; the superior and middle arteries were noted to be postcaval and the inferior artery was precaval. There were also two right renal veins draining into the inferior vena cava and following a regional distribution with the superior vein draining the inferior portion of the renal mass. Despite generally being asymptomatic, the detection of renal anatomical variants is clinically important for appropriate patient management and surgical interventions.

Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites.

Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.

English

A 7-day-old new-born was referred to Department of Radiodiagnosis of North Bengal Medical College and Hospital to evaluate enlargement of head circumference. On clinical examination of this new-born we found macrocephaly and absent right thumb as well as deformed left thumb. No other clinical abnormalities were seen in this new-born apart from this. Facial structures, spine, upper and lower limbs, trunks were normal clinically. Transcranial ultrasound was done using LOGIQ P9 ultrasound machine which revealed an open lip schizencephaly involving right cerebral hemisphere with absence of corpus callosum. Trans abdominal sonography revealed non visualisation of left kidney in left renal fossa as well as in its usual ectopic position. Therefore, the new-born underwent magnetic resonance imaging (MRI) of brain and whole abdomen which confirmed ultrasound findings. MRI additionally revealed there was no ocular, anorectal and genito-urinary malformations. Infantogram was done to evaluate the skeleton of this new-born. Fetal echocardiography revealed no obvious cardiac anomalies.

Techniques of orthotopic renal transplantation in pigs. One donor to two recipients via inverted grafting.

ABSTRACTPurposeAlthough transplanting two kidneys from a single donor to two recipients has some advantages, the right and left kidneys are not anatomically identical; thus, a surgical procedure considering the anatomical features of the donor kidneys is needed when transplanting them into the opposite renal fossae. Based on vast experience, the surgical details of pig orthotopic kidney transplantation from one donor to two recipients was reported.MethodsWhen the right kidney was transplanted to the left renal fossa, the graft was inverted upside down, not backwards, thus ensuring that the anteroposterior relationship of the renal vessels was maintained and anatomically natural vascular anastomosis could be performed.ResultsUsing this technique, we could have developed a pig experimental model that is safe and has a high success rate, even for researchers in the middle of their training. This technique of inverting the graft upside down was reported in human kidney transplantation to make vascular anastomosis easier.ConclusionsIn pig orthotopic kidney transplantation from one donor to two recipients, an anatomically natural vascular anastomosis could be performed via inverted grafting when the right kidney was transplanted into the left renal fossa.

1945 Isolated Gastric Varices as the Sole Manifestation of Renal Cell Carcinoma

INTRODUCTION: Isolated gastric (fundal) varices (IGV) are a consequence of left (sinistral) portal hypertension commonly caused by splenic vein thrombosis (SVT). It occurs when SVT results in a backflow into the collateral short gastric and gastroepiploic vessels. Common causes of SVT include pancreatic and splenic pathologies. Renal cell carcinoma (RCC) is an extremely rare cause, and by itself, RCC is lethal because of the vagueness of its presenting symptoms. CASE DESCRIPTION/METHODS: A 76 year-old male with a past medical history of chronic anemia is presenting with two day history of hematochezia. He denies any personal or family history of colon cancer. He is not on anticoagulation or NSAID regimen. On evaluation, patient was noted to have non-remarkable vital signs. Physical exam was fairly unremarkable. Initial CBC was remarkable for severe anemia with hemoglobin of 6.1. MCV was normal. After routine transfusion, he was evaluated by gastroenterology and underwent an EGD, colonoscopy and capsule endoscopy. EGD was remarkable for 2 cm diameter non bleeding fundic gastric lesion. Colonoscopy and capsule endoscopy were unremarkable except for findings of dark blood in the distal ileum and throughout the colon. Tagged RBC scan was negative. Endoscopic ultrasound was obtained that showed multiple tubal, anechoic structures in the cardia of the stomach consistent with varices. CT abdomen and pelvis then confirmed a giant mass filling the left renal fossa presumably primary renal cell neoplasm with displacement of the pancreas and splenomegaly. CT chest was obtained and confirmed pulmonary nodules likely suggesting metastatic lesions. He then underwent splenectomy and nephrectomy with adjuvant chemotherapy for the metastatic disease. DISCUSSION: Sinistral (left) portal hypertension (SPH) was first outlined by Greenwald and Wasch in 1939. It is a clinical syndrome in which a patient with a patent portal vein and normal hepatic (liver) function tests develops isolated gastric variceal bleeding secondary to splenic vein thrombosis. Interestingly, only two cases have documented renal cell carcinoma as a cause of SPH in the last 30 years. Patients with this condition need to be considered for a prophylactic splenectomy and removal of associated arteries and veins, as well as a total nephrectomy. In this case, with metastatic lesions to his lungs, involving hematology/oncology and general surgery and gastroenterology in the multidisciplinary decision making process would be in his best interest.

Proximal ureteral atresia in a duplex kidney with preserved renal function: A case report and review of literature

Ureteral atresia is a rare congenital anomaly and is usually associated with renal dysplasia. Distal atresia is more common and other associated urinary anomalies are rare. We report a case of an eight year old boy who presented with left flank pain and vomiting. Ultrasound abdomen and pelvis and renal scinitigraphy were suggestive of hydro-ureteronephrosis with obstructed drainage. He was suspected to have ureteric stricture and taken up for surgery. Cystoscopy and retrograde pyelogram revealed an incomplete duplication with lower moiety ureter ending blindly. Exploration of left renal fossa showed a duplex anomaly with normal upper moiety and hydronephrosis of lower moiety with an ureteric stump. Ureteropelvic anastomosis was done between the dilated renal pelvis and the blind ending ureter. Patient was doing well post operatively with good function in both moieties. Review of literature shows only two previously reported cases of proximal ureteric atresia. Preservation of renal function in an older child has also been reported only once. Ureteral atresia is usually diagnosed intra-operatively and various reconstruction options are available in patients with preserved function.

Spontaneous regression of adrenal metastasis from renal cell carcinoma after sunitinib withdrawal: case report and literature review

BackgroundThe spontaneous regression of metastatic renal cell carcinoma is a rare phenomenon, with an estimated incidence of < 1%. We report a case of post-nephrectomy renal cell carcinoma adrenal metastasis, followed by the spontaneous regression of the metastasis after withdrawal of sunitinib.Case presentationThe patient was a 55-year-old male with clear cell type renal cell carcinoma who previously underwent a left laparoscopic radical nephrectomy. After 51 months of follow up, a recurrence in the left renal fossa was observed and subsequently excised. Four months after excision, an abdominal Computerized tomography (CT) identified an adrenal metastasis of 1.6 cm. The patient was treated with sunitinib. However, the treatment was discontinued because of gastrointestinal side effects and fatigue. Eleven months after the discontinuation of sunitinib treatment, a progression in the adrenal metastasis growth (5.7 cm) was observed, whereas 16 months after the discontinuation, a regression of the adrenal metastasis growth (3.4 cm) was observed. During subsequent follow-ups, a gradual reduction in the size of the adrenal metastasis (1.8 cm) was observed. After 44 months from the discontinuation of sunitinib treatment, the patient was still alive and followed up in the outpatient department.ConclusionsSunitinib is a multi-targeted inhibitor of vascular endothelial growth factor (VEGF) receptors. This compound reduces tumor angiogenesis and has been approved worldwide for the treatment of advanced renal cell carcinoma. To our knowledge, this is the fourth case of the spontaneous regression of metastatic renal cell carcinoma after the discontinuation of sunitinib treatment.

Giant retroperitoneal teratoma displacing kidney causing acquired crossed non-fused renal ectopia: rare case report

This is a rarest of rare case of surgical resection of giant retroperitoneal teratoma in a 15 yr old female child, causing displacement of left kidney to right by its huge volume (45X30X25cm= 33750cm3), making it appear like acquired crossed confused renal ectopia. Teratomas can occur anywhere in abdomen. Ovary being most common site followed by retroperitoneum. The most common age group is &lt;1yr of age but they can present in any age. There are various case reports describing giant teratomas of various sizes in children and adults. Largest reported size is of 35x35cm size in a 33 yr old female. The case author has operated is rare case ever reported of ‘most voluminous retroperitoneal teratoma in 15 yr old female’ with displacement of all intra-abdominal structures by its volume. Tumor was 45x30x25cm with 12kg weight. When presented patient had complaints of vague discomfort and extreme abdominal distension progressive over last 1 yr. Patient underwent surgery -Excision of tumor, which needed dissection from superior mesentric artery and vein, splenic vein, pancreas, retroperitoneum, splenic vein, diaphragm and left kidney. Left kidney was rotated to right side, causing it to appear like ‘acquired crossed confused renal ectopia’ The left kidney was safely replaced to its original position in left renal fossa. The histopatholgy of tumor was of mature teratoma with no evidence of malignancy. Patient remained symptom free and recurrence free during 5 yrs follow up. Mature cystic teratomas are benign in nature they can attain enormous size in abdomen and can displace any intrabdominal structure. Surgeons should be aware that these big tumors can be resected with preservation of displaced structures in abdomen. Careful surgery is essential for preservation of abdominal organs and to ensure quality of life of patient.

Incidental Detection of Perinephric Urinary Leak on Bone Scintigraphy in a Patient with Urinary Bladder Carcinoma.

A 71-year-old male patient with urothelial carcinoma of the bladder was referred for 99mTc-methylene diphosphonate bone scintigraphy to assess for skeletal metastasis. While the bone scan showed no abnormal skeletal uptake, tracer activity was detected in the extrarenal region of the left renal fossa on the planar image; single photon emission computed tomography-computed tomography (CT) demonstrated tracer pooling in the perirenal collection. In addition, the CT detected nontracer-avid parenchymal lung nodules and hypodense liver lesions consistent with metastatic disease. The perinephric urinary leak was drained by percutaneous drainage, confirmed by diuretic renography the following day.

Does BLOODCARE Powder Prevent Postoperative Chylous Ascites After Lymphadenectomy for Gynecological Malignancies?

The aim of this study was to evaluate the effect of an intraoperative hemostatic cellulose agent (BLOODCARE powder [Life Line, Brno, Czech Republic]) on reducing the incidence of postoperative chylous ascites (PCA) after complete pelvic and para-aortic lymphadenectomy (PPALN) in patients with gynecological cancers treated with laparotomy. This case control study reviewed 150 patients with gynecological cancer who underwent PPALN. In the study group (n = 75), BLOODCARE powder was applied below the left renal vein and bilateral obturator fossa. In the control group (n = 75), no sealant agent was used after the procedure, such as fibrin glue or a hemostatic cellulose agent. The demographic and surgical characteristics of the patients in both groups were similar. Chylous ascites occurred in 9 cases (6%). The incidence of PCA was lower in the study group (1 [1.3%] vs 8 [10.7%]; P = 0.03). Logistic regression analysis indicated that using BLOODCARE powder during the surgery independently protected against the development of PCA. Using BLOODCARE powder during retroperitoneal surgery may prevent PCA. This simple, effective agent should be used after PPALN for gynecological cancers.

P12.04: Congenital megalourethra: a rare form of obstructive uropathy

Introduction: Congenital megalourethra is a rare form of functional lower urinary tract obstruction (LUTO) caused by primary or secondary agenesis/hypoplasia of the penile corporal tissues. In primary absence/hypoplasia of the corpora spongiosa and cavernosa the amniotic fluid volume is usually normal, the renal function is preserved and the outcome is commonly good. In obstructive (secondary) megalourethra there is higher incidence of renal failure leading to oligohydramnios and pulmonary hypoplasia, thus higher perinatal mortality rates are observed. The prenatal diagnosis of LUTO is suspected when distended bladder with or without hydroureter and hydronephrosis is detected on ultrasound. In addition, in megalourethra a cystic structure in the perineal region is usually found. The thin-walled distended urethra can be relatively easy mistaken with a loop of umbilical cord. The differential diagnosis is made by colour Doppler. In all cases of LUTO oligohydramnios is associated with poor prognosis. Case report: A 19-year-old primigravida was referred at 20+2 w.g. for a routine second trimester fetal morphology survey. The scan revealed a male fetus with dilated penile portion of the urethra, distended bladder, empty left renal fossa and right moderate pyelectasia. The amniotic fluid was reduced. Megalourethra and unilateral left renal agenesis was suspected. After extensive counselling the parents opted for termination of pregnancy. Post-abortem autopsy confirmed the prenatal diagnosis. No other associated structural abnormalities were found. The fetal karyotype was normal, 46 XY. Conclusion: Congenital megalourethra is a rare form of LUTO that should be always suspected in cases of urinal retention. Early prenatal diagnosis and extensive evaluation of all prognostic factors allow adequate obstetrical management.

Congenital Unilateral Fallopian Tube and Renal Agenesis in a Patient with Primary Infertility

A 35-year-old nulligravid normo-ovulatory woman presented for the evaluation of primary infertility. Hysterosalpingography revealed normal filling (Fig. 1A) and intraperitoneal spillage of radiographic contrast through the right fallopian tube (Fig. 1B). No fill or spillage of contrast was noted through the left fallopian tube. A diagnostic hysteroscopy confirmed the presence of the right ostium (Fig. 2A); the left ostium was visually absent (Fig. 2B). Magnetic resonance imaging was subsequently performed, which showed blunting of the endometrium within the left cornua at the level of the uterotubal junction. There was no evidence of a kidney in the left renal fossa or within the pelvis (Fig. 2C). These findings indicated the congenital absence of the left fallopian tube and kidney. The patient underwent ovulation induction with intrauterine insemination and conceived in her second cycle. Fig. 2(A) Diagnostic hysteroscopy confirming the presence of the right ostium (white arrow). (B) Hysteroscopy indicating the absence of the left ostium (white X). (C) Single-shot fast spin echo magnetic resonance imaging confirming the presence of the right kidney (dotted white circle) in a coronal section. The same section shows an absent left kidney (white X). View Large Image Figure Viewer Download Hi-res image

Spontaneous regression of adrenal metastasis from renal cell carcinoma after sunitinib withdrawal: Case report and literature review

The spontaneous regression of metastatic renal cell carcinoma is a rare phenomenon, with an estimated incidence of < 1%. We report a case of post-nephrectomy renal cell carcinoma adrenal metastasis, followed by the spontaneous regression of the metastasis after withdrawal of sunitinib. The patient was a 55-year-old male with clear cell type renal cell carcinoma who previously underwent a left laparoscopic radical nephrectomy. After 51 months of follow up, a recurrence in the left renal fossa was observed and subsequently excised. Four months after excision, an abdominal Computerized tomography (CT) identified an adrenal metastasis of 1.6 cm. The patient was treated with sunitinib. However, the treatment was discontinued because of gastrointestinal side effects and fatigue. Eleven months after the discontinuation of sunitinib treatment, a progression in the adrenal metastasis growth (5.7 cm) was observed, whereas 16 months after the discontinuation, a regression of the adrenal metastasis growth (3.4 cm) was observed. During subsequent follow-ups, a gradual reduction in the size of the adrenal metastasis (1.8 cm) was observed. After 44 months from the discontinuation of sunitinib treatment, the patient was still alive and followed up in the outpatient department. Sunitinib is a multi-targeted inhibitor of vascular endothelial growth factor (VEGF) receptors. This compound reduces tumor angiogenesis and has been approved worldwide for the treatment of advanced renal cell carcinoma. To our knowledge, this is the fourth case of the spontaneous regression of metastatic renal cell carcinoma after the discontinuation of sunitinib treatment.

Ectopic Spleen Mimicking Kidney Activity Post-Nephrectomy

Ectopic spleen may simulate kidney activity on renal scintigraphic imaging. Accurate diagnosis requires correlation with the patient’s history and anatomic imaging studies. We report a case where the spleen migrated to the left renal fossa and mimicked the left kidney after a left nephrectomy.

Prenatal sonographic diagnosis of multicystic congenital mesoblastic nephroma

The authors report an unusual presentation of congenital mesoblastic nephroma as a multilocular cystic renal lesion. Prenatal sonography revealed a unilateral, encapsulated, multilocular cystic mass with solid components measuring 5.7 × 5.4 × 4.3 cm in the left renal fossa. There was no increase in vascularity and no signs of hydrops fetalis. On the forth postnatal day left-sided radical nephrectomy was performed and histopathological examination revealed cellular type congenital mesoblastic nephroma. A multicystic appearance is rare as the vast majority of prenatally diagnosed congenital mesoblastic nephroma cases presented in the literature are of the classic type with solid homogenous or heterogenous appearence.

Subepithelial pelvic hematoma

IntroductionSubepithelial pelvic hematoma (Antopol–Goldman lesion) is a rare condition that clinically simulates a renal or pelvic neoplasm, whose final diagnosis is established in most of the cases by the pathologist after the nephrectomy. To avoid this, imaging tests and high diagnostic suspicion are essential. Material and methodsThe case of a 43-year-old female patient is presented. She had no background of interest and she came due to experiencing an acute pain in the left renal fossa after a physical effort. This patient was studied by Ultrasonography, Computed Tomography (CT), and evolutively with magnetic resonance (MR). ResultsThe X-ray studies showed a lesion in the left renal sinus with characteristics suggestive of subepithelial renal pelvis hematoma, without data suggesting underlying lesion. The treatment of the patient was conservative, confirming the disappearance of the lesion in the follow-up studies. ConclusionKnowledge of the X-ray findings of the Antopol–Goldman lesion in different imaging tests and an elevated index of suspicion are crucial in the management of patients affected by this uncommon condition. These make it possible to avoid an unnecessary nephrectomy.