Left Renal Hilum Research Articles

Extrarenal Visceral Arteries Injuries during Left Radical Nephrectomy: A 50-Year Continuing Problem

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.

Ectopic adrenocortical adenoma characterized by hypogonadism: a case report and review of the literature

BackgroundCurrently, there is a scarcity of cases and diagnostic data regarding ectopic adrenocortical adenomas, particularly in relation to their impact on gonadal function and localization diagnostic techniques. We report a typical case of ectopic adrenocortical adenomas and the data of treatment follow-up, and review the literature of 31 available cases of ectopic adrenocortical adenomas.Case presentationA 27-year-old Chinese female patient was admitted to our hospital for hypertension, hyperglycaemia and primary amenorrhea. The patient was functionally diagnosed with ACTH-independent CS and hypogonadotropic hypogonadism. Radiological evaluations, including Computed Tomography (CT) and functional imaging, identified a mass at the left renal hilum. Histological assessments post-surgical excision confirmed the mass to be an ectopic adrenocortical adenoma. A subsequent 3-month follow-up showed no signs of disease recurrence, a swift recovery of the cortisol axis was observed, with a partial recuperation of the gonadal axis. Review: Our literature review shows that the most common ectopic areas of cortisol adenomas are renal hilum and hepatic region. The most positive biomarker is Melan A, and only a few cases have been diagnosed with functional localization.ConclusionEctopic adrenocortical adenomas may be asymptomatic in the early stage and can impact gonadal function. Physicians who treat hypogonadism must be aware of the need to test cortisol levels and perform functional localization in patients with lumps present.

Benefits of Intraoperative Fluorescence and Intelligent Insufflation in Hand-Assisted Laparoscopic Nephrectomy in Living Donor: Initial Experience

Introduction: The innovative technique of hand-assisted laparoscopic nephrectomy, with smaller incisions and greater versatility for the surgeon, along with an intelligent insufflation system, minimizes intraoperative complications, ischemia time, and postoperative morbidity in the donor. The use of Indocyanine Green (ICG) has revolutionized the visualization of blood vessels and renal parenchyma, providing crucial information about perfusion for transplantation purposes. Case Presentation: Surgery was performed on a 36-year-old male following the complete protocol for left kidney donation. The procedure lasted 06 hours and 15 minutes, with insufflation pressure set at 8 mmHg using an intelligent insufflation system. A total of 17.5 milligrams of ICG were administered in three doses. Indocyanine green filter was used for the dissection of Gerota's fascia, ureter, left adrenal vein, left gonadal vein, renal hilum, and ureteral section. Organ extraction achieved a warm ischemia time of only 03 minutes and 28 seconds. The patient was discharged due to clinical improvement after 48 hours. Follow-up on days 10 and 17 revealed no postoperative complications, pain-free status, and expected laboratory parameter evolution. Conclusion: The integration of indocyanine green with the technique of hand-assisted laparoscopic nephrectomy using an intelligent insufflation system proves to be a promising approach, allowing clear identification of anatomical elements and facilitating surgery. This approach not only reduces transoperative risks but also decreases hospitalization time and postoperative morbidity, setting a new standard in renal surgical practice.

Collecting duct carcinoma with retroperitoneal mass as initial presentation: a rare case report

BackgroundCollecting duct carcinoma (CDC) is a rare renal tumor, originating from the distal collecting duct. CDC rarely presents as a primary tumor outside the renal system.Case presentationIn this study, we report a rare case of collecting duct carcinoma, with an initial presentation of retroperitoneal lymph node metastasis, and no identifiable primary renal tumor on CT, at the time of diagnosis. The patient was a 64-year-old man presenting with lower back pain. Preoperative CT showed a round, soft tissue mass, measuring 6.7 × 4.4 × 3.3 cm, in the left retroperitoneum with no exact occupying lesion in the left kidney. Clinically, ectopic pheochromocytoma was considered to be a differential diagnosis, and tumor resection was performed. Postoperative pathological results demonstrated that the mass was a fused lymph node, and the tumor cells were destroying the structure. The final diagnosis was lymph node metastatic collecting duct carcinoma, by histology and immunohistochemistry. No further treatment was performed as no space occupying lesion was found in the kidney. Three months later, CT was reexamined, and a mass of 3.6 cm in diameter, was found in the lower left kidney, along with multiple soft tissue masses, in the left renal hilum. Considering recurrence or metastasis, the patient was recommended to undergo surgical treatment, but the patient refused. Four months later, CT was re-examined. The tumor had rapidly progressed but the patient refused treatment again. As per the author’s press release (eleven months after the first discovery), the patient is still alive.ConclusionCDC is a rare malignant renal carcinoma, with a high chance of rapid progress, regional lymph nodes involvement and metastasis. It presents diagnostic challenges to clinicians and pathologists, particularly, in the absence of radiographically detectable intrarenal lesions. Definite diagnosis is based on pathological examination combined with immunohistochemical staining.

Persistent descending mesocolon as a vital risk factor for anastomotic failure and prolonged operative time for sigmoid colon and rectal cancers

BackgroundThe diagnostic criteria and effect of persistent descending mesocolon (PDM) on sigmoid and rectal cancers (SRCs) remain controversial. This study aims to clarify PDM patients' radiological features and short-term surgical results.MethodFrom January 2020 to December 2021, radiological imaging data from 845 consecutive patients were retrospectively analyzed using multiplanar reconstruction (MRP) and maximum intensity projection (MIP). PDM is defined as the condition wherein the right margin of the descending colon is located medially to the left renal hilum. Propensity score matching (PSM) was used to minimize database bias. The anatomical features and surgical results of PDM patients were compared with those of non-PDM patients.ResultsThirty-two patients with PDM and 813 patients with non-PDM were enrolled into the study who underwent laparoscopic resection. After 1:4 matching, patients were stratified into PDM (n = 27) and non-PDM (n = 105) groups. The lengths from the inferior mesenteric artery (IMA) to the inferior mesenteric vein (1.6 cm vs. 2.5 cm, p = 0.001), IMA to marginal artery arch (2.7 cm vs. 8.4 cm, p = 0.001), and IMA to the colon (3.3 cm vs. 10.2 cm, p = 0.001) were significantly shorter in the PDM group than those in the non-PDM group. The conversion to open surgery (11.1% vs. 0.9%, p = 0.008), operative time (210 min vs. 163 min, p = 0.001), intraoperative blood loss (50 ml vs. 30 ml, p = 0.002), marginal arch injury (14.8% vs. 0.9%, p = 0.006), splenic flexure free (22.2% vs. 3.8%, p = 0.005), Hartmann procedure (18.5% vs. 0.0%, p < 0.001) and anastomosis failure (18.5% vs. 0.9%, p = 0.001) were significantly higher in the PDM group. Moreover, PDM was an independent risk factor for prolonged operative time (OR = 3.205, p = 0.004) and anastomotic failure (OR = 7.601, p = 0.003).ConclusionPDM was an independent risk factor for prolonged operative time and anastomotic failure in SRCs surgery. Preoperative radiological evaluation using MRP and MIP can help surgeons better handle this rare congenital variant.

A case of chyluria with nephrotic-range proteinuria caused by lymphatic malformation, leading to a diagnosis of Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome (KTS) is a rare syndrome, which is clinically diagnosed by the presence of unilateral limb hypertrophy with vascular malformation including cutaneous capillaries, veins and lymphatic vessels. Most cases typically exhibit cutaneous manifestations such as port-wine stains and limb hypertrophy from infancy, but cases with mild manifestations may remain undiagnosed. We here report a case of KTS who was diagnosed by chance chyluria. A 15-year-old girl who exhibited hematochyluria with nephrotic-range proteinuria was referred to our hospital. She had been diagnosed as idiopathic scoliosis accompanied by left lower limb hypertrophy in the past. She noticed her milky urine for the first time two months before. Immediately thereafter, she noticed edema of her left leg. Hematochyluria with nephrotic-range proteinuria was found by our initial urine examination. Magnetic resonance imaging suggested venous or lymphatic malformation along the left common iliac vein at the retroperitoneal side. Lymphoscintigraphy showed congestion of radioisotope around backside of the pancreas to the left renal hilus, suggesting an existence of lymphostasis. Based on the findings, we diagnosed the patient as KTS. After admission, hematochyluria and proteinuria were decreased and became insignificant by three days with bed rest. Her left leg edema was reduced. After taking a guidance to avoid intensive exercise, she was discharged in two weeks. Because the present case exhibited mild manifestations, diagnosis was made by urine abnormalities for the first time. The case suggests that we should be aware of the presence of undiagnosed patients of KTS due to relatively mild manifestations.

Extra-Kidney Mass

A 64-year-old man with hypertension (156/76 mm Hg) without associated tachycardia was admitted to our hospital for a 1-week history of left-sided loin pain. Routine blood work indicated that hemoglobin was 10.3 g/dL and the ratio of neutrophil-to-lymphocyte (NLR) was 4.9. Complete metabolic panel and serum catecholamines were normal. Computed tomography (CT) revealed a round soft tissue mass measuring 55 × 45 × 35 mm located beside the left renal hilum and 10 mm away from the celiac trunk. 2 renal hilum lymph nodes were visible.

UNILATERAL LEFT MALROTATED KIDNEY WITH VASCULAR AND HILAR VARIATIONS: A CADAVARIC CASE REPORT

During our dissection classes for abdomen, some abnormal appearance in a male cadaver in the Department of Anatomy, Rajendra Institute of Medical science, Ranchi was observed 1. The anomaly in the position of the kidney in the abdomen i.e., left kidney of the cadaver was lying below the normal level so much that the right kidney appeared to be higher than it with hilum facing ventromedially. (Usually, Right kidney lies somewhat lower than the left because of the relationship with the liver, and also the hilum is medial facing). (Figure.1) 2. Also, kidney is usually drained by one renal artery and one renal vein. But in this case the left kidney was drained by two renal arteries and both of them originated from the abdominal aorta itself. (Figure.2) The accessory renal artery was originating from the level above the origin of primary renal artery, and entering the hilum hence the arrangements of left renal hilum vary with respect to the normal arrangement. 3. Hilum relations that usually holds anterior to posterior, is renal vein exits renal artery enters and the renal pelvis exits, but in this case the left kidney hilum relations were also altered from anterior to posterior I.e., left renal artery enters, left renal vein exits, accessory renal artery enters and renal pelvis exits the hilum.

ACTH-Independent Cushing's Syndrome Caused by an Ectopic Adrenocortical Adenoma in the Renal Hilum.

We report a rare case of Cushing’s syndrome induced by an ectopic adrenocortical adenoma. A 57-year-old woman was diagnosed with adrenocorticotropic hormone (ACTH)-independent Cushing’s syndrome based on clinical manifestation and laboratory information. She was found to have a mass in the left renal hilum via contrast-enhanced computed tomography (CT). The mass was negative, as seen in somatostatin receptor imaging with 99mTc-hydrazinonicotinyl-Tyr3-octreotide (HYNIC-TOC), and showed mild fluorodeoxyglucose (FDG) activity via positron emission tomography (PET)/CT. The results of adrenal venous sampling suggested a left-side adrenal origin of hypercortisolism, possibly secreted by the mass in the renal hilum. Histopathology after surgical resection of the mass confirmed an ectopic adrenocortical adenoma, which was responsible for the patient’s Cushing’s syndrome. During the 8-month follow-up after surgery, no recurrence of Cushing’s syndrome was found.

V13-01 SUPERIOR MESENTERIC ARTERY INJURY DURING ROBOTIC LEFT RADICAL NEPHRECTOMY: PREVENTION AND MANAGEMENT

You have accessJournal of UrologyCME1 May 2022V13-01 SUPERIOR MESENTERIC ARTERY INJURY DURING ROBOTIC LEFT RADICAL NEPHRECTOMY: PREVENTION AND MANAGEMENT Aref S. Sayegh, Anibal La Riva, Laura C. Perez, Luis G. Medina, Edward Forsyth, Ryan Powers, Ben Challacombe, Michael Stifelman, Inderbir S. Gill, and Rene Sotelo Aref S. SayeghAref S. Sayegh More articles by this author , Anibal La RivaAnibal La Riva More articles by this author , Laura C. PerezLaura C. Perez More articles by this author , Luis G. MedinaLuis G. Medina More articles by this author , Edward ForsythEdward Forsyth More articles by this author , Ryan PowersRyan Powers More articles by this author , Ben ChallacombeBen Challacombe More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , and Rene SoteloRene Sotelo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Injury to the Superior Mesenteric Artery (SMA) during renal surgery is a rare but potentially devastating complication. It can rarely occur in patients with large left renal tumors and bulky lymphadenopathy, or in the setting of re-do surgery with significant retroperitoneal and intraabdominal scarring, which may distort the vascular anatomy. In most cases, the inadvertent injury occurs due to misidentification of the SMA as the renal artery. Failure to recognize and repair an SMA injury may result in ischemic bowel and/or mortality. Herein, we present three different scenarios of injury to the SMA when misidentified as the left renal artery during left robotic radical nephrectomy. We also describe how to avoid and manage SMA injury. METHODS: A compilation of three video clips were collected anonymously from different surgeons to demonstrate how the SMA was misidentified, injured, recognized intraoperatively, and repaired either in a transperitoneal or retroperitoneal robotic approach to left nephrectomy. RESULTS: Left robotic radical nephrectomy was started as usual. Descending colon was reflected medially, gonadal vein and ureter were used as landmarks to trace the left renal hilum. An artery arising from the aorta was apparently coursing towards the kidney and was assumed to be the left renal artery in all cases. In the first case, the SMA misidentification was timely recognized, and the injury was avoided. The second case demonstrates the SMA being clipped. Suspicious was raised after a dilated left renal vein was seen; therefore, clip removal was performed. Lastly, the third case involved a complete transection of the SMA, and it was repair intraoperatively because of awareness of severe consequences. Increases in operative time of patients experiencing an intraoperative complication are expected. Increases in length of hospital stay may occur depending on the type of complication, and sequelae can occur. CONCLUSIONS: Proper anatomic identification and recognition of the SMA may prevent its injury. Intra-operative SMA injury should be promptly identified and repaired to avoid its severe consequences. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1031 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aref S. Sayegh More articles by this author Anibal La Riva More articles by this author Laura C. Perez More articles by this author Luis G. Medina More articles by this author Edward Forsyth More articles by this author Ryan Powers More articles by this author Ben Challacombe More articles by this author Michael Stifelman More articles by this author Inderbir S. Gill More articles by this author Rene Sotelo More articles by this author Expand All Advertisement PDF DownloadLoading ...

Bilateral En-Block Horseshoe Kidney Laparoscopic Nephrectomy

AbstractHorseshoe kidney (HSK) has a prevalence of 1 in every 500 individuals. The management of patients with HSK is usually conservative, except in the presence of symptoms such as obstruction, stones, glomerulopathies, and tumors. In the following case report, we describe how a bilateral en-block transmesenteric laparoscopic nephrectomy in supine position was performed.A 5-year-old boy, with proximal hypospadias and early onset of chronic kidney disease due to focal segmental glomerulosclerosis on biopsy, underwent a genetic molecular evaluation that confirmed a pathogenic mutation at the WT-1 gene. Due to the increased risk of developing Wilms tumor, he underwent a bilateral transmesenteric nephrectomy.In a five-minute video, we describe how we performed an en-block transperitoneal and transmesenteric laparoscopic nephrectomy with special attention to patient positioning, including the feasibility of performing the dissection of the left renal hilum and isthmus with the patient in supine with no need for repositioning, and then moving to the dissection of the right renal hilum and completion of the procedure.The case herein reported enables us to describe the technical key-points to perform a bilateral en-block laparoscopic nephrectomy with shorter operative time and reduction of blood loss by preserving the entire specimen, without the need for an isthmus transection.

Extranodal Rosai-Dorfman-Destombes disease mimicking renal cell carcinoma: a case report and review of literature

Rosai-Dorfman-Destombes disease (RDD) is an uncommon histiocytic disorder of unknown aetiology. Extranodal involvement occurs in a significant proportion of patients but involvement of the kidney is rare. Here we present a case report of extranodal RDD of the kidney. Imaging revealed a heterogeneously enhancing solid mass lesion in left renal hilum infiltrating renal medulla and deeper layers of renal cortex. With the clinical diagnosis of suspected left renal cell cancer, laparoscopic left radical nephrectomy was performed. Macroscopic examination showed specimen covered with Gerota’s fascia and perinephric pad of fat. Renal capsule could be easily split off. On cut section, ill circumscribed solid lesion having variegated appearance with areas of necrosis and haemorrhage, involving middle and lower pole, was noted. Renal sinus appeared to be involved. Microscopic examination showed sheets of histiocytes with abundant eosinophilic to vacuolated cytoplasm. There was emperipolesis of intact lymphocytes. Also, seen were sheets of plasma cells, lymphocytes with intervening dense hyalinised stroma. Retro peritoneal lymph nodes and para-aortic lymph nodes also showed similar histological picture. Immunohistochemistry showed that the histiocytes were positive for S100 and CD68. IgG4-positive plasma cells were not seen. These findings showed that the lesion represented and extranodal RDD of the kidney. Although rare, extranodal RDD should also be included in the differential diagnosis of a renal mass and frozen section be advised whenever feasible.

The renal protective efficacy of ketamine vs. propofol vs. ketofol against renal ischemia / reperfusion injury: An experimental rat study

The purpose of this study was to investigate the renal protective efficacy of propofol, ketamine, and ketofol in an ischemia/reperfusion injury (IRI) model experimentally induced in rats. Thirty-five male Sprague-Dawley rats were randomly assigned into five groups: sham (Group 1), control (Group 2), ketamine (Group 3), propofol (Group 4), and ketofol (Group 5). Following administration of intramuscular ketamine hydrochloride anesthesia, the left renal hilum was exposed to 60-minutes clamping. Ketamine (Group 3), propofol (Group 4), and ketofol (Group 5) were administered 15 min prior to reperfusion. After six hours of reperfusion, the left kidneys were harvested for histological injury scoring. Mean histopathology scores were 0.42±0.53 in group 1 (Sham), 2.97±0.21 in group 2 (Control), 2.68±0.15 in group 3 (Ketamine), 2.40±0.16 in group 4 (Propofol), and 2.51±0.22 in group 5 (Ketofol). The score in group 4 (Propofol) was significantly lower than those in groups 2 (control) and 3 (Ketamine) (P=.002 and P=.0120, respectively), but did not differ significantly from that in group 5 (Ketofol) (P=.347). The score in group 5 (Ketofol) was significantly lower compared to group 2 (control) (P=.006), but no significant difference was determined with Group 3 (Ketamine) (P=.137). No significant difference was also observed between Group 3 (Ketamine) and Group 2 (control) (P=.021). The study results indicated no superiority of ketofol over ketamine or propofol against renal IRI. However, the renal protective effect of propofol against IRI was greater than that of ketamine.

Patterns of Treatment Failure after Concurrent Chemoradiotherapy or Adjuvant Radiotherapy in Patients with Locally Advanced Cervical Cancer

Objective: To identify patterns of therapy failure after radiotherapy in Chinese patients with locally advanced cervical cancer (LACC). Methods: A retrospective study was conducted at a Chinese hospital from June 2012 to July 2018. All analyses were done using SPSS 26. Results: 105 patients with treatment failure were included. After a median follow-up of 27 months (range 10–82), the 3-year survival rate after therapy failure was 19.4%. In multivariate analysis, squamous cell carcinoma antigen (SCC-Ag) <4 ng/mL (p < 0.001) and disease-free interval >12 months (p = 0.013) showed significant survival benefits. We identified 3 types of failure: distant lymph node metastasis (n = 50), hematogenous metastasis (n = 53) and pelvic failure (n = 48). Most metastatic para-aortic lymph nodes (PALN) were inferior to the level of left renal hilum (84.8%, n = 28). A total of 80% of patients with supraclavicular lymph nodes (SCLN) metastasis ignored imaging on supraclavicular region. For solitary SCLN or lung metastasis, the prognosis was better than that combined with other sites failure, respectively (p = 0.005; p = 0.001). Many patients with central sites recurrence received insufficient doses of intracavitary brachytherapy (IBT) for low tolerance to pain. Conclusion: The distribution of metastatic PALN is asymmetrical and optimizing clinical target volume to minimize toxicity of para-aortic radiation is necessary. The effect of ultrasonography as preliminary screening and follow-up means on SCLN metastasis can be expected. Pain management and psychological interventions are essential for patients receiving IBT.

Classification of the colonic splenic flexure based on three-dimensional CT analysis.

BackgroundMobilization of the splenic flexure can be a challenging surgical step in colorectal surgery. This study aimed to classify the splenic flexure based on the three-dimensional (3D) coordinates of the splenic hilum and left renal hilum. This classification was used to compare splenic flexure mobilization during colorectal resection.MethodsCT images of patients with colorectal cancer treated between April 2018 and December 2019 were analysed retrospectively. 3D mutual positioning of the splenic flexure from the ligament of Treitz to the splenic hilum or the left renal hilum was used to classify patients into three groups using cluster analysis. The difference in the procedure time between groups was also analysed in a subset of patients undergoing laparoscopic colectomy with complete splenic flexure mobilization.ResultsOf 515 patients reviewed, 319 with colorectal cancers were included in the study and categorized based on the 3D coordinates of the splenic hilum and left renal hilum as caudal (100 patients), cranial (118) and lateral (101) positions. Male sex (P < 0.001), older age (P = 0.004) and increased bodyweight (P = 0.043) were independent characteristics of the lateral group in multiple logistic regression analysis. Thirty-four patients underwent complete splenic flexure mobilization during the study period; this took significantly longer (mean 78.7 min) in the lateral group than in the caudal and cranial groups (41.8 and 43.2 min respectively; P = 0.006).ConclusionLocating the splenic flexure using 3D coordinates could be helpful in predicting a longer duration for mobilization of the splenic flexure.

Opioid Preconditioning Modulates Repair Responses to Prevent Renal Ischemia-Reperfusion Injury.

Progression to renal damage by ischemia-reperfusion injury (IRI) is the result of the dysregulation of various tissue damage repair mechanisms. Anesthetic preconditioning with opioids has been shown to be beneficial in myocardial IRI models. Our main objective was to analyze the influence of pharmacological preconditioning with opioids in renal function and expression of molecules involved in tissue repair and angiogenesis. Experimental protocol includes male rats with 45 min ischemia occluding the left renal hilum followed by 24 h of reperfusion with or without 60 min preconditioning with morphine/fentanyl. We analyzed serum creatinine and renal KIM-1 expression. We measured circulating and intrarenal VEGF. Immunohistochemistry for HIF-1 and Cathepsin D (CTD) and real-time PCR for angiogenic genes HIF-1α, VEGF, VEGF Receptor 2 (VEGF-R2), CTD, CD31 and IL-6 were performed. These molecules are considered important effectors of tissue repair responses mediated by the development of new blood vessels. We observed a decrease in acute renal injury mediated by pharmacological preconditioning with opioids. Renal function in opioid preconditioning groups was like in the sham control group. Both anesthetics modulated the expression of HIF-1, VEGF, VEGF-R2 and CD31. Preconditioning negatively regulated CTD. Opioid preconditioning decreased injury through modulation of angiogenic molecule expression. These are factors to consider when establishing strategies in pathophysiological and surgical processes.

Anesthetic preconditioning increases sirtuin 2 gene expression in a renal ischemia reperfusion injury model

Renal transplant surgical proceedings are known to elicit periods of hypoxia and consequent blood flow reestablishment triggering ischemia-reperfusion (I-R) injury. Kidney damage induced by I-R injury associates with a higher risk of graft dysfunction and rejection. Anesthetic preconditioning exerts a beneficial effect on I-R injury by reducing oxidative stress, inflammation and apoptosis. However, the degree of renoprotection stimulated by commonly used anesthetics, as well as their mechanisms of action, are largely unknown. Sirtuins are class III histone deacetylases that reduce cellular stress, promote genome stability and regulate senescence. So far, the relationship between sirtuins and anesthetic preconditioning in the context of renal I-R has not been studied. The main objective of the present work was to determine the renal expression of sirtuins after I-R damage in rats under different anesthetic preconditioning treatments. Unilateral ischemia was performed via occlusion of the left renal hilum for 45 min and followed by 24 hours of reperfusion. Anesthetic preconditioning schemes (morphine 0.5 mg/kg, fentanyl 10 µg/kg, propofol 7.5 mg/kg, or dexmedetomidine 25 µg/kg) were administered 1 hour before ischemia. Creatinine levels were determined in serum, and expression of kidney injury molecule 1 and sirtuin 1, 2, 3 and 7 in kidney tissue was quantified by RT-PCR. Anesthetic preconditioning with morphine, fentanyl, propofol and dexmedetomidine reduced kidney injury markers after I-R and modulated sirtuin gene expression. Opioids or dexmedetomidine administration before ischemia increased sirtuin 2 expression and correlated with improved renal function. Anesthetic preconditioning is a promising strategy to prevent I-R injury associated with transplantation. Our results suggest that sirtuin 2 is involved in the protective mechanisms of some commonly used anesthetics against I-R damage.

Management of Stage II Germ Cell Tumors: Be Sure, Be Patient, Be Safe.

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.A healthy 27-year-old man discovered a left testicular mass. Several months later he saw an urologist, who palpated a suspicious mass on the left testicle; an ultrasound confirmed a 2-cm solid mass. Serum tumor marker testing disclosed a slightly elevated alpha-fetoprotein (AFP) of 12.3 µg/L (upper limit of normal, 8.0 µg/L), and a normal β-human chorionic gonadotropin (HCG). Staging imaging with a contrast-enhanced computed tomography (CT) scan of the chest/abdomen/pelvis showed no evidence for retroperitoneal lymphadenopathy or distant metastases. He underwent a left radical orchiectomy, and pathology showed a 1.5-cm mixed germ cell tumor with 85% embryonal, 10% yolk sac tumor, and 5% mature teratoma histologies. Lymphovascular invasion was present. His AFP normalized after surgery. After discussion of management alternatives, he chose active surveillance, but 4 months later a scheduled surveillance CT scan identified a 1.4-cm left para-aortic lymph node just below the left renal hilum (Fig 1). Serum tumor markers remained negative. He returns to discuss his results and potential management options.

Ectopic adrenal adenoma causing gross hematuria: Steroidogenic enzyme profiling and literature review

IntroductionAberrant cortical adrenal tissues are not generally identified in adults. Herein, we present a very rare case of an ectopic adrenal tumor located in the renal hilum that caused gross hematuria.Case presentationA 33‐year‐old man suddenly presented with asymptomatic gross hematuria. Abdominal computed tomography revealed a 35‐mm mass in the left renal hilum encroaching the renal vein. Following the surgical removal with frozen section of the mass, his gross hematuria immediately improved. Pathological analysis of the specimen revealed the features adrenal adenoma. Immunohistochemical staining for key steroidogenic enzymes confirmed the adrenocortical origin without excessive hormone production.ConclusionThis is the first case of an ectopic adrenocortical adenoma in the renal hilum that caused gross hematuria without hormonal symptoms.

Pulmonary inflammatory myofibroblastic tumour and IgG4-related disease presenting with lower limb paralysis

A 40-year-old man presented with numbness of the lower limbs and pain in the lower back for 11 months. Abdominal CT revealed multiple retroperitoneal masses around the left renal hilus...