Left Renal Parenchyma Research Articles

Ipsilateral synchronous papillary renal neoplasm with reverse polarity and urothelial carcinoma in a renal transplant recipient: a rare case report with molecular analysis and literature review

BackgroundRenal transplant recipients (RTRs) have a 3- to 5-fold higher risk of developing malignant tumors than the general population, with new malignant tumors after transplantation considered to be the leading cause of death in RTRs. In pathological practice, it is rare for neoplasms with different histology to be located in the same organ. We report the first case of a synchronous papillary renal neoplasm with reverse polarity (PRNRP) and urothelial carcinoma (UC) in the ipsilateral kidney in an RTR. Molecular detection was conducted by next-generation sequencing.Case presentationA 68-year-old female suffered from uremia 19 years ago and underwent renal transplantation (RT) after receiving dialysis for 6 months. Hematuria occurred one month ago and an enhanced CT showed that there were two abnormal density foci in the middle and lower parts of the autologous left kidney. A laparoscopic left nephrectomy and ureterectomy were performed. Gross examination revealed a mass (I) in the left renal parenchyma, 2*1.8*1.5 cm in size, that protruded from the renal capsule, and a cauliflower-like mass (II), 5*2.5*2 cm in size, adjacent to the mass (I). Microscopic findings revealed these lesions were PRNRP and UC, respectively. PCR analysis revealed a KRAS gene mutation (G12D in exon 2) in the PRNRP, while NGS analysis revealed FGFR3 (S249C in exon 7) and KDM6A (Q271Ter in exon 10 and A782Lfs in exon 17) mutations in the UC.ConclusionsWe report here for the first time an extraordinarily rare case of synchronous renal tumors of a PRNRP and UC in the ipsilateral kidney of an RTR. We identified simultaneous KRAS, FGFR3, and KDM6A mutations in two different renal masses in the ipsilateral kidney. Pathologic assessment with comparative molecular analysis of mutational profiles facilitates tumor studies after RT and may be of great value in clinical management strategies.

Case report of trans-renal ablation procedures for a recurrent pheochromocytoma in von Hippel-Lindau disease

Pheochromocytoma is one of recurrent tumors in patients with von Hippel-Lindau (VHL) disease. For patients with bilateral adrenal glands, unilateral adrenalectomy is the treatment of choice; however, for patients with a single adrenal gland, hemiadrenalectomy or tumorectomy can be performed instead of adrenalectomy to preserve adrenal function. Currently, adrenalectomy is recommended even if recurrent pheochromocytomas occur in the residual adrenal tissue. Consequently, adrenal insufficiency cannot be avoided in these patients. Percutaneous radiofrequency ablation (RFA) is used as an alternative treatment for preserving adrenal function; however, RFA is difficult to perform when major organs are present in the approaching pathway. The trans-hepatic approach is the only reported safe route to approach a right adrenal tumor to avoid pneumothorax. In this case report, we performed percutaneous RFA and hydrodissection through the left renal parenchyma to treat a recurrent pheochromocytoma in the small residual left adrenal tissue, which is surrounded by several critical organs. Our goal was to show our experience of image-guided trans-renal RFA and hydrodissection in a patient with VHL disease.

Celiac plexus neurolysis in pancreatic neoplasm with celiacomesenteric trunk: a case report

BackgroundCeliac plexus neurolysis is an effective mode of long-term palliation of somatic pain in inoperable upper gastro-intestinal neoplasm. CT guidance is the most accepted method of localising the tip of the needle, through which, the neurolytic agent, commonly Absolute Alcohol, is introduced along the celiac ganglion. Three dimensional assessment of the retroperitoneal anatomy avoids injury to adjacent viscera and vascular structures. Para-aortic needle tip position between the origins of celiac and superior mesenteric arteries is an accepted position to inject neurolytic agent. We report a case of successful celiac plexus neurolysis in a patient with a celiacomesenteric trunk. Till date no such case has been reported, primarily due to the Low incidence of celiacomesenteric trunk.Case presentationA 63-year-old man developed progressive icterus and severe abdominal pain over 3 months. The pain severity was 6/10. An Ultrasonography and contrast enhanced CT of the abdomen revealed inoperable carcinoma of head of pancreas and a celiacomesenteric trunk. The pancreatic mass extended along the right lateral border of the celiacomesenteric trunk, not extending upto the aorta. Considering the severity of pain, poor compliance to opioid pain medication, and a possibility of early tumour extension upto the aortic margin, celiac plexus neurolysis was considered. The procedure was performed under CT guidance and local anaesthesia, using a mixture of absolute alcohol, Bupivacaine and diluted iodinated contrast. Bilateral paravertebral antecrural access was performed, using 22 gauge Chiba needles, after localisation on preprocedural CT-scan. On the left, hydrodissection was performed using normal saline, to displace the left renal parenchyma from the trajectory of the needle to be used for neurolysis. The patient’s pain visual analogue scale score reduced to 0/10, immediately after the procedure. He had a post procedural hypotension, managed conservatively by complete bed rest for 1 day and intravenous fluid administration.ConclusionsCeliac plexus neurolysis can safely be done in aberrant upper abdominal vascular anatomy, under CT guidance and local anaesthesia. To avoid periprocedural complications, hydrodissection may be effectively used to displace normal anatomical structures from the trajectory of the access needle, through which a mixture of absolute alcohol and local anaesthetic may be delivered.

Metanephric adenoma in a young female: a rare case report from Nepal

Introduction: Metanephric adenomas (MAs) of the kidney are rare benign epithelial lesions in the kidney that have been described in the literature, mainly through case reports, representing ~0.2% of renal masses. No prior case reports have been published from Nepal. We report one such case with MA presented to our center. Case presentation: A 25-year-old lady presented with complaints of recurrent hematuria for the past 6 months. Ultrasound of the abdomen revealed left gross hydronephrosis and reduced left renal parenchyma. A contrast-enhanced computerized scan of the abdomen and pelvis showed a heterogeneously enhancing soft tissue density lesion 65 mm×57 mm at the left renal pelvis extending into mid calyx and distally to proximal ureter, ~34 mm distal to pelviureteric junction causing moderate hydronephrosis, likely urothelial cell carcinoma. Urine cytology was negative for malignancy. Laparoscopic left nephroureterectomy with bladder cuff excision lymphadenectomy was done. The histopathology report came out to be consistent with MA and the lymph nodes were negative for malignancy. Immunohistochemistry study showed that the cells were positive for PAX8. During follow-up, she did not have hematuria and her postoperative period was uneventful. Discussion: From this report, we want to highlight the need to consider MA as a differential diagnosis of renal mass and differentiate MA from upper tract urothelial carcinoma, renal cell carcinoma, Wilms tumor, and papillary adenomas. Conclusion: MA is a rare renal lesion that may present as upper tract urothelial carcinoma. MA should be evaluated through histology and immunohistochemistry studies.

Quantitative evaluation of renal tissue changes in patients with liver cirrhosis by shear wave elastography.

Hepatocirrhotic nephropathy progresses rapidly and has a poor prognosis, and early detection of renal changes in patients with cirrhosis is particularly important for its prevention and treatment. The objective of this study was to evaluate the value of shear wave elastography (SWE) in the early diagnosis of hepatocirrhotic nephropathy. 206 hepatic cirrhosis patients with normal conventional renal function were enrolled and divided into Child-Pugh grade A (Group A), Child-Pugh grade B (Group B), and Child-Pugh grade C (Group C) according to the Child-Pugh grading method. Meanwhile, 60 healthy volunteers matched in age and sex were selected as the control group. The maximum Young's modulus (Emax), average Young's modulus (Emean), and minimum Young's modulus (Emin) of the left renal parenchyma were measured by SWE in all subjects. The Emax, Emean, and Emin values of the left renal parenchyma were compared between the cirrhosis and control groups. The Emax, Emean, and Emin values of left renal parenchyma in cirrhosis group were higher than those in control group (p = 0.00, 0.00, 0.00). The Emax, Emean, and Emin values of left renal parenchyma in cirrhosis group B and group C were higher than those in control group (p = 0.00, 0.00, 0.00; p = 0.00, 0.00, 0.00), but these values in cirrhosis group A were not significantly different from control group(p = 0.48, 0.52, 0.92). Comparison of the Emax, Emean, and Emin values in left renal parenchyma of three cirrhosis groups, the values of Group B and Group C were higher than those of Group A (p = 0.00, 0.00, 0.00; p = 0.00, 0.00, 0.00), and there was no significant difference between Group B and Group C (p = 0.71, 0.18, 0.39). SWE can detect renal tissue damage in patients with liver cirrhosis earlier than changes identified during routine laboratory examination by quantitatively measuring the elastic parameters of renal parenchyma and may become a new method for early diagnosis of hepatorenal syndrome.

Missed Double-J Ureteric Stent Presenting as a Large Stone Burden: A Case Report

Ureteric stenting using a Double-J Stent (DJS) is one of the commonly used urological management techniques to ensure adequate drainage from the renal pelvis to the bladder. However, DJS placements are known to be associated with various consequences and complications. Hereby, the authors present a case of a 46-year-old male who presented to the Emergency Department with left flank pain and haematuria that had persisted for one week. The patient had previously undergone ureteric stenting one year prior for the management of a left ureteric calculus. Unfortunately, he had not returned for follow-up due to the Coronavirus Disease 2019 (COVID-19) pandemic. X-ray of the Kidney, Ureter, and Bladder (KUB) and Computed Tomography (CT) of the KUB revealed a missed left ureteral stent that was completely encrusted and associated with the highest stone burden. This stent was causing obstruction of the left renal pelvis-calyceal system and thinning of the left renal parenchyma. The patient also had a co-existing staghorn calculus and urinary tract infection. After completing a course of antibiotics, the encrusted ureteral stent was surgically removed using cystolitholapaxy with pneumatic lithotripsy, ureteral lithoclast, and percutaneous nephrolithotomy. A new DJS was placed to maintain drainage through the ureter. The patient had no complications during the follow-up period. Authors reported a case of a missed DJS with the highest stone burden within a year to highlight the importance of patient and family education. Authors recommended implementing electronic follow-up systems for patients who undergo ureteric stenting to prevent lost to follow-up, minimise long-term complications, and ensure patient safety.

Emphysematous Pyelonephritis, Emphysematous Cystitis, and Emphysematous Ureteritis: A Case Report

Emphysematous urinary tract infections (EUTIs) are rare, severe, and suppurative infections affecting various parts of the urinary tract. We report a case of a 75-year-old male presenting with hematuria and generalized weakness withuncontrolled diabetes mellitus (DM) and hypertension. He tested positive for COVID-19on the second day of hospital admission. A non-contrast-enhanced CT of the abdomen and pelvis revealed gas within the left renal parenchyma, walls of the left ureter, and urinary bladder, establishing the diagnosis of EUTIs. The patient was treated using intravenous antibiotics without any surgical intervention, and four weeks later was stable and transported tolong-term acute care (LTAC) facility. DM is the most common risk factor for the development of EUTIs and Escherichia coli is the most common causative pathogen.

Application of shear wave elastography in the study of renal tissue elasticity in patients with diabetic nephropathy

Objective To investigate the clinical value of real-time shear wave elastography(SWE) in early diagnosis of diabetic nephropathy(DN). Methods One hundred and fifty-five patients with type 2 diabetes mellitus (DM) in our hospital were selected as DN group and 54 healthy volunteers with matched age-sex were selected as control group. According to the criteria of Mogensen staging, patients of DN group were divided into 3 subgroups according to urine protein/creatinine (ACR): group A (DM or DN Ⅰ, Ⅱ), ACR 300 mg/g. All subjects were examined by SWE technique to detect the maximum, mean and minimum Young′s modulus values (Emax, Emean, Emin) of the middle of left renal parenchyma, the values of Young′s modulus in the control group and DN patients were compared. The relationship between Young′s modulus and ACR in patients with DN was analyzed. Results The Emax, Emean and Emin in DN patients were all greater than those in control group (P<0.05). In group A, B and C, Emax, Emean and Emin gradually increased (P<0.05). Spearman correlation analysis showed that there was a positive correlation between Young′s modulus and ACR in patients with DN (r=0.817, 0.764, 0.609; all P=0.000). ROC curve analysis showed that the area under the curve of Emax diagnosis DN Ⅲ stage was 0.810, the cut-point value was 6.65 kPa, the sensitivity was 79.0%, and the specificity was 81.7%; the area under the curve of Emean diagnosis DN Ⅲ stage was 0.785, and the cut-off value was 3.69 kPa, sensitivity 62.8%, specificity 78.3%. Conclusions SWE technique can quantitatively analyze renal parenchyma hardness in patients with different stages of DN, which may provide new diagnostic information for early diagnosis of DN. Key words: Ultrasonography; Diabetic nephropathy; Shear-wave elastography; Renal parenchyma elasticity

Quantitative assessment of renal tissue elasticity in patients with liver cirrhosis by shear wave elastography

Objective To investigate the value of shear wave elastography (SWE) in the early diagnosis of hepatic cirrhosis nephropathy. Methods Seventy-three hepatic cirrhosis patients with normal conventional renal function were enrolled in the study, and were subdivided into Child-Pugh A group, Child-Pugh B group and Child-Pugh C group. Forty healthy volunteers were served as the control group. All the subjects underwent SWE to obtain the Young′s modulus value of left renal cortex, medulla and parenchyma which included Emax, Emin, Emean. The Young′s modulus value were compared among different groups. Results Compared to the control group, the Emax, Emean of left renal cortex, modulus and parenchyma in hepatic cirrhosis group were higher(P 0.05). The Emax and Emean of left renal cortex, medulla and parenchyma were higher both in group B and group C than those in control group(P 0.05). Conclusions SWE can quantitatively determine the elastic parameters of renal tissue in patients with different degrees of cirrhosis, the change of renal tissue elasticity is earlier than that of routine laboratory examination, SWE can early detect renal tissue damage in patients with liver cirrhosis. Key words: Ultrasonography; Liver cirrhosis; Kidney; Shear wave elastrography

Retroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping for cancer of the left upper calyx: a case report

BackgroundCurrently, the standard treatment for renal pelvis carcinoma is radical nephroureterectomy with bladder cuff excision. To describe the feasibility of retroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping for cancer of renal pelvis, we report this special case for the first time.Case presentationA 67-year-old woman received this operation. Preoperative ureteroscopy revealed a papillary neoplasm with a pedicle in the upper calyx of the left kidney. After entering the retroperitoneal space and dissociating the renal artery and renal vein, the target artery was clamped beyond the final bifurcation before entering the parenchyma. After incision of the left renal parenchyma and exposure of the upper calyceal neck, the tumor was found confined to the upper calyx. Thereafter, the renal calyx and parenchyma were sutured successively after complete resection of the neoplasm. Postoperative pathological examination confirmed that the Grade I papillary carcinoma was confined to the mucosal layer. Thus far, there is no evidence of recurrence during the follow-up period for more than 42 months after surgery.ConclusionsRetroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping of the kidney provides a feasible treatment modality for noninvasive tumors that are limited to the calyx.

SPONTANEOUS RENAL RUPTURE TREATED BY TRANSCATHETER ARTERIAL EMBOLIZATION: A CASE REPORT

We describe our experience with a case of spontaneous renal rupture. A 43-year-old man visited our hospital with a chief complaint of left back pain with no identifiable triggering factors. A CT scan showed a rupture involving the left renal parenchyma and hematoma around the kidney. However, there were no apparent causes of the renal rupture, such as tumors and vascular lesions. Based on these findings, he was diagnosed with spontaneous renal rupture. Due to progression of anemia during the course, he underwent transcatheter arterial embolization of the kidney. He continues to undergo imaging examinations on a regular basis and has shown no development of apparent neoplastic lesions for 13 months.

Diagnosis and Treatment of Abnormally Calcified Renal Masses (3 Case Reports)

Object Improve the diagnosis and treatment of calcified renal masses. Method We respectively reviewed 3 cases of abnormally calcified renal masses admitted to our hospital. We evaluated the clinical manifestations in the patients we treated and reviewed the literature regarding the diagnosis and treatment of calcified renal masses. Case 1, a 21 year old male, was evaluated for a right renal space-occupying lesion found incidentally on physical examination. CT imaging revealed a space-occupying lesion in the middle lower pole of the right kidney with peripheral circular calcifications and irregular calcifications. The lesion was low density on CT. Case 2, a 44 year old male, presented with right flank swelling pain and discomfort for 10 days. KUB and CT imaging demonstrated an abnormal round calcification in the dorsal midpole of the left kidney. Case 3, a 53 year old female, presented with dull left flank pain for more than 2 years. KUB and CT showed a round calcified lesion in the upper pole of the left kidney. Results The diagnosis of renal cancer was made before surgery in patient 1 and radical nephrectomy was carried out. The pathological diagnosis was papillary renal cell carcinoma. The patient was followed for 27 months and wasfree of recurrence and metastases. The preoperative diagnosis of patient 2 was benign renal tumor. The patient underwent enucleation of the renal tumor. Pathologic examination revealed clear cell renal carcinoma. A radical nephrectomy was then performed. The patient was followed for 37 months and was free of recurrence and metastases. The preoperative diagnosis in patient 3 was left renal calyceal stones. The patient underwent wedge resection of left renal parenchyma. Pathologic examination revealed an abnormal left renal calcification with inflammatory cell infiltration. The patient was followed for 39 months and remained in good health. Conclusion Calcified renal masses are rare manifestations of renal cancer. It is difficult to make the diagnosis before surgery, but the prognosis is favorable. Nephron sparing surgery (NSS) is the choice of treatment.

Blood Oxygen Level–Dependent Magnetic Resonance Imaging of the Kidneys

The aim of this study was to quantify the influence of image resolution on the apparent transverse relaxivity (R2*) of the magnetic resonance (MR) signal in human renal tissue in vivo and in phantom measurements. This prospective study included 17 healthy volunteers (age, 32 ± 8 years, 6 women). Parametrical R2* maps were computed via monoexponential fitting of multiecho 2-dimensional fast-field echo data measured at 1.5 T (repetition time [TR], 150 milliseconds; flip angle [FA], 40°; minimum echo time [TE], 4.6 milliseconds; ΔTE, 5 milliseconds; 16 echoes) and at 3 T (TR, 140 milliseconds; FA, 70°; minimum TE, 2 milliseconds; ΔTE, 5 milliseconds; 16 echoes) with varying nominal volumes of the encoded voxels (from 5.76 to 36.0 mm). For each voxel size, mean R2* values were computed in regions of interest drawn in the left and right renal parenchyma. For data acquired using minimum voxel size, the mean R2* values were computed over the cortex and medulla separately. The squared 2-norm of the residuals was computed to evaluate the goodness of the pixel-wise exponential fits. Six multiecho MR images of a water phantom were acquired using a 2-dimensional fast-field echo sequence (FA, 50°; TR, 108 milliseconds; TE, 4 milliseconds; ΔTE, 20 milliseconds) at 3 T after shim adjustment and in the presence of a uniform background gradient of 40 μT/m. The nominal voxel size was varied in a range between 2 and 12.5 mm. Mean R2* values of 13.04 ± 0.71 s (right renal cortex) and 16.47 ± 1.92 s (right renal medulla) were computed at 1.5 T. At 3 T, the R2* of the right medulla was 28.27 ± 1.52 s and the cortical R2* was 19.22 ± 2.32 s. Comparable relaxivity values were found over the left kidney at both field strengths. Increasing R2* values were observed for increasing voxel volume in both the water phantom and renal tissue data. At a constant slice thickness of 4 mm, the decrease in the in-plane resolution from 1.2 × 1.2 mm to 3.0 × 3.0 mm led to a maximum increase of the renal R2* of 15% at 1.5 T and of 12% at 3 T. Increasing the slice thickness from 3 to 8 mm at a constant in-plane resolution of 1.5 × 1.5 mm resulted in a maximum increase of the renal R2* of 30% at 1.5 T and of 26% at 3 T. On the other hand, increasing the voxel size improved the goodness of the fit implied by the smaller residuals. The phantom experiments and in vivo acquisitions of healthy renal tissue documented a significant dependence of the apparent R2* relaxation rate on the spatial resolution of the MR imaging data. In clinical practice, the voxel volume for the quantification of renal R2* should be optimized in a compromise between minimizing the effects of macroscopic field inhomogeneity and maintaining a sufficiently high signal-to-noise ratio and goodness of fit. When comparing quantitative R2* among different publications, the influence of the spatial resolution should be taken into account.

慢性肾病早期肾间质纤维化磁共振功能成像的初步研究

目的：探讨MR DWI和BOLD应用于临床评价慢性肾病患者早期肾间质纤维化功能改变的价值。方法：收集了26例经肾穿刺活检证实为早期肾间质纤维化的慢性肾脏患者，男12例，女14例，平均年龄38.7岁(16~71岁)；26例健康自愿者为对照组，其年龄、性别与病例组匹配。采用GE 3.0T磁共振仪行T1WI、T2WI、DWI (b = 600 s/mm2)及BOLD扫描成像。利用工作站Fuctool软件对所有DWI和BOLD图像进行后处理，由两名有经验的主治医师对研究对象肾实质兴趣区的ADC值和R2*值进行测量和统计分析。结果：病例组26例早期肾间质纤维化的慢性肾病患者中15.4%(4/26)血清肌酐、尿素升高；84.6%(22/26)尿微量蛋白定量升高；病例组左、右肾实质ADC值较对照组减小(P 0.05)。结论：慢性肾病早期肾间质纤维化阶段存在肾组织水分子运动及肾组织血氧饱和度及氧含量的变化；早期肾间质纤维化肾实质ADC值有降低趋势，而R2*值有增加趋势；两者联合应用可以在肾间质纤维化早期诊断及疗效评价方面发挥作用。 Objective: To investigate the clinical value of DWI and BOLD MRI in evaluating functional changes of early renal interstitial fibrosis in patients with chronic kidney disease (CKD). Methods: Study protocol was approved by the local ethics committee. A group of 26 patients with renal biopsy confirmed CKD were studied (12 males and 14 females; aged 16 - 71 years, with a mean age of 38 years) and 26 age- and sex-matched healthy volunteers served as control group. T1WI, T2WI, DW and BOLD MR imaging were detected with a GE 3.0T MRI scanner. Post-processing of all ADC and R2* maps of kidney with Fuctool software was done in a workstation. ADC and R2* values of interested regions in the renal parenchyma were measured and analyzed by two experienced doctors. Results: Among study group, 4 patients (15.4%) had serum creatinine and urea elevated, and 22 (84.6%) had microalbuminuria detected. The ADC values of left and right renal parenchyma were significantly lower (P 0.05). Conclusion: Motion of water molecules and changes of blood oxygen saturation and content exist in renal tissues at the early stage of renal interstitial fibrosis. The ADC values of renal parenchyma tend to decrease whereas R2* values tend to increase at the early stage of renal interstitial fibrosis. Taking the ADC and R2* together has a great value in early diagnosis and therapeutic efficacy evaluation.

A Case of Central Metanephric Adenoma Successfully Treated With Laparoscopic Nephron-sparing Surgery

Metanephric adenoma is an extremely rare renal tumor and, even more infrequently, is centrally located. Herein we summarize a series of images concerning a central metanephric adenoma in a female adult successfully treated with laparoscopic nephron-sparing surgery. The patient presented with no symptoms but was found to have a lesion in the middle portion of the left renal parenchyma for 1 month prior. She underwent retroperitoneal laparoscopic nephron-sparing surgery with total resection of the renal mass. To our knowledge, we present here the most detailed, challenging, and complicated laparoscopic nephron-sparing surgery yet to be reported with a diagnosis of metanephric adenoma in the central location.

気腫性腎盂腎炎と気腫性膀胱炎の併発例

We report a case of emphysematous pyelonephritis coexisting with emphysematous cystitis. A 57-year-old woman seen for abdominal pain, diarrhea, and high fever had been referred after computed tomography (CT) elsewhere had shown an air density mass in the left kidney and pelvis. Abdominal CT on admission showed emphysematous change in the left renal parenchyma and intramural bladder. Serum analysis results showed disseminated intravascular coagulation (DIC) and uncontrolled diabetes. Klebsiella pneumoniae was isolated in the blood. She was diagnosed with sepsis based on these findings due to concurrent emphysematous pyelonephritis and cystitis caused by K. pneumoniae. She was treated conservatively with meropenem, intravenous immunoglobulin, and gabexate mesilate and cured. Concurrent emphysematous cystitis and pyelonephritis is rare., with ours only the fourth case reported in Japan.

Unilateral renal cystic disease

Unilateral renal cystic disease of kidney is a non-familial and non-progressive disorder, characterized by replacement of the renal parenchyma by a cluster of multiple cysts with a normal contralateral kidney. This rare condition is not related to autosomal dominant polycystic kidney disease; as such, hepatic and pancreatic cysts are not seen. We report a case of unilateral renal cystic disease in an elderly male documented by CT and serial ultrasound examinations. An elderly asymptomatic male (with normal renal function tests and urine examination) was found to have multiple cysts in left kidney during a routine ultrasound examination with thinned out intervening parenchyma; the right renal parenchyma was normal in size and echotexture. There was no evidence of hepatic or pancreatic cysts. Screening of family members did not reveal any evidence of autosomal dominant polycystic kidney disease. Contrast enhanced CT revealed multiple clustered cysts in left kidney, with normal enhancement of the intervening parenchyma [Figure 1]. The right kidney was normal without any cyst. Unilateral renal cystic disease was presumed, and patient put on follow-up. Serial ultrasounds over two years have documented the stability of the left renal cystic lesions, confirming the diagnosis. Figure 1 CECT abdomen shows multiple simple cysts replacing the left renal parenchyma with normally enhancing intervening parenchyma. Radiological picture was stable on follow-up Unilateral renal cystic disease, also called unilateral polycystic kidney disease, localized cystic disease of kidney, and segmental polycystic kidney, is characterized by replacement of renal parenchyma, either total or localized to a portion of kidney, by multiple cysts.[1–4] This is distinct from ADPKD, which is bilateral with involvement of both cortex and medulla. In children, ADPKD can have asymmetric onset; in these cases long term follow-up and screening of family members can make the distinction from unilateral cystic disease. The extrarenal manifestations of ADPKD (hepatic and pancreatic cysts, cerebral aneurysms) are not seen in unilateral renal cystic disease. Nephrolithiasis and hyperattenuating cysts are also generally seen in ADPKD.[4,5] When unilateral cystic disease of kidney is focal, it may be confused with a cystic neoplasm like multilocular cystic nephroma or cystic RCC. Careful analysis of multiple sequential images reveal a continuum of cysts in localized cystic disease of kidney with normal intervening parenchyma as compared to focal encapsulated mass in case of cystic neoplasms with compression of adjacent renal parenchyma.[1,4] The renal function is preserved with near normal concentration of contrast by the affected kidney. This allows distinction from multicystic dysplastic kidney (an entity seen in infants and children) in which the intercystic parenchyma is dysplastic and non functional; the dysplastic core in MCDK may show some enhancement, but has a different appearance from the normal renal tissue.[1–5]

Xanthogranulomatous pyelonephritis in pediatric patients: Case report and review of literature

Xanthogranulomatous pyelonephritis (XPN) is an unusual and rare form of chronic renal suppuration. XPN is often mistaken for renal malignancy; hence nephrectomy is commonly performed and the diagnosis confirmed by histopathology. Recent advances in imaging have allowed the radiological features to be characterized, such that routine nephrectomy is avoided. Approximately 240 cases of XPN have been reported in children. We report a 17-year-old female who presented with a 2-month history of increasing abdominal pain and intermittent episodes of increased frequency and dysuria. Plain antero-posterior radiograph of the abdomen revealed a left staghorn calculus. Computed tomography scan with intravenous contrast revealed a low-density inflammatory area and reduced cortical dye uptake on the left renal parenchyma as compared to the opposite side. A dimercapto-succinic acid renal scan revealed that the affected kidney contributed 18% of differential function. A diagnosis of XPN was made. The patient underwent percutaneous nephrostomy tube placement in an attempt to salvage the kidney. The patient eventually failed conservative management. Our review of the literature suggests that medical management has worked in some focal XPN cases, but has not been sufficiently tested in diffuse XPN.

Postrenal biopsy AVM leading to severe hypertension and dilated cardiomyopathy

A 3-year-old girl with Alport syndrome presented with decompensated heart failure from hypertension-induced cardiomyopathy 6 months following renal biopsy. Selective renal angiography revealed a large left renal arteriovenous fistula (AVF) with poor perfusion to the left renal parenchyma. The AVF was treated by transcatheter embolization using an Amplatzer vascular plug. Her blood pressure normalized after embolization, and her cardiac function normalized over the following 4 months.

Nefrectomía simple laparoscópica transumbilical con el uso de cistoscopio flexible e instrumentos laparoscópicos estándar

We present our initial experience with transumbilical surgery in a simple nephrectomy performed with a flexible cystoscope and standard laparoscopic instruments. A 15 year-old child, with severe left renal parenchyma atrophy, secondary to recurrent urinary tract infection (UTI) complicated with left pyelonephritis. Decision for simple nephrectomy was taken and we planned to perform a single port laparoscopic nephrectomy. In the lumbotomy position, two 5mm ports were insertend through a 3 cm umbilical incision. One trocar permitted the progression of the flexible cystoscope (Olympus) and the other the entrance of the PKS Plasma Trissector. The latter was then changed for a 10mm port to allow the entrance of the Weck clips. A Maryland grasper for countertraction was placed without port in the lef-upper quadrant and progressed directly into de peritoneal cavity under direct vision. The standard laparoscopic steps were duplicated uneventfully. Mean operative time was 90 minutes and mean blood loss was 200 mL. Hospital stay was 18 hours. No transfusion was needed. Single port urologic surgery will expand in the future. There is lack of commercial availability of the ideal hardware needed for the procedures. Versatility of urologic instruments allow for its use in different settings.