Left-sided Flank Pain Research Articles

Man with left-sided flank pain.

Man with left-sided flank pain.

From flank pain to splenic abscess: a complex case of infective endocarditis with literature review

BackgroundInfective endocarditis (IE) is a severe condition characterized by inflammation of the heart endocardium and valves, commonly caused by Gram-positive bacteria. Complications such as embolic phenomena and organ abscesses can arise, necessitating timely diagnosis and intervention.Case presentationWe report the case of a 20-year-old female with a history of cerebral and splenic infarctions due to IE. The patient presented with left-sided flank pain, urinary burning, and fever. Examination revealed mitral and aortic valve involvement, splenomegaly, and neurological deficits. Despite initial antibiotic therapy, the patient developed a splenic abscess and drug-induced neutropenia. She required aortic valve replacement and was successfully managed with a multidisciplinary approach.ConclusionMultidisciplinary management, including timely surgical intervention and advanced imaging, is essential for favorable outcomes in IE patients. This case underscores the importance of early detection and tailored treatment strategies in managing severe complications associated with IE.

1215 Cardiovascular Compromise and Hypertensive Crisis Secondary to Phaeochromocytoma

Abstract Phaeochromocytoma is a rare tumour of the chromaffin cells in the adrenal medulla, which secretes catecholamines. While associated with genetic disorders e.g., MEN-2, they tend to occur sporadically, and are often initially asymptomatic, found incidentally on imaging. Classical symptoms of Phaeochromocytoma include headaches, sweating, and palpitations, with sustained or paroxysmal hypertension which is refractory to a cocktail of antihypertensives. A variety of presentations have been reported in the literature including, but not limited to colitis, intracerebral haemorrhage, and PRES syndrome. We present a case of a 64-year-old man with an incidental left adrenal nodule. This radiologically indeterminate lesion was initially asymptomatic. Secretion studies revealed elevated metadrenaline levels, and an MIBG scan with positive avidity unveiled the lesion's pheochromocytoma nature. Whilst awaiting surgical intervention, the patient required emergency admission with a hypertensive crisis, presenting with left-sided flank pain and a blood pressure peaking at 220mmHg systolic. ECG findings were consistent with a myocardial infarction-like picture, and echocardiogram demonstrated regional wall motion abnormalities. CT coronary angiography revealed no significant coronary arterial disease – confirming that the patient’s presentation was in fact secondary to the pheochromocytoma. Pre-operative optimization is crucial for safe surgery. After the crisis, surgery was delayed by 6 weeks for cardiac rehabilitation. The patient was admitted a week before the procedure for optimal haemodynamics. Adrenalectomy proceeded as planned after alpha-blockade. A structured endocrine surgery clinic follow-up was established to assess the patient's ongoing recovery, and cardiovascular status. This case highlights cardiovascular implications of phaeochromocytoma, stressing a multidisciplinary approach for hypertensive crises and optimising outcomes.

Infected Kidney Stone in a Patient with Undiagnosed ADPKD: An Unusual Source of Postpartum Sepsis

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic diseases and has an incidence rate of 1 in 1,000-2,500. It is characterized by the development of cysts throughout the renal parenchyma and causes a progressive decline in renal function and eventually renal failure. In non-pregnant patients, common complications include hypertension, chronic pain from cysts, hematuria, urinary tract infection (UTI), and nephrolithiasis. Women who have chronic kidney disease (CKD) during pregnancy are at higher risk for both maternal and neonatal adverse outcomes including preeclampsia, worsening of renal function, preterm birth, and fetal growth restriction. Specific to ADPKD, some studies reported poor fetal outcomes and decline in maternal renal function with an increased risk of developing gestational hypertension, preeclampsia, and UTI. However, this research is not consistent and other studies suggest that there is only an increase in maternal complications if they have preexisting hypertension or elevated creatinine prior to pregnancy. This case presents a patient who was diagnosed with ADPKD as part of her workup for postpartum fever of unknown origin, and ultimately sepsis, from an infected kidney stone. Case Report: A 29-year-old G2P0010 at 37 0/7 weeks was admitted for induction of labor for fetal growth restriction. She ruled in for preeclampsia with severe features during her intrapartum course. After her vaginal delivery, she remained in the hospital for blood pressure control. On PPD4, she ruled in for sepsis based on a fever of 102.2 F, hypotension, and tachycardia. Despite the absence of fundal tenderness or purulent lochia, patient was started on IV Gentamicin and Clindamycin empirically for endometritis. CT of the abdomen and pelvis showed severe polycystic kidney disease worse on the left and enlarged uterus with thickened endometrial echoes. Her urinalysis was positive for leukocyte esterase and white blood cells and blood cultures returned positive for gram negative rods; but still no source had been confirmed. Due to worsening sepsis, Internal Medicine (IM) was consulted, and antibiotics were changed to Cefepime and Flagyl. Nephrology was also consulted due to incidental finding of ADPKD and AKI. On PPD5, her leukocytosis worsened, and she continued to be febrile, so infectious disease (ID) was consulted. ID escalated the antibiotics to IV meropenem and suspected a gynecologic source of her sepsis. By PPD6, the blood cultures grew E. coli and by PPD7 her leukocytosis reached a peak of 30.5 103uL. She was transitioned to Cefazolin 1g IV q8hrs. On PPD 9, she was discharged home with 12 days of Ceftriaxone 2 g IV daily. On PPD 16, however, the patient was sent into the ED for evaluation after experiencing a fever of 101.3F in her obstetrician’s office and concern over retained products of conception due to a thickened endometrium noted on ultrasound. Despite undergoing dilation and curettage and continuing IV antibiotics, the fevers persisted. She began to report left sided flank pain. An MRI of the abdomen and pelvis was ordered and revealed moderate to severe left hydronephrosis due to an obstructing 6 mm stone at the left ureteropelvic junction. Urology was consulted and the patient had a cystoscopy, left retrograde pyelogram, ureteroscopy, and ureteral stent placement. During the procedure, purulence and sediment was noted in the left kidney, consistent with infected kidney stone. Urology suspected this was the source of her infection. She remained afebrile after the procedure and completed an additional week of Cefdinir. Upon discharge home, she followed up with urology and underwent an additional laser lithotripsy and basket extraction of stones. Discussion: While UTI and nephrolithiasis are known complications of ADPKD during pregnancy, it is important to recognize early symptoms. It is estimated that women with ADPKD have a 14% increased risk of UTI. Untreated UTIs can lead to pyelonephritis, which is associated with preterm birth, low birth weight, and pregnancy loss. A less thought about complication of ADPKD, both in the pregnant and non-pregnant population, is nephrolithiasis. It is estimated that the incidence of nephrolithiasis ranges from 10 to 36% in patients with ADPKD. Nephrolithiasis can cause obstructions, worsen UTIs, and become infected, which is what occurred with the patient described above. It is thought that having large cysts, like our patient, places them at even higher risk for nephrolithiasis due to urinary statis. Our patient had multiple risk factors for nephrolithiasis. Ultimately, we had a favorable outcome, but if her infected kidney stone was diagnosed in a timelier fashion, she could have avoided worsening sepsis and a hospital readmission. Conclusion: In patients with ADPKD and sepsis of unknown etiology, there needs to be a high suspicion for UTI, pyelonephritis, infected nephrolithiasis, and infected cysts, as all of these are associated with increased morbidity and mortality, especially during pregnancy and the post-partum period.

Infected Kidney Stone in a Patient with Undiagnosed ADPKD: An Unusual Source of Postpartum Sepsis

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic diseases and has an incidence rate of 1 in 1,000-2,500. It is characterized by the development of cysts throughout the renal parenchyma and causes a progressive decline in renal function and eventually renal failure. In non-pregnant patients, common complications include hypertension, chronic pain from cysts, hematuria, urinary tract infection (UTI), and nephrolithiasis. Women who have chronic kidney disease (CKD) during pregnancy are at higher risk for both maternal and neonatal adverse outcomes including preeclampsia, worsening of renal function, preterm birth, and fetal growth restriction. Specific to ADPKD, some studies reported poor fetal outcomes and decline in maternal renal function with an increased risk of developing gestational hypertension, preeclampsia, and UTI. However, this research is not consistent and other studies suggest that there is only an increase in maternal complications if they have preexisting hypertension or elevated creatinine prior to pregnancy. This case presents a patient who was diagnosed with ADPKD as part of her workup for postpartum fever of unknown origin, and ultimately sepsis, from an infected kidney stone. Case Report: A 29-year-old G2P0010 at 37 0/7 weeks was admitted for induction of labor for fetal growth restriction. She ruled in for preeclampsia with severe features during her intrapartum course. After her vaginal delivery, she remained in the hospital for blood pressure control. On PPD4, she ruled in for sepsis based on a fever of 102.2 F, hypotension, and tachycardia. Despite the absence of fundal tenderness or purulent lochia, patient was started on IV Gentamicin and Clindamycin empirically for endometritis. CT of the abdomen and pelvis showed severe polycystic kidney disease worse on the left and enlarged uterus with thickened endometrial echoes. Her urinalysis was positive for leukocyte esterase and white blood cells and blood cultures returned positive for gram negative rods; but still no source had been confirmed. Due to worsening sepsis, Internal Medicine (IM) was consulted, and antibiotics were changed to Cefepime and Flagyl. Nephrology was also consulted due to incidental finding of ADPKD and AKI. On PPD5, her leukocytosis worsened, and she continued to be febrile, so infectious disease (ID) was consulted. ID escalated the antibiotics to IV meropenem and suspected a gynecologic source of her sepsis. By PPD6, the blood cultures grew E. coli and by PPD7 her leukocytosis reached a peak of 30.5 103uL. She was transitioned to Cefazolin 1g IV q8hrs. On PPD 9, she was discharged home with 12 days of Ceftriaxone 2 g IV daily. On PPD 16, however, the patient was sent into the ED for evaluation after experiencing a fever of 101.3F in her obstetrician’s office and concern over retained products of conception due to a thickened endometrium noted on ultrasound. Despite undergoing dilation and curettage and continuing IV antibiotics, the fevers persisted. She began to report left sided flank pain. An MRI of the abdomen and pelvis was ordered and revealed moderate to severe left hydronephrosis due to an obstructing 6 mm stone at the left ureteropelvic junction. Urology was consulted and the patient had a cystoscopy, left retrograde pyelogram, ureteroscopy, and ureteral stent placement. During the procedure, purulence and sediment was noted in the left kidney, consistent with infected kidney stone. Urology suspected this was the source of her infection. She remained afebrile after the procedure and completed an additional week of Cefdinir. Upon discharge home, she followed up with urology and underwent an additional laser lithotripsy and basket extraction of stones. Discussion: While UTI and nephrolithiasis are known complications of ADPKD during pregnancy, it is important to recognize early symptoms. It is estimated that women with ADPKD have a 14% increased risk of UTI. Untreated UTIs can lead to pyelonephritis, which is associated with preterm birth, low birth weight, and pregnancy loss. A less thought about complication of ADPKD, both in the pregnant and non-pregnant population, is nephrolithiasis. It is estimated that the incidence of nephrolithiasis ranges from 10 to 36% in patients with ADPKD. Nephrolithiasis can cause obstructions, worsen UTIs, and become infected, which is what occurred with the patient described above. It is thought that having large cysts, like our patient, places them at even higher risk for nephrolithiasis due to urinary statis. Our patient had multiple risk factors for nephrolithiasis. Ultimately, we had a favorable outcome, but if her infected kidney stone was diagnosed in a timelier fashion, she could have avoided worsening sepsis and a hospital readmission. Conclusion: In patients with ADPKD and sepsis of unknown etiology, there needs to be a high suspicion for UTI, pyelonephritis, infected nephrolithiasis, and infected cysts, as all of these are associated with increased morbidity and mortality, especially during pregnancy and the post-partum period.

Nutcracker syndrome in childhood

Nutcracker phenomenon (NP) is defined as the compression of the left renal vein, often occurring between the aorta and the superior mesenteric artery (SMA). Patients with symptoms associated with the Nutcracker anatomy are called “Nutcracker syndrome” (NCS). Renal vein compression results in venous congestion, outlet obstruction, and increased pressure in the left renal vein. The clinical manifestations of NCS in children vary widely depending on the severity of compression. It can range from being asymptomatic to presenting with intermittent or persistent micro or macrohematuria, orthostatic proteinuria, renovascular hypertension, abdominal pain, left-sided flank pain, dysmenorrhea, pain in the testicles or scrotum, and left varicocele. Hematuria, proteinuria, and flank pain are prevalent symptoms. The anatomical and physiological degree of compression of the left renal vein can be diagnosed through Doppler ultrasound (DUS), computer tomography (CT) scan, or magnetic resonance imaging (MRI). In cases with mild symptoms, conservative treatment is an appropriate option, and ACE inhibitors can be used for patients with proteinuria. In more severe cases where conservative approaches and medical treatment fail to yield satisfactory results, endovascular, laparoscopic, or open surgical interventions are employed.

Inguinal Arteriovenous Malformation

Arteriovenous malformations (AVMs) are rare disorders, with inguinal region involvement being particularly uncommon, as they typically manifest in the neck, limbs, trunk, and intracranial or extracranial sites. Despite their varied presentation across organs and tissues, AVMs can lead to cardiac failures due to high output, necessitating management even in asymptomatic cases. We present the case of a 37-year-old male with a known history of hypertension and severe depressive disorder, referred to the urology department for bilateral renal calculi evaluation. The patient complained of sudden-onset, moderate-intensity left-sided flank pain, with no signs of infection or constitutional symptoms. A non-contrast CT scan revealed bilateral renal calculi and an intriguing mass in the scroto-inguinal region. Further investigation through contrast-enhanced computed tomography identified an AVM originating from the right internal iliac artery, located a few millimeters next to the scrotum. A multidisciplinary team, including interventional radiology, urology, and vascular surgery, collaborated to develop a curative strategy. Angioembolization was performed successfully in a single session, involving catheterization and ligation of the feeder vessel using a lipiodol-glue mixture. Postoperatively, the patient remained stable with mild pyrexia (99°F), a heart rate of 76 bpm, and blood pressure fluctuating between 110-125 mmHg systolic and 72-80 mmHg diastolic. The absence of glue leakage upon saline injection confirmed the effectiveness of embolization. The patient experienced relief from pain and was mobilized on the second postoperative day. This case underscores the importance of a comprehensive approach in managing rare presentations of AVMs, emphasizing successful angioembolization as a viable therapeutic option

Primary Renal Leiomyosarcoma: Case Report and Review of the Literature

Renal leiomyosarcoma is an extremely rare malignant tumor. On clinical presentation and radio imaging it is challenging to make an accurate preoperative diagnosis. In our case, a 59-year-old female presented with history of left-sided flank pain, intermittent hematuria and weight loss of 6 months duration. She was known case of hypertension and diabetes mellitus of 20 years and on regular treatment. On the abdomino-pelvis sonography showed an exophytic cortical mass lesion measuring 4.0 x 3.8 cm lesion. Magnetic resonance imaging abdomen and pelvis (plain) shows a well defined non encapsulated exophytic predominantly solid mass lesion measuring 4.3 x 4 x 4.5 cm is noted in the anterior cortex of left kidney at interpolar region. There was no evidence of any regionalor distant metastesis. Patient underwent left radical nephrectomy. On histopathology reported as renal leiomyosarcoma. Immuhistochemistry showed smooth muscle actin diffusely and desmin focally positive. We present this review of rare case of primary renal leiomyosarcoma for its clinical presentation, radiographic findings, and pathologic features.

Adrenal Myelolipoma. An Interesting Case Report

Introduction: Adrenal myelolipoma is a rare urological lesion, benign in nature, and composed of a variable mixture of mature adipose and hematopoietic elements. The true incidence of these tumours is not well known. Despite their benign biology, these lesions can be a cause of dilemma for a urologist; we describe a case of incidental diagnosis of adrenal myelolipoma in a patient who presented with upper abdominal pain and reviews the literature on its aetiology, diagnosis, and management. Finally, the optimal treatment for myelolipoma depends on the size and symptoms of the mass and the needs of the patient. Case Report: Here we present a case of a 60-year-old female who presented with chronic left-sided flank pain and right upper abdomen that had been worsening over the past three weeks. Conclusion: Myelolipoma is a rare, non-functional, benign tumour. Patients having high blood pressure don't respond well to antihypertensive. They respond effectively to the medication after the removal of the tumour. So we recommend that all patients with myelolipoma not responding well to non-surgical management should plan for surgery for a better outcome.

Trampolinspringen-induzierte Makrohämaturie

Es wird über den Fall eines 12-jährigen Jungen mit sportinduzierter, rezidivierender Makrohämaturie und linksseitigen Flankenschmerzen berichtet. Nach umfangreicher laborchemischer sowie bildgebender Diagnostik wird in Zusammenschau des charakteristischen klinischen Bildes die Diagnose Nussknackersyndrom gestellt. Unter konservativen Maßnahmen sowie Verzicht auf den auslösenden Sport kam es zu einer klinischen sowie bildmorphologisch bestätigten Maturation.

Challenging retrograde intrarenal surgery in a pelvic ectopic kidney- an institutional case report and review of literature

Retrograde intrarenal surgery (RIRS) has been increasingly used as an effective treatment modality for treatment of stones in anatomically abnormal kidneys. A challenging RIRS in a 27-year-old man, done for a 1 cm calculus in a pelvic ectopic kidney is being presented here in order to highlight the technical difficulties encountered, safety and outcome of RIRS for pelvic ectopic kidneys. A 27-year-old man presented with the chief complaints of left sided flank pain of one year duration. He was discovered to have a left pelvic ectopic kidney 7 years back and later discovered to have a calculus within it 1 year back. He had a history of an attempted rigid ureteroscopy 2 months back at another hospital where they were unable to reach the stone, so they placed a Double J stent over a guidewire. The patient was worked up and taken up for surgery at our institution. Intraoperatively there was a kink at the PUJ, below which the access sheath was placed under C arm guidance and with the flexiscope, the kink was negotiated to reach the stone. Holmium laser was used to disintegrate the stone and DJ stent was placed. Post operatively patient was stable and discharged on day 2. RIRS is a safe and effective modality for the treatment of calculi in pelvic kidneys as seen, technical difficulties like kinks can be overcome by flexiscopy.

Clinical profile of patients with renal stone disease in a tertiary care hospital

Renal stone is a common condition affecting human beings of both genders and all age groups worldwide. Their presentation vary from unilateral loin region pain to nausea vomiting, to burning micturation or even haematuria. Patient profile of renal stone disease differs from one geographical region to another. Therefore this prospective observational study was conducted inDattaMeghe medical college, Wanadongri, Nagpur to find out patient characteristics of this region. 100 patients were included in the study. 82% patients were females most of whom were housewives. 48% patients belonged to the age group 41-60 years. Most common presentation was left sided flank pain. CT scan and USG abdomen were equally accurate in determining the size of the renal stone. Most of the females were managed conservatively whereas most males required intervention like URS or PCNL for their treatment.

Case of congenital ureteropelvic junction obstructive nephrolithiasis with acute urinary retention-X-ray abdomen (KUB view)

 A 36-year-old male patient was brought to casualty with complaints of colicky left sided flank pain, nausea, hematuria and difficulty in urination since 3 months. The patient came with no passage of urine since last 12 hours and sudden onset of pain. Per abdomen examination reveals tenderness at costovertebral angle with tachycardia and tachypnea. Patient was advised for X-ray abdomen KUB. Large left calculus in lower calyx with hydronephrosis as shown in (A) with mild tenderness over left flank. Catheterization was done. The patient was further advised for routine blood investigations, renal ultrasound, urine examination. The emergency surgery decision was taken on next day. Open pyelolithotomy with anderson-hynes pyeloplasty under general anesthesia was done. Post operatively patient was managed by Inj. Ceftriaxone 700 mg IV 12 hourly, Inj. Gentamycin 60 mg IV 8 hourly, Inj. Pantoprazole 40 mg IV 12 hourly and Inj. Neomol 1g IV 8 hourly. Liquid tolerated diet was advised to patient on post-operative day 2. Patient suggested to take very low calcium diet. After 7 days patient vitals was normal and shifted to normal diet and oral medication. The patient was advised to increase liquid diet and water intake. The final diagnosis was congenital ureteropelvic junction obstructive large (2.6 cm) nephrolithiasis with acute urinary retention, while the differentials included renal cell carcinoma, renal vein thrombosis, polycystic kidney disease.

203. Gardnerella vaginalis Bacteremia in Male Patients: A Case Series and Review of the Literature

Background Introduction: Gardnerella vaginalis is a colonizer of the female genitourinary tract and can cause serious morbidity as a pathogen. It is an uncommon cause of infection in men and bacteremia with this organism is rare. We describe two cases of G. vaginalis bacteremia in male patients. A literature search was performed for cases of G. vaginalis bacteremia in men. A total of 13 patients were identified and discussed.Methods Case 1: A 52-year-old man with diabetes and prior nephrolithiasis presented for dysuria, hematuria, and left sided flank pain. He was febrile and tachycardic with mild left costovertebral angle tenderness, leukocytosis and acute kidney injury. Urinalysis revealed pyuria. Computed tomography of the abdomen and pelvis showed pyelonephritis and a small calculus of the proximal left ureter. He was treated with ceftriaxone and then piperacillin-tazobactam. Aerobic culture of the urine yielded < 10,000 cfu/mL of mixed gram-positive flora. Blood cultures yielded G. vaginalis after 48 hours. He was treated with ciprofloxacin 500 mg orally twice daily for 7 total days and clinically recovered. Case 2: A 61-year-old man with alcohol use disorder and gout, presented with altered mental status. He had leukocytosis and acute kidney injury and was treated with vancomycin and cefepime with clinical improvement. Admission blood cultures demonstrated G. vaginalis in the anaerobic bottle of 1 of 2 cultures, reported 96 hours after collection. Urine culture was negative. The patient was treated with amoxicillin-clavulanate on discharge to complete a 14-day course with clinical resolution.Resultssee aboveGram stain of G. vaginalis on blood culture Conclusion Discussion: G. vaginalis is a facultative anaerobic gram-positive pleomorphic rod, which can be gram variable due to poor staining of the thin peptidoglycan cell wall. Isolation and identification are often delayed. Bacteremia in men is rare but nearly all have originated in the genitourinary tract. The most severe cases of G. vaginalis bacteremia implicate endocarditis, urethral stricture and an empyema as the sources. Collection of blood cultures and speciation are often delayed, ranging from 48 hours to 7 days. Selection and duration of treatment have ranged widely in previously reported cases, likely due to the lack of guidance regarding effective treatment.Disclosures Andrew Chou, MD, bluebird bio (Shareholder)

Ureteric Stone-Related Escherichia coli Bacteraemia Associated with Spondylodiscitis

Escherichia coli (E. coli)-related urosepsis associated with a ureteric stone has been shown to cause a systemic bacteraemia that can spread to other parts of the body. Hematogenous spread of infection is the most common cause of pyogenic spondylodiscitis. A 74-year-old female presented with acute left-sided flank pain and was found to have an obstructing 9 mm distal ureteric stone. After initial management involving ureteric stent insertion, the patient deteriorated and developed an E. coli associated bacteraemia, which proved difficult to treat. Further investigations revealed a subsequent spondylodiscitis, which required a 6-week course of antibiotics and no additional intervention. This case presents the likely association of stone-related bacteraemia, complicated by urinary tract instrumentation leading to spondylodiscitis, and demonstrates the importance of clinicians’ awareness of other causes of unresolving sepsis in an elderly patient.

56/f-Fever and left-sided flank pain : Preparation for the medical specialist examination: part 11

56/f-Fever and left-sided flank pain : Preparation for the medical specialist examination: part 11

52/m-Sterile leucocyturia, night sweats and left-sided flank pain : Preparation for the medical specialist examination: part10

52/m-Sterile leucocyturia, night sweats and left-sided flank pain : Preparation for the medical specialist examination: part10

Young Male With Penile Pain

A 27-year-old man with a history of nephrolithiasis presented to the emergency department with dysuria and penile pain. He reported a foreign body sensation and pain at the distal tip of his penis. One week prior, he had experienced transient left-sided flank pain. The patient also endorsed a small amount of hematuria and a weakened urinary stream. Given these symptoms, a bedside ultrasound was performed (Figure 1).

Lower ureteral compression through external vascular elongation in a cyclist: A case report.

Introduction and importanceThere is sparse literature about lower ureteric obstruction due to aberrant blood vessels. We report a case of a patient who was referred to our hospital due to left sided flank pain caused by external compression of the distal ureter.Case presentationA 47-year-old male patient presented with left sided flank pain. A computed tomography scan revealed external compression of the lower ureter. Hypertrophy of the psoas muscle due to extensive cycling for 20 years lead to concomitant kinking and elongation of the iliacal vessels which caused the distal ureteric obstruction. Robotic-assisted laparoscopic ureterocystoneostomy with psoas hitch technique was performed.Clinical discussionLower ureteric obstruction, mostly seen in children, is mostly caused by vascular anomalies such as a persistent umbilical artery. After literature review, we presume it to be the first reported case of distal ureteric obstruction caused by external vascular elongation.ConclusionThe external elongation of pelvic vessels due to excessive cycling and the concomitant extrinsic compression of the distal ureter should be considered as rare but possible cause of lower uretic obstructions.

Adolescent Male With Severe Renal Trauma

A 15-year-old previously healthy boy was admitted for a blunt abdominal trauma owing to a cycling crash. On admission he was alert; blood pressure and pulse rate were 145/95 mm Hg and 75 beats/min, respectively. Physical examination result was remarkable for severe left-sided flank pain with guarding. No others injuries were found. His urine was like blood and laboratory tests showed a normal hemoglobin level, at 13.5 g/dL, with hematocrit level 40.9%.