Left Ureteral Orifice Research Articles

Serious contracted bladder and vesicoureteral reflux after intravesical Mitomycin-C treatment

CASE REPORT We present a patient with serious contracted bladder and bilateral grade V vesicoureteral reflux which developed after intravesical Mitomycin­C treatment. The 78­years­old male patient had a history of transurethral bladder tumor and prostate resection at the same session in another center, because of a solitary, papillary tumour with a diameter of 20 mm near the left ureteral orifice and an enlarged prostate. Before the operation intravenous urography was done, showed normal bladder capacity (figure 1). The histology revealed transitional cell carcinoma (T1, G1) and benign prostatic hyperplasia. Intravesically 20 mg Mitomycin­C was given weekly for the first six weeks, then monthly for 10 months. During the treatment he developed increasing frequency and urge incontinence, but the treatment was not interrupted. Two years after the end of instillation the patient presented to our department with right flank pain, frequency and urge incontinence. Serum levels of creatinine and urea were 228 μmol/L and 11.3 mmol/L, respectively. Urine culture, including culture for tuberculosis, was negative. His renal ultrasound showed bilateral hydronephrosis, and thin renal cortex. Cystogram revealed contracted bladder and bilateral grade V vesicoureteral reflux (figure 2). Cystoscopy showed golf­hole ureteral orifices and low capacity (50 ml) of the bladder. There were no sign of tumour recurrence. Due to co­morbidity of the patient (hypertension, ischemic heart disease) reconstructive surgery could not be performed; therefore percutaneous suprapubic cystostomy was placed. One year after suprapubic cystostomy placement, the patient was very well, he had no symptoms and his serum level of creatinine stabilized at about 150 μmol/L. DISCUSSION Mitomycin­C, doxorubicin and epirubicin are the most frequently used intravesical chemotherapy to prevent recurrence of superficial bladder cancer after transurethral resection. These drugs can be used for single, immediate, postoperative instillation or for adjuvant repeat instillations. The efficacy of these drugs are similar [1, 2]. Side effects of intravesical chemotherapy (cystitis, bladder irritation) are usually moderate and localized to the bladder. However, rarely it can cause severe, even fatal, complications, especially after immediate post­operative instillation when there is a bladder wall perforation [3]. Mitomycin­C is considered to be a safe intravesical chemotherapeutic drug, but rarely it can cause contracted bladder, which can require urinary diversion [4]. The cause of contracted bladder in the present case was most likely chemocystitis caused by intravesical Mitomycin­C therapy; we were able to exclude other common cause of contracted bladder (tuberculosis, schistosomiasis, interstitial cystitis, irradiation cystitis). Perhaps, long­term (1­year­long) treatment and the absence of treatment interruption, even though the patient’s symptoms facilitated this serious adverse effect. CLINICAL IMAGES OPEN ACCESS

Incomplete transverse vesical septum: An unusual congenital anomaly

A rare case of incomplete transverse vesical septum with urinary tract tuberculosis is being reported. A 52-year-old male presented with lower urinary tract and systemic symptoms. On investigation he had anemia, leucocytosis, and high serum creatinine. On cystopanendoscopy, there was a transverse ledge of tissue connecting the two lateral walls of the bladder approximately 4 cm proximal to the bladder neck dividing the caudal vesical cavity into anterior and posterior parts. Also, the left ureteric orifice had double barrel look. To our knowledge this is the first ever reported case of incomplete transverse vesical septum.

Laparoscopic Repair of Rectovesical Fistula after Radical Retrobupic Prostatectomy

We present the video of a laparoscopic repair of a rectovesical fistula after radical retropubic prostatectomy. The rectal lesion had not been detected during the first procedure. The rectal bladder fistula appeared on the 14th post-operative day. After three weeks from the procedure,the patient underwent a laparoscopic repair of the rectovesical fistula. A temporary external colon conduit was performed at the same time. We performed a cystoscopy before the surgery; it showed a fistula behind the bladder neck at 5 o'clock, distally to the left ureteral orifice. Two ureteral stents were inserted into both the ureters to make sure not to determine any injury to these structures during the operation. With the patient in the supine position, we introduced 5 trocars with the Hasson technique trans-peritoneally. The pouch of Douglas was opened and the bladder was divided from the rectum.The bladder posterior wall was widely opened till reaching the rectal bladder fistula.The fistula was located distally to the left ureteral orifice, very close to the bladder neck. Through a blunt dissection, we divided the margins of the rectal fistula from those of the posterior bladder wall.Indeed, we performed a suture of the rectal wall without any tension. The rectal lesion was closed in a double-layer suture with 3-0 Vicryl.We introduced a probe into the rectum to make sure there was no leakage on the suture. A flap of peritoneum of the Douglas was put between bladder and rectum.We closed the longitudinal opening of the trigone and the bladder posterior wall through a continuous suture.An external colic conduit was packaged to guarantee the closure of the fistula. The left colon was put through the abdominal wall widening the 5 mm trocar opening located on the left pararectal space. The operative time was 240 minutes. There were no post-operative complications. The bladder catheter was removed at 1 month after surgery,only after performing a cystography, which showed no leakage.Two months later, the colostomy was closed. At a 12-month follow-up the patient had no fistula recurrence. The treatment of arectovesical fistula after radical prostatectomy remains a complex procedure: different types of corrective surgical approaches have been described. The laparoscopic approach is an alternative to standard procedures. The optical magnification allows a good view of the fistula in a very deep and narrow space. It also allows easy performing of the colostomy.

Laparoscopic Extravascular Renal Vein Stent Placement for Nutcracker Syndrome

To report our experience in the laparoscopic extravascular management of the nutcracker syndrome. Three patients (two men and one woman) between the ages of 20 and 35 years (mean 25.7 y) underwent laparoscopic extravascular stent placement in the left renal vein for management of the nutcracker syndrome that is associated with severe recurrent gross hematuria and left gonadal vein varices. The postoperative follow-up was 16 to 37 months (mean 25.3 mos). All patients met the criteria for establishing the diagnosis of the nutcracker syndrome. Ultrasonography, CT, and MRI revealed visible entrapment of the left renal vein between the superior mesenteric artery and aorta. Bleeding from the left ureteral orifice was detected by urethrocystoscopy and ureterorenoscopy. We attempted a novel laparoscopic method to manage this anatomic anomaly. No complications occurred during surgery. Total relief was achieved in two men without a relapse of symptoms, and abnormalities were not found in the results of the urine test. There is partial relief in a 20-year-old woman because of microhematuria after the operation. The indications for surgical management with the nutcracker syndrome depend on the severity of the symptoms, and laparoscopic extravascular stent placement in the renal vein is a feasible approach for reestablishing free renal venous outflow. This slightly invasive treatment can eliminate the symptoms of the condition. Longer follow-up and more experience are necessary to make conclusions about its feasibility in contemporary practice, however.

Incidental Ureteral Catheterization With Cystometry Catheter During Video Urodynamics: A Prompt Diagnosis

Multichannel video urodynamics (VUDS) was performed for postlaparoscopic radical prostatectomy urinary incontinence. A temporary wavy rise was noted in vesical pressure (P ves) before filling. Shortly upon filling, a sudden rise was noted in P ves and the patient developed left flank pain. The catheter tip was visible fluoroscopically in the left upper ureter and the pump was stopped immediately. After several unsuccessful attempts, the catheter was finally placed under cystoscopic guidance. The left ureteral orifice was at the posterolateral position just at the membranous urethra. The VUDS was completed uneventfully with no further complications. Careful monitoring during VUDS is paramount to detect such complications early, especially in situations of altered trigonal anatomy.

Epididymal tissue in the dilated portion of a dysgenetic kidney with an ipsilateral seminal vesicle cyst and ectopic ureteral insertion

Epididymal tissue in the dilated portion of a dysgenetic kidney with an ipsilateral seminal vesicle cyst and ectopic ureteral insertion

Diagnosis and Surgical Treatment of Nutcracker Syndrome: A Single-Center Experience

Conclusion: Left renal vein transposition is an efficient surgical treatment for nutcracker syndrome. In some cases however pelvic pain remains following left renal vein transposition. Summary: The nutcracker syndrome is an unusual problem where the left renal vein is narrowed as it passes between an angle formed between the abdominal aorta and the superior mesenteric artery. This narrowing of the left renal vein can lead to increase venous pressure within the renal circulation and promote development of varices of the renal pelvis and ureter with resulting hematuria. Other symptoms associated with nutcracker syndrome include orthostatic proteinuria, flank pain, left-sided varicocele, pelvic congestion, and chronic fatigue. The authors retrospectively reviewed 23 patients with the diagnosis of nutcracker syndrome treated at their institution from July 1998 to July 2007. Nutcracker syndrome was suspected based on the combination of clinical examination, ultrasound, CT imaging, and MRI imaging. Hematuria was the most common presenting symptom (21 of 23 patients). One patient presented with orthostatic proteinuria and 1 with pelvic congestion syndrome. No patient had renal function deterioration and 13 of 23 undergoing cystoscopy had bleeding noted from the left ureteral orifice. Only 7 underwent transposition of the left renal vein with the indication of transposition being recurrent gross hematuria in 6 patients and persistent orthostatic proteinuria in 1 patient. Sixteen patients who had more mild symptoms were followed without operation. Patients with microscopic hematuria or intermittent short periods of painless gross hematuria were followed closely without treatment. Patients with flank or abdominal pain were treated with low-dose aspirin treatment. Four women with pelvic congestion syndrome were treated with medroxyprogesterone acetate. Patients undergoing left renal vein transposition did so through a mid-line abdominal incision with mobilization of the left colon and small bowel to give access to the retroperitoneum. The inferior adrenal vein, ovarian/testicular vein, and the lumbar vein draining into the left renal vein were ligated and transected. The left renal vein was excised with the small rim of vena cava and injected with heparin. Reanastomosis was then performed to a more caudad portion of the inferior vena cava. All 7 patients treated with renal vein transposition had normal pre-operative creatinine levels with no increase following renal vein transposition. Hematuria and proteinuria ceased spontaneously 5 to 14 days following surgery with no clinical relapses. Of the 16 patients treated conservatively, clinical improvement occurred in 11 with total relief of symptoms in 2 patients and partial relief in 9 patients. There was no relief of symptoms in 5 patients following a mean follow-up of 41.2 months. Comment: The pressure gradient between the left renal vein near the renal hilum is normally between 0 and 1 mmHg (J Urology 1982; 127: 1070-1071). An elevated gradient of more than 3 mmHg between the left renal vein and the vena cava is used as a criteria to diagnose nutcracker syndrome. All patients in this series had such a gradient. The study indicates that left renal vein transposition works well to alleviate symptoms in patients with nutcracker syndrome and elevated renal vein IVC pressure gradients. Equally important is that patients with mild symptoms do well treated conservatively. It would appear reasonable to reserve surgical treatment of nutcracker syndrome to those patients with recurrent gross hematuria or persistent orthostatic proteinuria who are not responsive to conservative management. The authors also point out that children and adolescents can have nutcracker syndrome that will frequently resolve as the child matures into adulthood. Surgical treatment of nutcracker syndrome in children and adolescents therefore, in most cases, should be avoided.

Bladder Leiomyomata and Pelvic Pain

A 57-year-old woman underwent superficial transurethral resection (TUR) of a 3-cm lesion near the left ureteral orifice found incidentally at sling placement. Intravenous pyelogram and computed tomography demonstrated a filling defect and homogenous mass (Fig. 1). She presented to our institution with persistent pelvic pain, and a completion TUR revealed a bladder leiomyoma. Interestingly, her pelvic pain resolved entirely. Three months later, magnetic resonance imaging and cystoscopy showed no recurrence.

Urinary TractSchistosoma haematobiumInfection: A Case Report

Urinary schistosomiasis, caused by Schistosoma haematobium , is reported to be endemic in 54 countries in Africa and the Middle East. 1 In some endemic areas, studies in school‐age children showed a high prevalence of S haematobium infection. 2,3 Humans can be infected by cercariae when they are in contact with contaminated freshwater. The adult coupled worms reside in the veins of the vesical and pelvic plexuses, where the female lays 20 to 290 eggs per day. 4 The urinary bladder, the lower ends of the ureters, and the seminal vesicles are the most commonly affected organs. 5 The pathological lesions in urinary schistosomiasis result from the granulomatous host response to the deposition of schistosome eggs in the tissues. Infection becomes established 10 to 12 weeks after cercarial penetration and is manifested by hematuria and urinary excretion of eggs. The case is presented of urinary schistosomiasis in a young African immigrant to Greece. The cystoscopic appearance and the histopathological changes of the bladder before and after treatment with praziquantel (PZQ) are shown along with the imaging findings of the urinary tract on computed tomography (CT) scan and ultrasonography (US). A 25‐year‐old woman from Ghana resident in Athens presented with pain in the left lumbar and abdominal regions. Physical examination revealed a healthy female with no abnormal signs on abdominal, genitourinary, and neurologic examination. The results of blood biochemical and hematological tests were normal except for a peripheral blood eosinophil count of 759/ μ L. US of the abdomen and genitourinary tract showed thickening of the bladder wall with no other pathologic findings and liver, spleen, and kidney of normal size and appearance. CT of the abdomen and genitourinary tract revealed (1) linear calcification occupying the entire bladder wall circumference, (2) circular calcification of the left ureteric orifice, (3) linear calcification …

Bladder paraganglioma with a calculus: A case report

A 2×1.5 cm tumor was found at the left wall 2 cm above left ureteric orifice during cystoscopy. The patient then received a partial cystectomy under general anaesthesia. No other tumors or paraaortic lymph node enlargement were found. The post-operative period was uneventful and her blood pressure recovered to normal after operation (123/76 mmHg). Histological examination: small round cells showed a solid proliferation. The tumor cells were multilateral or round, full of hobby red Iraq graininess in the cytoplasm, a vacuole like nucleus and less nuclear disruption. There was a large number of capillary vessels in the mesenchyme. Immunohistochemical results showed that vimentin and keratin staining were negative. However, chromogranin A、synaptophysin and NSE were positive. Paraganglioma, pheochromocytoma or chromo-receptor tumors, originate from the paraganglion and have a high hereditary component. They usually occur in the neuroendocrine system from the

Symptomatic Calcification of Subureteral Collagen Ten Years After Injection

Bovine glutaraldehyde cross-linked collagen is an injectable bulking agent used to treat urinary incontinence and vesicoureteral reflux. A 16-year-old girl had previously undergone left subureteral injection of collagen at the age of 6 years. She presented to our clinic after passing a 7-mm calcification with a history of hematuria and intermittent back pain. Computed tomography showed two hyperdense foci measuring 2 mm each in the region of the left ureterovesical junction that did not change on follow-up imaging. On cystoscopy, two submucosal calcifications were located medially and inferiorly to the left ureteral orifice and were removed endoscopically.

Transvaginal repair of a vesico-vaginal fistula using a mobilised vaginal flap to form the bladder base: a case report

We describe a case of a vesico-vaginal fistula in a 32-year-old lady presenting with true urinary incontinence. There was a 1.5 x 1.5 cm deficit in the bladder wall and the left ureteric orifice was very close to the edge of the defect. For a successful transvaginal repair, we used a mobilized vaginal flap to bridge the defect in the bladder wall. This avoided the mobilization of the bladder wall and also prevented the left ureteric orifice from getting entrapped in the suture line. Adjacent wall of vagina was mobilized and stitched over the first layer to achieve water tight repair. Her post operative period was uneventful. The repair healed well and she was discharged in a good condition.

Ectopic prostatic tissue in the bladder

Ectopic prostatic tissue in the bladder has rarely been reported and usually involves the midline in the form of vestigial remains of embryonic prostatic elements. To our knowledge there are only 32 reports on this lesion in the literature in English. Prostatic heterotopia may be endoscopically confused with malignancy in the urinary system. We report three cases of ectopic prostatic tissue at the retrotrigonal area and left ureteral orifice. The patients presented with gross or microscopic hematuria and all the lesions had a polypoid appearance. The histopathologic and immunohistochemical examination revealed the prostatic nature of the tissue. No recurrences were evidenced. The authors review the literature concerning this lesion which should be recognized by urologists and pathologists, who must be aware of its benign nature.

Pathologic Quiz Case

70-year-old male chronic smoker presented with gross hematuria for 1 day. Ultrasonography of urinary system revealed a plaquelike soft tissue mass at the bladder base, associated with bilateral hydronephrosis and hydroureters. Cystoscopy found a sessile and indurated tumor at the posterior wall of the urinary bladder, involving the left lower ureteric orifice. The patient developed acute renal failure during investigation for his bladder tumor. Magnetic resonance imaging showed a bilaterally dilated urinary system due to tumor encasement in the bladder. Bilateral percutaneous nephrostomy was performed, followed later by total cystectomy and ileal conduit. A solid tumor measuring 14 mm across was found in the posterior wall of the urinary bladder, deeply infiltrating to the perivesical adipose tissue. Microscopically, the malignant cells were arranged in tightly cohesive nests. These tumor cell balls were surrounded by empty spaces (Figure 1). Conventional transitional cell carcinoma elements were occasionally found. In areas, these tumor cells were of high-grade nuclear morphology with nuclear pleomorphism, high nuclear-to-cytoplasmic ratio, irregular nuclear outline, and coarse chromatin (Figure 2). The surface epithelium exhibited carcinoma in situ. There was multifocal angiolymphatic invasion as well as lymph node metastasis in the perivesical soft tissue (Figure 3). What is your diagnosis?

URETERAL REIMPLANTATION DURING ROBOT ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

Ureteral injury during radical prostatectomy is a well described complication. Reports describing ureteral reimplantation exist in the open surgical literature.1 In the laparoscopic literature recognition of this injury intraoperatively has allowed for primary end-to-end ureterorrhaphy.2 Too ur knowledge laparoscopic ureteral reimplantation during radical prostatectomy has not previously been described. CASE REPORT A 62-year-old man with Gleason sum 7 prostate adenocarcinoma presented for robot assisted laparoscopic radical prostatectomy. The Montsouris technique was used. After extirpation of the prostate the bladder neck was inspected. Indigo carmine was infused intravenously and was seen effluxing from only the left ureteral orifice. A 0.038-inch guidewire was used to cannulate the right ureteral orifice, confirming ureteral transection at the level of the seminal vesical. Investigation posteriorly in the area of the initial seminal vesical dissection revealed the proximal end of the ureter effluxing blue urine. Our standard vesicourethral anastomosis was used, with 8 interrupted 2-zero polyglactin absorbable suture. The bladder was distended and the mobilized distal ureter was positioned toward the right lateral dome without tension. A cystotomy was made at the corresponding site. The distal 5 mm section of ureter was resected and spatulated. Through the lateral accessory port a 6Fr 26 cm double pigtail ureteral stent was passed over a wire up to the kidney. The distal end of the stent was placed in the cystotomy. Using 4, 4-zero absorbable sutures in an interrupted fashion, the ureter was securely implanted with mucosal apposition. To augment this anastomosis, a layer of detrusor was used to buttress the anastomosis. A self-suctioning drain was left in the pelvis for 48 hours. The patient had no other perioperative complications and was discharged home on postoperative day 2. The urinary catheter was removed at 8 days postoperatively. Five weeks later the stent was removed cystoscopically. At 3 months postoperatively excretory urography demonstrated normal upper tract architecture and drainage (see figure). DISCUSSION

Filarial chyluria: long-term experience of a university hospital in India.

Filariasis is an endemic problem in various Indian states. We evaluated the results of long-term follow up (10-20 years) of patients with filarial chyluria. We conducted a retrospective analysis of 160 patients treated for filarial chyluria who presented to the Banaras Hindu University Hospital from 1982 to 1992. Eighty-four patients (52.5%) were treated using diethylcarbamazine (DEC) and a fat restricted diet and 76 patients (47.5%) underwent surgery. To examine the long-term effects of filarial chyluria we analysed data on post-treatment recurrence, weight gain, dietary freedom, chyluria free period and a number of other associated factors. Previous history of filariasis or its complication was documented in 19% of patients. In 71% of cases, cystoscopy showed that chylous efflux was predominant in the left ureteric orifice. The long-term remission rate was 62% in the conservatively managed group (DEC + fat restricted diet), whereas 90% of patients in the operated group were cured. Postoperative recurrence rate was 10%. There was more weight gain and dietary freedom along with a longer chyluria free period in the operated group relative to the conservatively managed group. Definitive surgical ablation of lymphatic urinary fistula is better than conservative medical management because it has a higher success rate, more dietary freedom and, therefore, better patient acceptability.

Laparoscopic Excision of a Seminal Vesicle Cyst in a Child

Seminal vesicle cyst is an exceedingly rare lesion, manifesting in less than 0.005% of the population.1 Most seminal vesicle cysts are small and asymptomatic. However, when symptoms occur it is usually during the early sexually active period (ie in the second and third decades of life in men).2 Symptoms at presentation may include irritative lower urinary tract problems, abdominal and perineal pain, lower abdominal mass, hemospermia and, rarely, hematuria. The seminal vesicle cyst is often associated with other urological anomalies, including renal agenesis, renal dysplasia and ureteral ectopia.3 Surgical management consists of transrectal aspiration, transurethral unroofing, transurethral resection of the ejaculatory duct, transurethral endoscopic examination and aspiration or open surgical excision. 4–6 The open surgical approach is considered the definitive form of treatment. However, it can be technically challenging and morbid. Recently, the laparoscopic approach has had a significant impact on the management of several urological disorders, including seminal vesicle cysts.7–9 We report the tenth case, and only the second known pediatric case, of a laparoscopic seminal vesicle cyst excision. In this case dissection of the cyst was facilitated by filling the cyst with indigo carmine cystoscopically immediately before laparoscopic excision. CASE REPORT A 7-year-old boy presented elsewhere with a 2-week history of suprapubic pain and dysuria. Initial antibiotic therapy for a presumed urinary tract infection was ineffective. Right testicular swelling subsequently developed and the patient was referred to a urologist. He underwent scrotal exploration, which identified only right epididymitis. Additional antibiotic therapy was given but the symptoms failed to resolve. He was referred to our institution with persistent orchitis. Physical examination revealed an unremarkable abdomen. Scrotal examination demonstrated a mildly enlarged and firm right testicle that was exquisitely tender on palpation. The right epididymis was also enlarged and tender but the spermatic cord was unremarkable. The rest of the examination did not show any other abnormalities. Abdominal, pelvic and scrotal ultrasound revealed an anechoic lesion posterior to the bladder and a mildly enlarged right epididymis along with an absent right kidney. Pelvic magnetic resonance imaging confirmed the absence of the right kidney and the presence of a pelvic cyst located to the right of the midline, consistent with a seminal vesicle cyst (fig. 1). Laparoscopic excision of the seminal vesicle cyst was elected. After induction of general anesthesia cystoscopy was performed with an 11Fr pediatric cystoscope. Examination of the bladder demonstrated elevation of the trigone and bladder base due to the seminal vesicle cyst. The left ureteral orifice was found in an orthotopic position. However, the right ureteral orifice and hemitrigone were absent. The posterior urethra was unremarkable. The ejaculatory duct was cannulated without difficulty using a 75 cm 3Fr ureteral

残存尿管に発生した原発性未分化癌の1例

A 72-year-old man referred our hospital with the chief complaint of macroscopic hematuria. He had undergone simple left nephrectomy for left renal stone when he was 27-years-old. His urine cytology showed class IIIb. They were 4 times. We performed random biopsy of the bladder and retrograde pyelography of the right But they were no positive findings for the cause of hematuria and for the existence of malignancy. After 2 months, he had macroscopic hematuria again. Cystoscopic re-examination revealed a fibrin out of the residual left ureteral orifice. Computed tomographic scan showed a perivesical mass. The diagnosis was the carcinoma of the ureteral stump. We performed ureterectomy. The pathological study revealed the undifferentiated carcinoma. This case is the first report of the undifferentiated carcinoma occurred on the residual ureteral stump in the Japanese literature.

Intravenous Stent Placement for Treatment of the Nutcracker Syndrome

The nutcracker syndrome was first reported in 1972 by de Schepper.1 It is a rare cause of hematuria. We placed a stent in the left renal vein to treat a recent case of the nutcracker syndrome. CASE REPORT A 37-year-old man presented with intermittent gross hematuria 4 years in duration. Physical examination revealed no abnormal findings. Laboratory tests were within normal range except for microscopic hematuria. Ultrasonography of the urinary tract and excretory urography were normal. Cystoscopy showed gross bleeding from the left ureteral orifice. Angiographic computerized tomography (CT) of the abdomen demonstrated that the left renal vein was compressed between the abdominal aorta and superior mesenteric artery (SMA), and had become stenosed. The distal portion of the left renal vein was dilated (fig. 1, A). Sagittal magnetic resonance angiography revealed that the angle between the abdominal aorta and SMA was only 21 degrees (normal 90) and the left renal vein exhibited oblate form due to compression (fig. 1, B). Left renal venography showed obstruction of left renal venous outflow, and intrarenal and perihilar varices (fig. 2, A). On the basis of these findings, we diagnosed the nutcracker syndrome. We used a venous endoprosthetic stent (Wallstent, Boston Scientific Corp., Natick, Massachusetts) for treatment. The stent was composed of thin stainless steel wire, which was bent into a cylindrical mesh structure. It was placed into the left renal vein via the left transfemoral vein. After stent placement left renal venography demonstrated that blood outflow was unobstructed (fig. 2, B). The patient received antiplatelet therapy postoperatively. Six days later the hematuria resolved. The patient has been free of hematuria for more than 3 months.

The Nutcracker Syndrome

A 56-year-old woman presented with intermittent gross hematuria and left flank pain. There was no history of renal trauma, urinary tuberculosis, urinary bilharziasis or other diseases. After some intensive physical exercises, viscosimetric examination was performed and intermittent hematuria was observed at the left ureteral orifice. Ureteroscopy of the collateral upper urinary tract excluded tumor, calculi and infection. A shadow resulting from compression of the ovarian vein on the left ureter was clearly observed on excretory urography. Computerized tomography confirmed stricture of the left renal vein between the superior mesenteric artery and abdominal aorta (fig. 1). Digital subtraction angiography of the bilateral renal artery demonstrated perirenal and periureteral venous reflux into the adrenal and ovarian veins, which was verified during the venous phase of the examination (fig. 2). Left renal arterial digital subtraction angiography showed drainage of dye during the arterial, essence and venous phases (fig. 2). No renal hemangiomas were diag-