Parapelvic Renal Cysts Research Articles

Parapelvic Renal Cyst Treatment with Flexible Ureteroscopy: Single Centre Experience.

This study aimed to assess the feasibility, safety, and efficacy of an endoscopic parapelvic renal cyst (PRC) incision using flexible ureterorenoscopy (fURS). We retrospectively reviewed data concerning 16 patients in whom PRC incisions had been performed using fURS between January 2016 and January 2022. Two patients were excluded from the study owing to a lack of follow-up information. The cysts of all the patients were evaluated preoperatively by computed tomography. The patients' age, gender, cyst size, presenting symptoms, postoperative complications, and pre- and post-treatment visual analogue scale (VAS) scores were evaluated. Surgical success was defined as a reduction of more than half of the cyst size in the sixth postoperative month. A total of 14 patients were included in this study. The patients' mean age was 52.6 ± 8.8 years, and the mean cyst size was 69.1 ± 15.5 mm. Twelve (85.7%) patients presented with flank pain. Clavien-Dindo grade 1 complications were observed in two patients (14.3%), and grade 2 complications were observed in one (7.1%). The median VAS scores were significantly lower after treatment than before in patients who presented with flank pain (2 (1-2.8) vs 8 (7-8), respectively; p = 0.002). Surgical success rate was detected in 11 patients (78.6%) six months after the treatment. Endoscopic incision of the PRC is a feasible treatment modality with high success rates and low complication rates. However, multicentre studies with larger populations and longer follow-ups are needed to evaluate the lasting effects.

Imaging of Perirenal and Intrarenal Lymphatic Vessels: Anatomy-based Approach.

The lymphatic system (or lymphatics) consists of lymphoid organs and lymphatic vessels. Despite the numerous previously published studies describing conditions related to perirenal and intrarenal lymphoid organs in the radiology literature, the radiologic findings of conditions related to intrarenal and perirenal lymphatic vessels have been scarcely reported. In the renal cortex, interlobular lymphatic capillaries do not have valves; therefore, lymph can travel along the primary route toward the hilum, as well as toward the capsular lymphatic plexus. These two lymphatic pathways can be opacified by contrast medium via pyelolymphatic backflow at CT urography, which reflects urinary contrast agent leakage into perirenal lymphatic vessels via forniceal rupture. Pyelolymphatic backflow toward the renal hilum should be distinguished from urinary leakage due to urinary injury. Delayed subcapsular contrast material retention via pyelolymphatic backflow, appearing as hyperattenuating subcapsular foci on CT images, mimics other subcapsular cystic diseases. In contrast to renal parapelvic cysts originating from the renal parenchyma, renal peripelvic cysts are known to be of lymphatic origin. Congenital renal lymphangiectasia is mainly seen in children and assessed and followed up at imaging. Several lymphatic conditions, including lymphatic leakage as an early complication and acquired renal lymphangiectasia as a late complication, are sometimes identified at imaging follow-up of kidney transplant. Lymphangiographic contrast material accumulation in the renal hilar lymphatic vessels is characteristic of chylo-urinary fistula. Chyluria appears as a fat-layering fluid-fluid level in the urinary bladder or upper urinary tract. Recognition of the anatomic pathway of tumor spread via lymphatic vessels at imaging is of clinical importance for accurate management at oncologic imaging. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Novel Pathogenic Variant of Fabry Disease in a Family with Parapelvic Cysts

Background: Fabry's Disease (FD) is a rare, multi-organ lysosomal disease, caused by the deficiency of the enzyme α-galactosidase A. This leads to the accumulation of glycosphingolipids, particularly globotriaosylsphingosine (Lyso-Gb3), in visceral tissues and vascular endothelium throughout the body, with renal, cardiac, and central nervous system damage such that quality and expectancy of life are impaired. Progressive accumulation of Gb3 in podocytes, epithelial cells and the tubular cells of the distal tubule and loop of Henle contribute to the renal symptoms of Fabry disease, which manifest as proteinuria and reduced glomerular filtration rate leading to chronic kidney disease and progression to end-stage renal disease. We report the case of a patient with hypertension and proteinuria whose diagnosis of Fabry's disease was suspected due to the ultrasound finding of parapelvic cysts. Case presentation: A 41-year-old man with proteinuria and hypertension presented to our outpatient Department. The patient underwent a genetic investigation for Fabry due to the ultrasound finding of parapelvic cysts. We found a novel mutation c.160del in exon 1 of GLA gene with aminoacidic change in p. (Asp55ThrfsTer66). The new mutation was also found in the mother and his brother. In males, the elevated accumulation of LysoGB3 was associated with the presence of renal parapelvic cysts. Conclusion: This mutation is not reported in Fabry disease-associated mutation databases and has not been previously described in the literature but, the absent enzyme activity found in our patient, the significant blood accumulation of LysoGb3, as well as the type of mutation suggest its pathogenetic role. In addition, the novel mutation would appear to correlate with the occurrence of pelvic cysts in male subjects. Therefore Fabry’s disease should be suspected in male patients with hypertension, proteinuria and ultrasonographic finding of parapelvic cysts, especially in patients with otherwise unexplained cardiac, neurologic and/or ocular abnormalities. Further studies are needed to corroborate the finding.

#6036 CYSTIC KIDNEY PHENOTYPE IS A FREQUENT, AGE- AND EGFR- DEPENDENT FINDING IN ALPORT SYNDROME

Abstract Background and Aims Alport Syndrome (AS), the most common genetic glomerular disease, due to pathogenic variants in COL4A3-COL4A5 genes, includes three main forms: X-linked AS (XLAS, COL4A5); autosomal recessive (ARAS, biallelic pathogenic variants in COL4A3 or COL4A4); autosomal dominant (ADAS; heterozygous COL4A3 or COL4A4 variant). An expanded phenotypic spectrum of AS has been described, including recent reports of multiple kidney cysts in affected patients. The aim of the study was to evaluate the prevalence and characteristics of renal cysts in a cohort of adult patients with AS. Method This retrospective study included subjects with AS followed at the Outpatient Nephrogenetic Clinic of Spedali Civili di Brescia (Italy) from 2002 to 2022 and with at least one available renal imaging study (Ultrasonography/CT scan). Genetic testing was performed by using a next generation sequencing multi-gene panel for kidney disease. Cystic phenotype was defined as the presence of ≥3 cysts in each kidney. The prevalence of renal cystic phenotype was compared between patients (pts) with AS and a group of age- and eGFR-matched pts with sporadic IgA nephropathy (IgA-N). Demographic and clinical features were compared between pts with or without cystic phenotype. Logistic regression was performed to test whether sex, age, type of variant and eGFR (CKD-EPI formula) were independently associated with the cystic phenotype. Results A total of 96 AS pts were studied. The pattern of inheritance was AD in the majority of the cohort (56%), XL in 25%, AR in 2% and unknown in the remaining 17%. The cystic phenotype was observed in 36 pts (38%). When compared to a matched IgA-N cohort (n = 79), the cystic phenotype was significantly more common in AS (42% in AS; 19% in IgA-N; p = 0,002). The majority of AS pts with cystic phenotype showed normal/reduced sized kidneys and multiple cortical and/or parapelvic renal cysts. Increased total kidney volume, in keeping with primary cystic kidney disease, was observed in three patients; however, pathogenic variants in known cysto-genes were excluded. At the time of renal imaging, AS pts with cystic phenotype were older and had a more marked reduction in kidney function than their non-cystic counterparts (Table 1). When stratifying patients based on age or eGFR, the prevalence of the cystic phenotype gradually increased in parallel with older age and declining eGFR (Figure 1). Independent predictors of the cystic phenotype were age (HR 1.96 [95% CI 1.31-2.94] per 10 years; p = 0.001) and eGFR (HR 0.75 [95% CI 0.64-0.89] per 10 ml/min/1.73m2;p = 0.001). Serial longitudinal ultrasounds were available for 15 cystic pts, among whom the cystic phenotype was first observed from 40 years of age onwards, at an overall median age of 59 (IQR 46–65). Conclusion Our data show that multiple bilateral kidney cysts, with no increase in kidney size, are frequently found in AS patients. The cystic phenotype is associated with older age and eGFR decline, suggesting that it can reflect the severity and/or duration of CKD. However, the higher frequency of cystic phenotype in AS than IgAN, the role of the collagen IV α3 to α5 chains in the basement membranes in the glomerulus and distal tubule, and the occurrence of kidney cysts in a canine model of ADAS, support a possible pathogenetic link between type IV collagen mutations and cystogenesis in AS. Finding kidney cysts should not discourage from considering the diagnosis of AS, particularly in adult patients and in the presence of familial CKD. Future prospective studies will be needed to shed light on the prognostic implications of the cystic phenotype and possible genotype-phenotype associations.

Transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts: A retrospective study.

ABSTRACTBackground:We aimed to investigate the clinical efficacy and safety of transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts.Materials and Methods:Between October 2017 and April 2021, the clinical data of 65 patients with parapelvic renal cysts were evaluated retrospectively. Thirty-one patients with parapelvic cysts (Group 1) underwent a transurethral flexible ureteroscopic incision and drainage with a holmium laser, whereas the other 34 patients (Group 2) underwent retroperitoneal laparoscopic unroofing. The patients' clinical features were documented. The surgery time, intraoperative blood loss, hospitalization time, complications and cyst size were recorded and statistically assessed one year following the procedure.Results:All of the patients were successfully treated with flexible ureteroscopic incision and drainage or retroperitoneal laparoscopic unroofing. In terms of clinical parameters, such as age, gender, BMI, location, cyst size, and Bosniak classification of renal cysts, no statistically significant difference was detected between Groups 1 and 2. Compared to the control group (Group 2), Group 1 demonstrated a shorter surgery duration, less intraoperative blood loss, and a shorter hospital stay (p < 0.001). However, no significant differences in complications and cyst size were observed between the two groups one year after the surgery (p > 0.05).Conclusions:Transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts has obvious advantages over traditional surgery, and is worthy of advancement and application, but its long-term effect needs further follow-up studies.

V15 - Endoscopic treatment of parapelvic renal cysts

V15 - Endoscopic treatment of parapelvic renal cysts

Flexible ureteroscopy with ultrasound guidance for the treatment of parapelvic renal cysts: A complementary approach for locating the cystic wall

BackgroundFlexible ureteroscopic incision and drainage is a relatively new surgical method for treating parapelvic cysts. Considering that the intraoperative localization of the cyst may fail with a flexible ureteroscope, we use an innovative ultrasound-guided method to locate the cystic wall during flexible ureteroscopic surgery.MethodsWe retrospectively reviewed 17 consecutive cases of parapelvic renal cysts treated by ultrasound-guided flexible ureteroscopy between March 2017 and May 2020. The differences between the simple flexible ureteroscopic technique and ultrasound-guided flexible ureteroscopic technique were compared. The surgical procedures, postoperative complications, results and patient follow-ups were evaluated.ResultsThe cyst wall was seen clearly in 10 patients with ureteroscopic vision. Another 7 patients underwent ultrasound-guided flexible ureteroscopic surgery since it was difficult to identify the cyst wall. The mean operative time was 25.9 ± 8.7 min and 37.1 ± 10.1 min for the conventional and modified techniques, respectively (P = 0.004); the mean time to search for cysts was 17.6 ± 5.8 min and 26.5 ± 8.4 min, respectively (P = 0.002); and the mean incision time was 7.1 ± 4.9 min and 12.1 ± 5.6 min, respectively (P = 0.000). All of the patients were followed-up for 12 months, and no serious complications or recurrence were observed.ConclusionsWe demonstrated that it is feasible and safe to treat parapelvic renal cysts by ultrasound-guided flexible ureteroscopic incision and drainage. The small sample size and need for further studies were the limitations of our work.

Fabry disease related nephropathy – case family report and literature review

Introduction and aim. Fabry disease (FD) is a ultrarare storage disorder which causes irreversible damage to the brain, heart, and kidneys in young patients. The aim of our study was to draw clinician’s attention to the need of considering FD in the differential diagnosis of kidney disorders. Description of the case. We present the case of a 45-year-old man who has been misdiagnosed for several years with arterial hypertension with organ complications. He was referred to the nephrological ward due to chronic advanced kidney disease of unclear etiology. After 2 months of thorough differential diagnostics, based on the clinical course (past stroke, membranoproliferative glomerulonephritis (MPGN), left ventricular hypertrophy, paroxysmal limb pain) and conducted genetic examination, FD was confirmed. Then, screening tests were performed among the patient’s family members, confirming the presence of the same mutation as in our patient in 4 women of which in 3 were diagnosed cardio-renal syndrome. The authors of other studies report glycolipid deposits in the kidney cells on a needle biopsy, usefulness assess podocyturia, globotriaosylceramide protein in the urine and renal parapelvic cysts in an ultrasound examination in diagnostic FD nephropathy. Conclusions. This is the first case report to describe membranoproliferative glomerulonephritis in a patient suffering from FD. In patients with FD and the same genotype, kidney damage has a different phenotype.

Analysis of the effect of holmium laser flexible ureteroscopic intrapelvic drainage in the treatment of parapelvic renal cysts

ObjectiveTo explore the efficacy, safety, and feasibility of holmium laser flexible ureteroscopic intrapelvic drainage in the treatment of parapelvic renal cysts. MethodsFrom September 2012 to February 2019, a total of 18 patients, aged from 28 to 62 (mean±standard deviation [SD]: 46.50±9.14) years, were diagnosed with parapelvic renal cysts and treated by holmium laser flexible ureteroscopic intrapelvic drainage. There were 10 males and eight females. All of the parapelvic renal cysts were unilateral, and two cases were complicated with pyelolithiasis. The diameters of the cysts ranged from 4.1 cm to 8.2 cm. ResultsAll the patients completed the operation successfully in one stage without conversion to open surgery; in two cases, it was difficult to find the cysts during the operation, and the localization was completed by B-ultrasound and percutaneous injection of methylene blue. The mean operative time was 33.89 (SD: 9.68; range: 22–54) min, and the mean hospitalization time was 2.67 (SD: 0.91; range: 2–5) days. Three months and 6 months of follow-up were performed after surgery. The cysts disappeared in 13 (72%) cases, and the diameter of the cysts in five (28%) cases decreased by more than 50%. ConclusionHolmium laser flexible ureteroscopic intrapelvic drainage in the treatment of parapelvic renal cysts is simple, safe, and effective, and can be used as the first choice for the treatment of parapelvic renal cysts.

Parapelvic cyst: A rare cause of ureteropelvic junction obstruction in a pediatric patient managed with robotic cyst decortication

We report a case of a right parapelvic renal cyst causing intermittent ureteropelvic junction obstruction (UPJO). A 13-year-old male was referred for right flank pain. Stone protocol CT revealed renal pelvis dilation with punctate stones. Due to concern for intermittently obstructive calculi, he underwent ureteroscopy, which was unremarkable. A diuretic renogram showed symmetric uptake with partial emptying on the right with pain after diuretic administration. In office, we potentiated a Dietl's crisis with ultrasound obtained before and after fluid intake. Comparison of ultrasounds revealed a parapelvic cyst causing calyceal dilation. He was counseled for robotic cyst decortication and possible pyeloplasty. A robotic cyst decortication was performed. Once decorticated, the cyst base was fulgurated and pararenal fat was interposed into the cyst base. Console time was 70min with minimal blood loss. The patient was discharged post-operative day 1. Follow-up renal ultrasound at 4 months demonstrated resolution of hydronephrosis and parapelvic cyst. Parapelvic renal cysts causing intermittent UPJO is a rare entity that may be missed on a diuretic renogram. Clinical suspicion and appropriate imaging with ultrasound or magnetic resonance imaging are useful. Robotic cyst decortication is a technically feasible approach to treat this condition.

Minimally Invasive Surgeries in the Management of Renal Parapelvic Cysts: A Retrospective Comparative Study.

To compare the efficiency and safety of two minimally invasive surgeries, laparoscopy and flexible ureteroscopy (fURS), in the management of renal parapelvic cysts. Between January 2013 and April 2019, patients who suffered from parapelvic cysts and received fURS or laparoscopy at our hospital were recruited for this study. All patients underwent biopsies of the cyst wall. Primary outcome was treatment success, which was defined as symptomatic and radiological. During follow-up, telephone contact and CT scans were used to record any relevant symptoms and any recurrence, respectively. A total of 33 patients (22 in fURS; 11 in laparoscopy) were included in this study. Flank pain prior to the procedures were reported by 14/22 patients and 6/11 in fURS and laparoscopy, respectively (P = .62), and patients had complete pain relief after the operation. The complication rate was significantly lower in the fURS group than in the laparoscopy group (P = .01). Minor complications were observed in 3/22 and 5/11 patients (Grade 1 and 2) in the fURS and laparoscopy group, respectively. All patients were controlled by conservative treatment. However, 1/11 major complication (Grade 3b) was detected in the laparoscopy group and managed by ureteroscopy to remove the obstruction under general anesthesia. Significant differences were found in operative time (P = .01) and postoperative hospital stay (P = .01), while medical expenses were similar between the two groups (P = .42). During follow-up, no recurrence was detected in CT scans. In the management of parapelvic cysts, two minimally invasive surgeries were comparable in efficiency. However, fURS was superior to laparoscopic unroofing with regard to the complication rate, operative time, and postoperative hospital stay.

Ultrasonography-assisted flexible ureteroscope for the treatment of parapelvic renal cysts: A comparison between the 1470-nm diode laser and the holmium laser.

The present study aimed to compare the efficacy and safety of a flexible ureteroscopic holmium laser incision with flexible ureteroscopic 1470-nm diode laser incision for the treatment of parapelvic renal cysts. The current study collected and analysing the clinical data of 90 independent renal cysts cases retrospectively, including 43 renal cysts cases that received holmium laser surgery (holmium laser group) and 47 renal cysts cases that received 1470-nm diode laser surgery (1470-nm diode laser group). Each group was divided into a thin-walled cyst subgroup and thick-walled cyst subgroup according to cyst wall thickness. Intracapsular hematoma was significantly lower in the 1470-nm diode laser group compared with the holmium laser group (0/47 vs. 4/43; P=0.048). The incision diameter in the 1470-nm diode laser group was significantly larger than the holmium laser group in the thick-walled parapelvic renal cysts subgroup [1.70(1.50,1.90) vs. 1.30(1.25,1.70) cm; P=0.007]. The renal cystic diameter of the two groups was markedly reduced one and six months after surgery. The difference was non-significant in the diameter of the renal cyst in the thin-walled cysts subgroups between the two laser groups 6 months after surgery (1.01±0.38 vs. 1.03±0.53 cm; P=0.454). However, the diameter of the renal cyst in the thick-walled cysts subgroup treated with the 1470-nm diode laser was significantly lower compared with the thick-walled cysts subgroup treated with the holmium laser 6 months after surgery (1.21±0.57 vs. 1.88±0.94 cm; P=0.002). The results demonstrated that the use of a 1470-nm diode laser or holmium laser surgery under a flexible ureteroscope is a safe and effective treatment for parapelvic renal cysts. For thick-walled parapelvic renal cysts, the 1470-nm diode laser appears to exhibit a lower postoperative recurrence rate and better long-term postoperative effects due to its improved haemostatic effect and larger intraoperative incision diameter.

Factors Influencing Surgical Outcome in Retrograde Management of Parapelvic Renal Cysts.

Objective: To investigate the outcomes of retrograde flexible ureteroscopy in managing parapelvic renal cysts and speculate the factors affecting therapeutic efficacy. Methods: Thirty-eight patients with parapelvic renal cysts were recruited and underwent retrograde flexible ureteroscopy using holmium laser. Parapelvic cysts were divided into peripheral type and central type based on the position of cyst convex to the perirenal tissue. Feasibility and safety were retrospectively evaluated, and cases were analyzed to detect their distinctive characteristics. Independent-sample t-test and chi-square test were undertaken for continuous variables and categorical variables, respectively. Results: Radiologic evidence of success was achieved in 31 (81.58%) cases after a mean follow-up of 14.4 months (range 6-26 months). No significant perioperative complications were identified. There were seven cases with features of peripherally located parapelvic cyst. Four cysts shown as irregular protrusion were unable reduce to less half of previous size. Reductions were recorded in the other three patients with spherically peripheral protrusion. There was significant difference between these two types (p = 0.029). Among the 31 patients with centrally located parapelvic cyst, 28 of these have simple cysts that achieved radiologic success and 3 of the 31 patients were identified as failed cases indicated by renal pelvis enveloped by cyst on radiologic investigation. The success rate of simple cysts was significantly higher than that of the later type (p < 0.001). Conclusion: The location and shape of parapelvic cyst may play a critical role in the radiologic outcome of internal incision and patients with simple central or spherical peripheral cyst may benefit more from retrograde flexible ureteroscopy combined with laser incision.

The preliminary experience of methylene blue assisted laparoscopy in the treatment of renal parapelvic cysts

Renal cyst is a common disease in humans and laparoscopic renal cyst decortication is the gold standard for treatment. However, specialized surgical skills are required for the treatment of renal parapelvic cysts. In this study, we describe an improved laparoscopic method for the treatment of renal parapelvic cysts involving the use of continuous infusion of methylene blue. Sixteen patients with renal parapelvic cyst were enrolled in this study. All patients underwent retrograde ureteral catheterization, with continuous perfusion of the renal pelvis using a solution of 0.2% methylene blue and saline, during laparoscopic decortication of the parapelvic cyst. In one patient, the cyst communicated with the renal collection system which was injured, but this was immediately repaired intraoperatively. All operations were successful, and none was converted to open surgery. There were no occurrences of persistent urinary fistula, bleeding, or other complications postoperatively. All patients were followed-up for 3–24 months, and results of postoperative imaging investigations revealed that all of our patients experienced either complete recovery or a greater than 50% decrease in size of the cysts. Our study demonstrates that methylene blue-assisted laparoscopic treatment is a safe, effective and practical method for the treatment of renal parapelvic cysts.

The Clinical Efficacy and Safety of Flexible Ureteroscopic Treatment for Parapelvic Renal Cyst and Secondary Renal Stone.

To explore the efficacy and safety of flexible ureteroscopic incision and drainage and flexible ureteroscopic lithotripsy for treatment of parapelvic renal cyst combined with secondary renal stone. 28 patients with parapelvic renal cyst combined with renal stone were treated with flexible ureteroscopic incision and drainage and flexible ureteroscopic lithotripsy simultaneously from May 2010 to December 2016. The follow-up was made 1, 3, 6?12 months and 2 years after surgical treatment in our outpatient department. Ultrasonic examination and CT were used to detect the residual stone and recurrence of renal cyst. The mean age of the patients was 45.3 ± 18.6 years. The average size of the parapelvic renal cysts was 4.3 ± 1.6 cm, including 27 with Bosniak category I and 1 patient with Bosniak II renal cysts. The mean size of the renal stones was 14.3 ± 3.9 mm. The mean operative time was 53.4 ± 20.7 minutes and the mean blood loss was 10.8 ± 5.6 ml. The mean hospitalization time was 3.2 ± 0.7 days. No severe complications were encountered. The complications included transient fever ( > 38°C) in 3 patients and significant hemorrhage in 1 patient. The stone-free rates one month and three months after operation were 89.3% and 96.4%, respectively. During the 2 years follow-up, the cyst recurrence rate was 14.3% and the stone recurrence rate was 7.1%. In this study, we firstly demonstrated that it is safe and effective to treat both renal stone and parapelvic renal cyst simultaneously by flexible ureteroscopic lithotripsy and flexible ureteroscopic incision and drainage, with satisfactory stone free rate and low cyst recurrence rate.

Two cases report of treatment of renal parapelvic cysts with incision and drainage by flexible ureteroscope combined with the All-Seeing needle

Flexible ureteroscopic incision and drainage is an innovative surgical option for renal parapelvic cysts these years. Finding the thinnest part of the renal parapelvic cyst is the key point of the surgery. This paper reports two patients with renal parapelvic cysts treated with flexible ureteroscopic incision and drainage combined with All-Seeing needle. The operations were successful and had good outcomes with the two-year follow-up. Key words: Kidney disease, cystic; Peripelvic cyst; Flexible ureterscope; All-Seeing needle

Incidental findings on magnetic resonance imaging of lumbosacral spine in patients with back pain and/orradiculopathy

Background and objective: An incidental lesion is an asymptomatic lesion found while examining a patient for an unrelated reason. Lumbar spine imaging may reveal either clinically insignificant spine incidental abnormalities and/or extra-spinal Incidental finding that, at times, may even explain the patient’s symptoms. This study aimed to evaluate the frequency and types of incidental findings in lumbosacral magnetic resonance examination and to find the correlation between the frequency distribution of findings in terms of age and sex. Methods: This cross-sectional study involved 1250 persons who were referred for lumbosacral spine magnetic resonance imaging because of low back pain and/or radiculopathy. The magnetic resonance images were viewed to evaluate the frequency of incidental findings which were divided into extra and intraspinal findings. Results: Incidental findings were noted in 332 (26.6%) patients of the 1250 comprising 94 (28.3%) males and 238(71.7%) females. Some of them had more than one incidental finding. Cortical and para pelvic renal cysts were the most common extra spinal incidental findings, while vertebral hemangioma was the most common intraspinal incidental finding. Conclusion: Incidental findings were common in magnetic resonance imaging examination of the lumbar spine, and most were clinically insignificant; however some of these findings may be more significant than the spinal problems being evaluated and can have a significant impact on patient management. Therefore, they should be included in the reports since they will give additional and valuable information.

Methylene Blue Injection via Percutaneous Renal Cyst Puncture Used in Flexible Ureteroscope for Treatment of Parapelvic Cysts: A Modified Method for Easily Locating Cystic Wall

ObjectiveTo describe a modified technique for easily locating cystic wall during flexible ureteroscopic surgery for treatment of parapelvic renal cysts. MethodsNineteen patients with symptomatic/asymptomatic parapelvic renal cyst were treated with modified or conventional flexible ureteroscopic surgery between February 2015 and March 2017, and the differences of the 2 techniques were compared. The detailed surgical procedures and results, postoperative complications, and patients’ follow-ups were evaluated. ResultsAll the patients received endoscopic management by flexible ureteroscope successfully, without requiring another complicated surgery. The cysts were seen clearly in 9 patients with modified method. Two of ten patients who underwent conventional ureteroscopic surgery changed to the modified surgery intra-operatively since it was difficult to identify the cyst. The total time of search and incision of cysts was 24.2 ± 6.2 minutes and 17.7 ± 2.5 minutes for conventional and modified technique respectively (P = .01), of which 11.4 ± 4.8 minutes and 5.1 ± 1.1 minutes to search the cysts, respectively (P = .002), and the mean time of the procedure of puncture was 8 ± 2.3 minutes. Duration of pure incising the cystic wall was 12.8 ± 3.3 minutes and 12.6 ± 2.5 minutes for patients who underwent conventional and modified technique, respectively (P = .859). All patients acquired relief from the presentation of flank discomfort after surgery. All of the patients were followed-up over 12 months and no serious complications and recurrence was observed. ConclusionThe modified technique can decrease time of searching the renal cyst and decrease the total time in flexible ureteroscopic treatment of parapelvic cysts. The limitations of our study were also observed and further studies are needed.

Variable phenotypic presentations of renal involvement in Fabry disease: a case series

Fabry disease is an X-linked genetic deficiency in the alpha-galactosidase enzyme resulting in intracellular accumulation of glycosphingolipids and multisystem organ dysfunction. Typically 50% of males and 20% of affected females have renal involvement, ranging from proteinuria or reduced renal function, renal parapelvic cysts and progressive renal disease ultimately requiring transplantation or dialysis. The phenotypic presentation of Fabry disease is incredibly varied and will even vary between family members with the same confirmed genetic mutation. In a cohort of patients affected by Fabry disease in the North East of England we examine the different phenotypic presentations of eight index cases (6 male, 2 female) with predominantly renal disease and the renal manifestations within their family members. The mean age of presentation was 40 years of age (range 23-59 years). Various multisystem manifestations were observed including cardiac, neurological, cerebrovascular and skin involvement. Two of the male index patients reached end stage renal disease (ESRD) requiring renal replacement therapy. Two female index patients had phenotypes limited to hypertension and proteinuria at presentation and the remaining patients had either stable or progressive chronic kidney disease at the time of diagnosis. We demonstrate the need for a high index of suspicion in order to consider Fabry disease as a diagnosis and the importance of cascade genetic screening to identify affected family members so that treatment can be initiated in a timely fashion.

Non-conservative management of simple renal cysts in adults: a comprehensive review of literature.

Renal cysts are common findings in nearly 10% of general population. According to Bosniak classification, they are classified into simple and complex renal cysts based on their CT characteristics. The majority of simple renal cysts are asymptomatic and require no intervention. Once they become symptomatic or complicated, a non-conservative management should be considered. This paper is a narrative review of existing manuscripts regarding the non-conservative management of renal cysts. To perform it a search through PubMed was carried out in January 2017. The search was conducted using the following key words: "simple renal cysts," "non-conservative management," "treatment outcomes comparison" etc. EVIDENCE SYNTHESIS: We found 1880 publications that were reviewed by 2 of our authors, and only 46 manuscripts were considered for this review. The most common treatment were investigated and compared to understand the best treatment modality in accordance with patients' and cysts' characteristics. Different treatment modalities are available for the management of simple renal cysts. Surgical exploration is a historical procedure that is no longer used. Simple aspiration without sclerotherapy has high recurrence rate (20-80%), so sclerosants agents are recommended. Ethanol is the most commonly used sclerosing agent with high efficacy up to 97%. Laparoscopy is the gold standard for management in large cysts especially in younger patients. Other techniques are described for parapelvic renal cysts like percutaneous endoscopic ablation and ureteroscopic marsupialization. Different factors affect the treatment decision including natural history of the cyst, presence of symptoms and/or complications and patients' choice. This literature overview shows that ethanol percutaneous sclerotherapy and laparoscopy are the most commonly reported treatment modality for simple renal cysts.