Perinephric Hematoma Research Articles

Radiofrequency ablation of renal cell carcinoma in patients with a solitary kidney: a retrospective analysis of our experience

This study was done to evaluate the feasibility and safety of radiofrequency ablation (RFA) of renal cell carcinomas (RCCs) in patients with solitary kidney. Seven patients (two men, five women; age range 52-70 years; mean age 59.7 years) were treated under computed tomography (CT) and ultrasound (US) guidance. Three patients had single lesions, and the remaining four had multiple lesions. Seventeen lesions (4 cortical, 13 exophytic, maximum diameter range 12-40 mm, mean 21.0 mm) not located close to the renal pelvis were treated. CT or magnetic resonance (MR) imaging follow-up studies were obtained for all patients at the end of the procedure and at 1, 3, 6 and 12 months; serum creatinine was also monitored. Ten ablation sessions were performed. In two patients, a perinephric haematoma was detected, and one of these patients had two episodes of self-limiting haematuria. Contrast-enhanced CT and MR imaging at the end of the procedure and at 1 month demonstrated 100% technical success; these results were confirmed at 3, 6 and 12 month. Fisher's test comparing serum creatinine obtained 1 day before and 1 day after the procedure showed no case of acute renal failure (mean serum creatinine 24 h before the procedure 1.02 mg/dl; mean serum creatinine 24 h after the procedure 0.95 mg/dl; p=0.114; not significant). Serum creatinine at follow-up was always within the normal range. Radiofrequency ablation in the solitary kidney is a safe and effective procedure for treating RCC.

Index of Suspicion * Case 1: Abdominal Trauma, Pain, and Tenderness Associated With Anemia and Hematuria in a 14-year-old Boy * Case 2: Ptosis, Diplopia, Tremors, and Mild Exophthalmos in a 9-year-old Girl * Case 3: Persistent Cough, Shortness of Breath, and Localized Decreased Aeration in an 18-year-old Girl

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell A 14-year-old boy is transferred from a local hospital. He was playing football and was struck in the abdomen by the head of another player who was wearing a helmet. He then fell on his abdomen. He immediately complained of left upper quadrant pain, and nausea. He was taken to a local ED and hospitalized. On admission, he was alert and oriented but experienced episodic hypotension. On examination, he looked pale and was found to have significant left upper quadrant abdominal tenderness. His initial Hct was 37%. Abdominal CT showed a 12×10×11 cm lobular enhancing mass over the left kidney, with questionable involvement of the colon and perinephric hematoma (Fig. 1). There was no free air. He was transfused with 1 unit of packed red blood cells and received 1 L of normal saline. His pain was controlled with morphine and he was transported to this institution. Figure 1. A CT scan of the abdomen shows a lobular enhancing mass over the left kidney. On arrival, he appears to be well developed and is in no acute distress, having a heart rate of 86 beats/min, respiratory rate of 20 breaths/min, blood pressure of 120/84 mm Hg, and oxygen saturation of 100% in room air. His abdomen is nondistended and has normal bowel sounds. However, he has left upper quadrant and left flank tenderness. Laboratory evaluations show Hct of 31.6%, normal coagulation studies and liver enzymes, lactose dehydrogenase concentration of 258 U/L (normal, 150 to 300 U/L), and urinalysis positive for blood and protein. Chest radiograph shows normal heart and lung fields. Additional investigation leads to the diagnosis. A 9-year-old girl presents with a 4-week history of a drooping right eyelid and occasional double vision. She does not complain of easy fatigability, and she is able to ride her bike long distances without …

Hyperreninemic hypertension following presumed abdominal trauma

An 18-year-old previously normotensive man was referred to a hypertension unit with blood pressure readings of 140-150/100-110 mmHg. Renal ultrasound had shown a right renal subcapsular fluid collection and an abdominal computed tomography scan had revealed a large cystic lesion surrounding the right kidney with a thick wall and irregular peripheral calcification consistent with a long-standing traumatic perinephric hematoma. Physical examination, renal artery duplex ultrasonography, magnetic resonance imaging of the abdomen, isotopic renography with technetium-99m diethylenetriamine pentaacetic acid, and a renal venous renin ratio study. Hyperreninemic hypertension as a result of presumed abdominal trauma. Removal of the affected kidney.

Wunderlich's Syndrome in a Tuberous Sclerosis Patient

Spontaneous non-traumatic renal hemorrhage known as Wunderlich's syndrome is known to occur in renal angiomyolipoma and may be the first manifestation of the disease. Angiomyolipomas in tuberous sclerosis are usually bilateral and multicentric. A 25yr old female, a case of Tuberous sclerosis with bilateral renal angiomyolipomas presented with right loin pain of increasing severity. On evaluation she had acute abdomen with increasing abdominal distension. Investigations revealed large right perinephric hematoma with bilateral renal angiomyolipomas. Exploratory laparotomy and right nephrectomy was done. Spontaneous hemorrhage in renal angiomyolipoma in a case of tuberous sclerosis and management are discussed. The online version of this article (doi:10.1007/s12262-010-0231-0) contains supplementary material, which is available to authorized users.

Multicenter Analysis of Postoperative CT Findings After Percutaneous Nephrolithotomy: Defining Complication Rates

To perform a multi-institutional study to characterize CT-detected complications after PNL. Computed tomography (CT) is commonly performed after percutaneous nephrolithotomy (PNL). One benefit of this imaging modality is the detection of procedure-related complications. Presently, the incidence of such complications is not well-defined. PNL procedures performed at 5 stone referral centers between July 2007 and June 2008 were reviewed. All patients undergoing CT within 24 hours after surgery were selected for further analysis. All CT studies were reviewed by a staff radiologist. One-hundred ninety-seven patients satisfied the study inclusion criteria. A body mass index >30 was present in 27.5% of patients. Treated stone burden was staghorn in 70 (35.5%), >2 cm in 72 (36.5%), and <2 cm in 55 (28%). Six treated renal units (3%) were ectopic; 45.4% of calculi were predominantly lower pole. Thoracic complications encountered were atelectasis in 88 (44.7%), pleural effusion in 17 (8.6%), pneumothorax in 3 (1.5%), hemothorax in 2 (1%), and hydrothorax in 1 (0.5%). Renal complications were perinephric hematoma in 15 (7.6%), collecting system perforation in 4 (2%), subcapsular hematoma in 3 (1.5%), urinoma in 2 (1%), and pseudoaneurysm in 1 (0.5%). There was 1 trans-splenic nephrostomy without splenic hematoma. No injuries to hollow viscera were detected. Two patients (1%) were found to have ascites. Major post-PNL complications detected by CT are uncommon, and when encountered, they are generally amenable to conservative management.

就寝中の咳嗽を契機に移植腎破裂を起こした1例

Renal allograft rupture (RAR) is a rare but serious complication of renal transplantation. The most common cause of RAR is acute rejection but other causes have increased in frequency with advances in immunosuppressive therapy. We report a patient with RAR attributed to coughing while asleep. A 53-year-old male received a living-donor renal transplantation for end-stage renal failure due to diabetic nephropathy. The clinical course was satisfactory, and he was discharged on the 12th postoperative day with a serum creatinine level of 1.24 mg/dl. On the 24th morning, he felt sudden swelling and pain over the incision area soon after a big cough. Ultrasound and computed tomography revealed a perinephric hematoma. Emergency surgical exploration showed complete laceration of the abdominal fascia and 4-cm rupture at the anterolateral aspect of the kidney. High intra-abdominal pressure when coughing had torn the fascia, and the graft appeared to have ruptured under the fascial tension. Bleeding was controlled with a polyglactin 910 2/0 mattress parenchymal suture enforced with application of a fibrin tissue-adhesive collagen fleece. Twelve months after the repair, the patient's renal function was stable with a serum creatinine level of 1.3 mg/dl.

Does Systematic Preliminar Colour Doppler Study Reduce Kidney Biopsy Complication Incidence?

While ultrasonography is widely performed prior to biopsy, colour Doppler examination is often used only to discover post-biopsy complications. Aim of this paper was to evaluate the usefulness of colour Doppler examination in planning the optimal site of puncture for renal biopsy. Present analysis includes 561 consecutive percutaneous renal biopsies performed from the same operator. Until August 2000 332 biopsies were performed after a preliminary ultrasonography (Group A). From September 2000, 229 patients underwent even a preliminary colour Doppler study (Group B). Postbioptic bleeding were categorized as minor (gross hematuria or subcapsular perinephric hematoma < 4 cmq of greater diameter) or major (hematoma >4 cmq of greater diameter; requiring blood transfusion or invasive procedures; leading to acute renal failure, urine tract obstruction, septicaemia, or death). Major complications were seen in 2.1% in Group A while in Group B only one case was reported (0.43%). Minor clinically significant complications occur in 7.8% in Group A and in 3.4% of cases of Group B. Colour Doppler reduced drastically the incidence of complications observed before the introduction of routine colour Doppler examination prior to biopsy. In our opinion, these data support the use of preliminary colour Doppler study when a biopsy is planned.

A single-center experience of preemptive anticoagulation for patients with risk factors for allograft thrombosis in renal transplantation

to review our single-center experience of preemptive anticoagulation for the prevention of allograft thrombosis in patients with hypercoagulable states. this is a retrospective cohort study. Included subjects were first-time kidney allograft recipients transplanted between 2003 and 2007 at a single center, with hypercoagulable states: prior venous thromboembolism, multiple vascular access thromboses, or identifiable thrombophilia. The predictor variable was preemptive anticoagulation and outcome variable was allograft thrombosis. Other risk factors for allograft thrombosis, characteristics of transplantation, and hemorrhagic complications were also examined. among this high-risk cohort (n = 48), 16 received preemptive anticoagulation and 32 did not. The anticoagulated group included significantly more subjects with identifiable thrombophilia (50.0% vs. 0%; p < 0.001). One subject (6.3%) in the anticoagulated group and 6 (18.8%) without anticoagulation developed allograft thrombosis (p = 0.40). A perinephric hematoma was observed in 5 (31.3%) and 2 (6.3%) with and without anticoagulation, respectively (p = 0.03). preemptive anticoagulation was associated with a non-significant trend towards decreased allograft thrombosis. It may be associated with increased risk of hemorrhage and should be considered cautiously in high-risk patients.

Perinephric Capsular Haematoma Associated with Complicated Pyelonephritis in a Patient with HIV.

A 53 year-old-male patient presented with 24 hours of left flank pain. He was an undiagnosed HIV positive individual with no history of trauma. He was anaemic and in acute renal failure with a serum creatinine of 4.14 mg/dL. A CT scan demonstrated a left perinephric capsular haematoma with retroperitoneal stranding. Due to haemodynamic instability, the patient was taken to the operating room and a nephrectomy was performed. Post-operatively, the patient required temporary haemodialysis. Pathologic examination of the specimen demonstrated active infection with a haematoma surrounding a fistulous tract communicating with the capsular surface. Infection is a rare cause of non-traumatic capsular hematomas of the kidney.

Perinephric hematoma: semi-automated quantification of volume on MDCT: a feasibility study

To evaluate feasibility and reproducibility of quantification of perinephric hematoma volume on multidetector-row CT (MDCT). Perinephric hematomas in 63 patients (42 males, 21 females, median age: 49 years) imaged with contrast-enhanced MDCT of the abdomen were evaluated. A semi-automated segmentation software was applied to quantify hematoma volume. Reproducibility for quantification of hematoma volume was evaluated by repeated measurements in 20 patients. Statistical analyses were performed by using Student's t test. Interobserver and intraobserver variability was evaluated by Bland-Altman plots. P < 0.05 denoted statistical significance Quantification of hematoma volume was feasible in all cases. One step, direct quantification of volume was possible in 21 patients (33.33%) with small hematomas that did not reach upper and lower renal poles (range: 3.12-183.98 mL; mean: 39.92 mL). Quantification of hematoma size was performed indirectly in 42 patients (66.67%) with larger hematomas that extended beyond the renal poles by subtracting the ipsilateral renal volume from the combined kidney and hematoma volumes (range: 27.08-2431.3 mL; mean: 435.31 mL). Mean quantification time was 45 and 71 s for small and large hematomas, respectively (P < 0.05). Mean intraobserver and interobserver variability for determination of hematoma volume was 0.14% (95% CI, -1.57% to 1.85%) and 2.04% (95% CI, -1.77% to 5.85%), respectively. There was no significant difference in renal volume between ipsilateral and contralateral kidneys (P > 0.05). Quantification of perinephric hematoma was feasible from MDCT data in all patients and was reproducible.

Complications of renal cryoablation: a single center experience

J Urol. 2010; 184: 42-7Purpose: We describe perioperative complications associated with renal cryoablation and identify potential risk factors for certain complications.Materials and Methods: We retrospectively analyzed the medical records of patients with unifocal renal masses treated with cryosurgery at a single center between 1997 and 2007. All complications associated with these procedures were documented and classified into grades 1 to 5 by the Clavien surgical complication classifica-tion. In-depth analysis was done to identify potential risk factors for the most common complications.Results: We evaluated 101 percutaneous, 52 laparoscopic and 9 open procedures. Complications were noted in 38 procedures (23.5%), including grades 1 to 4 in 19 (11.7%), 8 (4.9%), 5 (3.1%) and 6 (3.7%), respectively, as the severest complication. The most common complication was flank pain (11 procedures), followed by perinephric hematoma and cardiovascular complications (10 each). Mass size (p = 0.001), number of cryoab-lation probes (p <0.001) and chronic anticoagulation (p <0.05) were associated with an increased incidence of significant hematoma. Cardiovascular complications were more common when upper pole lesions were treated, and when an open approach was used (each p <0.05). Respiratory complications occurred in 7 procedures and were associated with patient age (p <0.05) and mass size (p <0.01). Conclusions: Cryoablation is a relatively safe procedure with a low complications rate in properly selected pa-tients. We identified potential risk factors that may help identify patients most at risk for certain complications and consequently assist in preprocedural planning and counseling.

Complications of Renal Cryoablation: A Single Center Experience

We describe perioperative complications associated with renal cryoablation and identify potential risk factors for certain complications. We retrospectively analyzed the medical records of patients with unifocal renal masses treated with cryosurgery at a single center between 1997 and 2007. All complications associated with these procedures were documented and classified into grades 1 to 5 by the Clavien surgical complication classification. In-depth analysis was done to identify potential risk factors for the most common complications. We evaluated 101 percutaneous, 52 laparoscopic and 9 open procedures. Complications were noted in 38 procedures (23.5%), including grades 1 to 4 in 19 (11.7%), 8 (4.9%), 5 (3.1%) and 6 (3.7%), respectively, as the severest complication. The most common complication was flank pain (11 procedures), followed by perinephric hematoma and cardiovascular complications (10 each). Mass size (p = 0.001), number of cryoablation probes (p <0.001) and chronic anticoagulation (p <0.05) were associated with an increased incidence of significant hematoma. Cardiovascular complications were more common when upper pole lesions were treated, and when an open approach was used (each p <0.05). Respiratory complications occurred in 7 procedures and were associated with patient age (p <0.05) and mass size (p <0.01). Cryoablation is a relatively safe procedure with a low complications rate in properly selected patients. We identified potential risk factors that may help identify patients most at risk for certain complications and consequently assist in preprocedural planning and counseling.

Emergency ultrasound diagnosis of a ruptured angiomyolipoma causing acute anemia

Abstract A 32-year-old female presented with acute, asymptomatic anemia. While vital signs and physical examination were stable and non-diagnostic, utilizing goal-directed bedside ultrasound, a perinephric hematoma consistent with a ruptured angiomyolipoma was discovered as the cause of the patient’s condition.

1479 COMPLICATIONS OF RENAL CRYOABLATION: A SINGLE CENTER EXPERIENCE

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 20101479 COMPLICATIONS OF RENAL CRYOABLATION: A SINGLE CENTER EXPERIENCE Abhinav Sidana, Piyush Aggarwal, Wasim H. Chowdhury, Zhaoyong Feng, Christos S. Georgiades, Bruce J. Trock, and Ronald Rodriguez Abhinav SidanaAbhinav Sidana More articles by this author , Piyush AggarwalPiyush Aggarwal More articles by this author , Wasim H. ChowdhuryWasim H. Chowdhury More articles by this author , Zhaoyong FengZhaoyong Feng More articles by this author , Christos S. GeorgiadesChristos S. Georgiades More articles by this author , Bruce J. TrockBruce J. Trock More articles by this author , and Ronald RodriguezRonald Rodriguez More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1195AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cryoablation serves as a promising nephron-sparing alternative to partial nephrectomy for treatment of small renal masses.We hereby describe peri-operative complications associated with renal cryoablation and identify potential risk factors for certain complications. METHODS Retrospective analysis of the medical records of patients with unifocal renal masses treated by cryosurgery at a single center, between 1997 and 2007, was conducted. All complications associated with these procedures were documented and classified into grades 1 to 5 according to Clavien Classification of Surgical complications. An in-depth analysis was done to identify potential risk factors. RESULTS 162 (101 percutaneous, 52 laparoscopic and 9 open) procedures were evaluated. Complications were reported in 38 (23.5%) procedures, out of which 19 (11.7%) had only Grade 1, 8 (4.9%) had Grade 2, 5 (3.1%) had grade 3, and 6 (3.7%) had Grade 4 as the most severe complication. The most common complication was flank pain seen in 11 procedures, followed by perinephric hematoma and cardiovascular complications seen in 10 procedures each. Mass size (OR=3.52, 95%CI 1.69-7.36, p=0.001), number of probes used for cryoablation (OR=3.98, 95%CI 1.94-8.18, p<0.001) and chronic-anticoagulation (OR= 5.29, 95%CI 1.36-20.67, p=0.016) were associated with increased incidence of significant hematoma. In multivariable logistic regression, the total number of probes was the only significant predictor for hematoma occurrence (p<0.001). To determine a potential binary cut-off for mass size or number of probes as predictors of hematoma we performed Receiver operator characteristic analysis. The risk for bleeding is maximum for mass size greater than 3. 4 cm or when 3 or more probes are used simultaneously for cryoablation. Multivariable analyses of cardiovascular complications revealed that, both the open approach (OR=7.15, 95% CI 1.12-45.55, p=0.037) and lesion location in the upper pole (OR=5.62, 95% CI 1.36-23.18, p<0.017) were significant predictors of cardiac complications. Respiratory complications occurred in 7 (4.3%) of the patients. Patients with respiratory complications had significantly higher mean age (77.9 (8.8) vs 67.7 (11.9), p=0.025) and mean mass size (3.5 (1.4) vs 2.3 (0.9), p=0.014). CONCLUSIONS Cryoablation is a relatively safe procedure with low complications rates in properly selected patients. Here we identify potential risk factors which may help identify patients most at risk for certain complications and consequently assist in pre-procedural planning and counseling. Baltimore, MD© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e570 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Abhinav Sidana More articles by this author Piyush Aggarwal More articles by this author Wasim H. Chowdhury More articles by this author Zhaoyong Feng More articles by this author Christos S. Georgiades More articles by this author Bruce J. Trock More articles by this author Ronald Rodriguez More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

510 CT GUIDED PERCUTANEOUS CORE-BIOPSY OF RENAL MASSES: SHORT-TERM COMPLICATIONS, A PROSPECTIVE STUDY

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging I1 Apr 2010510 CT GUIDED PERCUTANEOUS CORE-BIOPSY OF RENAL MASSES: SHORT-TERM COMPLICATIONS, A PROSPECTIVE STUDY Erez Lang, Laurian Copel, Nadav Berkovitz, Judith Sandbank, Paul Gotlieb, Dan Leibovici, Arie Lindner, and Amnon Zisman Erez LangErez Lang More articles by this author , Laurian CopelLaurian Copel More articles by this author , Nadav BerkovitzNadav Berkovitz More articles by this author , Judith SandbankJudith Sandbank More articles by this author , Paul GotliebPaul Gotlieb More articles by this author , Dan LeiboviciDan Leibovici More articles by this author , Arie LindnerArie Lindner More articles by this author , and Amnon ZismanAmnon Zisman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.586AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine the short-term complications of CT-guided percutaneous core-biopsy of renal masses METHODS This is a prospective ongoing study from 01/07. An average of 2.5±0.9 cores (range 1-4) were obtained with an automatic 18G core-biopsy needle. Categorized measures of largest mass diameter (<4cm, 4-7cm, >7cm) were used for the analysis of complications RESULTS Fifty-two patients,31 males (60%), average age 67 range (34-86) underwent renal biopsies. Twenty-one (40%) were without complications. Twenty-nine (56%) patients developed clinically insignificant local hematoma: Fourteen (27%) were directly discharged and fifteen (29%) were hospitalized (<48hr). Two (4%) patients developed pneumothorax, one of whom required chest-tube drainage. All patients were hemodynamically stable. No patient required blood transfusion, angiography or surgery. There were no case fatalities. The risk of perinephric hematoma increased with the number of cores from 1 to 3 (complication free rate: 67%, 29% and 29% respectively). Four cores were generally taken from larger lesions, mostly carried out without complications (80%). Although the average number of cores increase with size from 2.1 (<4cm) to 2.5 (4-7cm) to 3.1(> 7cm), complication-rate decreased from 68% to 56% to 45%, respectively CONCLUSIONS The most prevalent short-term complication post CT-guided percutaneous renal core-biopsy is clinically insignificant local hematoma. Only one patient (1.9%) needed minor surgical intervention (chest tube). Hematoma rate rises with number of cores and is inversely associated with lesion size Tel Aviv, Israel© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e201 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Erez Lang More articles by this author Laurian Copel More articles by this author Nadav Berkovitz More articles by this author Judith Sandbank More articles by this author Paul Gotlieb More articles by this author Dan Leibovici More articles by this author Arie Lindner More articles by this author Amnon Zisman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Truly tubeless percutaneous nephrolithotomy

The technique of percutaneous nephrolithotomy (PCNL) has been steadily refined since its development in the 1970s. As the procedure has evolved, avoiding the potential morbidity of a large bore nephrostomy tube has led to the search for alternatives to drain the kidney. These have included a smaller bore nephrostomy, externalised ureteric catheter, or internal ureteric stent. Desai and colleagues1 compared uncomplicated PCNLs randomised to have a small 9-Fr nephrostomy versus a conventional 20-Fr tube versus a JJ stent. The group with a smaller tube had reduced analgesic requirements and hospital stay, without additional complications, and the stented group had the lowest analgesic requirement and shortest hospital stay. However, this approach does induce stent-related morbidity which is variable in nature but sometimes significantly affects the patient's quality of life and requires a separate procedure for removal.1 In a recent series of 170 patients in whom a stent was placed post PCNL, five required a postoperative emergency nephrostomy insertion for obstruction.2 In the series of Yates et al.,3 immediate and early complication rates were higher in the stented group including haematuria requiring re-admission, clot colic, stent pain and stent migration. They also described a delayed presentation of perinephric haematoma and abscess formation.3 True tubeless PCNL has been evaluated by Crook and colleagues4,5 and found to be safe and well-tolerated. No differences were seen in stone free rates, transfusion, and complication or re-admission rates. Mean length of stay was shorter in the tubeless group (2.3 days vs 3.4 days).4,5 Yates and colleagues advocate that a nephrostomy-free PCNL should be adopted as the standard for patients requiring PCNL in the UK. We would argue that this exposes patients to an increased risk of complication, as demonstrated by their study. Instead, patients should be treated as individuals. If postoperative bleeding or retained calculi are a possibility requiring a ‘second-look’, then a nephrostomy should be sited to provide access or a tamponade effect. The use of a ureteric stent or catheter provides neither of these. They should otherwise be left truly tubeless. By stenting every patient, are the authors' treating the patient or themselves?

Should ultrasound guided percutaneous renal biopsy in children be done in a day care setting?

Percutaneous renal biopsy (PRB) is an important diagnostic tool in pediatric nephrology units. But controversy exists whether the procedure can be done in the day care setting. This study was done to document complications of PRB done with automated gun under continuous ultrasonographic guidance and to find whether the procedure can be undertaken as a day care procedure. Retrospective analysis of 67 PRBs is presented. A total of 44% (n = 30) minor and 12% (n = 8) major complications such as gross hematuria, perinephric hematoma, and hemodynamic instability were observed through the study period. All major and 90% of minor complications were detected within four hours in the current study. The procedure may be undertaken in the day care setting with strict pre and postprocedure monitoring up to eight hours in children with normal blood pressures, renal functions, hemoglobin concentrations, and coagulation parameters.

Acute Renal Failure and Severe Hypertension from a Page Kidney Post-Transplant Biopsy

Page kidney refers to a clinical picture characterized by acute onset of hypertension due to external compression of the kidneys from hematoma, tumor, lymphocele, or urinoma. Hypertension is believed to result from renin-angiotensin-aldosterone activation triggered by renal hypoperfusion and microvascular ischemia. Renal failure, in addition to hypertension, may occur in the setting of a single functional kidney or a diseased contralateral kidney. We report a case of a patient who had a transplant kidney biopsy complicated by a subcapsular perinephric hematoma. The patient presented with an acute increase in blood pressure and a rapid rise in serum creatinine following a transplant kidney routine biopsy. He underwent emergent evacuation of the perinephric hematoma, with consequent decrease of his blood pressure and return of serum creatinine back to his baseline level. Early recognition and rapid intervention are needed in order to correct hypertension and reverse acute renal failure in Page kidney occurring in renal transplant recipients.

How long is strict bed rest necessary after renal biopsy?

No consensus exists on the amount of bed rest required after renal biopsy. Moreover, forced prolonged bed rest can be uncomfortable in patients undergoing renal biopsy. To evaluate whether the length of strict bed rest affects the incidence of pain and other complications after renal biopsy. STUDY DESIGN, FACILITY, AND PATIENTS: This single-center retrospective observational study was conducted in 94 consecutive patients undergoing biopsy of a native kidney between November 2005 and December 2006 at Mie University Hospital. The control group was composed of 317 patients who underwent biopsy of a native kidney between January 2001 and October 2005. The incidence of biopsy-related complications was compared between two periods of strict bed rest: 2 h of strict bed rest with no abdominal bandage (November 2005 to December 2006) and 7 h of strict bed rest with an abdominal bandage (January 2001 to October 2005). The primary outcome was the incidence of back pain requiring analgesics. The secondary outcomes were: need for transfusion or hemostatic intervention, decrease of >/=10% in hemoglobin (Hb) after biopsy, macroscopic hematuria, infection possibly related to biopsy, need for single or indwelling bladder catheterization, and other biopsy-related complications. The incidence of back pain requiring analgesics decreased with a shorter period of strict bed rest [7.5% versus 21.1%, odds ratio (OR) 0.30, 95% confidence interval (95% CI) 0.12-0.64, p = 0.004]. Even after adjustment for age, sex, perinephric hematoma size, and number of biopsy punctures, the incidence of back pain decreased significantly (OR 0.34, 95% CI 0.14-0.73, p = 0.01). With a shorter period of strict bed rest, there were no significant differences in bleeding complications (need for transfusion or other hemostatic intervention), decrease of >or=10% in Hb or macroscopic hematuria. However, the need for indwelling bladder catheterization decreased significantly (36.2% versus 50.5%, OR 0.55, 95% CI 0.34-0.88, p = 0.013). Shortening the period of strict bed rest after renal biopsy from 7 h to 2 h decreased the incidence of back pain, but there was no increase in bleeding or other biopsy-related complications. Our findings suggest that a shorter period of strict bed rest can safely reduce discomfort in renal biopsy patients.

Shock Wave Lithotripsy: A Randomized, Double-blind Trial to Compare Immediate Versus Delayed Voltage Escalation

To present a randomized trial investigating immediate vs delayed voltage escalation during shock wave lithotripsy (SWL). SWL efficiency is affected by the energy setting of the lithotripter, the consumption level of the electrode, and the rate of shock wave administration. Preliminary data have suggested that delaying voltage escalation for SWL might both improve fragmentation and minimize renal injury. A total of 160 patients with previously untreated radiopaque renal calculi were randomized to undergo immediate vs delayed voltage escalation SWL. Success was defined as an asymptomatic patient who was stone free or had adequate fragmentation (sand or fragments < or = 4 mm) at 3 months after treatment. Of the 160 patients, 83 were treated with immediate voltage escalation SWL and 77 patients with delayed escalation. The groups were similar in sex, body mass index, stone area, and stone location. The overall success rate at 3 months was 72.5% for immediate vs 54.5% for delayed SWL (P = .021). After adjusting for body mass index, sex, and stone location, the stone area decreased more rapidly in patients treated with immediate voltage escalation (P = .002). A trend was also seen for immediate voltage escalation to be more effective in the treatment of smaller calculi with a cross-sectional area of < 100 mm(2) (P = .089) compared with calculi with a cross-sectional area of > or = 100 mm(2) (P = .248). No differences were seen in the complications or ancillary procedures between the 2 treatments (P = .667 and P = .355, respectively). No perinephric hematomas were observed in either group. These results suggest that delayed voltage escalation might not provide superior stone fragmentation compared with conventional, immediate voltage escalation.