Perivesical Space Research Articles

Multifaceted Approach in Diagnosing and Managing Pelvic and Hip Echinococcosis: A Case Report

Echinococcosis, a zoonotic disease caused by Echinococcus granulosus or Echinococcus multilocularis, forms hydatid cysts in various organs, occasionally affecting the skeletal system. The present case study delves into a rare instance of pelvic and hip echinococcosis, underscoring the diagnostic and treatment challenges posed by such atypical manifestations. Hereby, the authors present a case of 42-year-old male, who presented with persistent lower back pain for four months. A combination of haematological tests, radiographic imaging and histopathological examination was employed to diagnose echinococcosis. Imaging techniques included X-rays, ultrasound, Non Contrast Computed Tomography (NCCT) and Magnetic Resonance Imaging (MRI), which revealed multiple cystic lesions with characteristics indicative of hydatid disease. Normal haematological tests showed no acute inflammation or infection. Radiographs displayed several expansile lytic lesions in the pelvis and femur, with double-walled cystic formations and interior septations being crucial for diagnosis. MRI showed the largest cyst in the perivesical space. Histopathology revealed laminated hydatid cyst walls and reactive alterations without cellular atypia. Echinococcosis should be considered when diagnosing cystic skeletal lesions, especially in endemic areas. This challenging condition requires a multidisciplinary strategy that integrates radiographic, serological and surgical methods, emphasising the need for increased awareness and diagnostic precision in atypical presentations of echinococcosis.

Abdominal CT findings in Puumala hantavirus-infected patients.

Previous clinical studies have reported abdominal findings on ultrasonography or MRI in Puumala hantavirus-infected patients. To determine if abdominal computed tomography (CT) can lead to a diagnosis of Puumala virus infection in the presence of a suggestive clinical picture. CT findings were studied retrospectively in 30 patients who presented to the emergency department of two (Belgian) hospitals with serologically confirmed Puumala hantavirus infection. The most frequent finding was perirenal fascial thickening (90%), followed by perirenal fat stranding (87%). Retroperitoneal fat stranding was found in 19 patients (64%) in the perivesical spaces along the fascia of the external iliac vessels with or without involvement of the presacral fat. Half of the patients had pelvic ascites, and pleural fluid was found in 7 of them. The right and left mean pole-to-pole kidney's lengths were respectively 125.7mm and 127.8mm in 28 patients. Retroperitoneal fat stranding, perirenal fascial thickening and/or perirenal fat stranding were found in most patients with acute Puumala virus infection who have undergone CT. Although nonspecific, these findings may help to suggest Puumala hantavirus infection in the right clinical settings.

High rising flames: a sign of complex extraperitoneal bladder rupture.

Extraperitoneal bladder rupture is the most common type of bladder injury following pelvic trauma and is seen in 80-90% of cases. Generally, the contrast extravasation seen on computed tomography (CT) cystography is confined to the perivesical space, giving a characteristic flame-shaped appearance. Occasionally contrast extravasation can extend to the scrotum, thigh or anterior abdominal wall, depending on the extent of injury. Here we report an unusual CT cystogram finding of complex extraperitoneal bladder rupture with associated pelvic fracture urethral distraction defect, showing large-volume contrast extravasation extending beyond the perivesical space to the left perinephric region resembling high rising flames.

Laparoscopic Excision of an Ectopic Pregnancy in a Non-Communicating Uterine Horn

Study Objective Describe an approach to a laparoscopic excision of a uterine horn ectopic pregnancy. Design N/A. Setting The patient was positioned in dorsal lithotomy in stirrups. Four ports were placed including an infra-umbilical port, a supra-pubic port, and two right or left lower quadrant ports 10mm from the midline above the level of the anterior superior iliac spine. Patients or Participants N/A. Interventions The right round ligament was coagulated and cut. The vesicouterine peritoneum was incised and the perivesical space was opened. The right fallopian tube was coagulated along the mesosalpinx. The right uterine artery and vein were isolated laterally and traced to the right horn pregnancy as well as to the left unicornuate uterus. A purse-string suture was performed using a running unidirectional barbed suture to isolate the vasculature pedicle feeding the horn pregnancy. The horn was separated from the uterus using the Harmonic Ace. The resulting pedicle was oversewed with barbed suture. Measurements and Main Results N/A. Conclusion Use of a purse string suture can be considered to minimize blood loss and spare the uterine vasculature at the time of uterine horn ectopic excision. Describe an approach to a laparoscopic excision of a uterine horn ectopic pregnancy. N/A. The patient was positioned in dorsal lithotomy in stirrups. Four ports were placed including an infra-umbilical port, a supra-pubic port, and two right or left lower quadrant ports 10mm from the midline above the level of the anterior superior iliac spine. N/A. The right round ligament was coagulated and cut. The vesicouterine peritoneum was incised and the perivesical space was opened. The right fallopian tube was coagulated along the mesosalpinx. The right uterine artery and vein were isolated laterally and traced to the right horn pregnancy as well as to the left unicornuate uterus. A purse-string suture was performed using a running unidirectional barbed suture to isolate the vasculature pedicle feeding the horn pregnancy. The horn was separated from the uterus using the Harmonic Ace. The resulting pedicle was oversewed with barbed suture. N/A. Use of a purse string suture can be considered to minimize blood loss and spare the uterine vasculature at the time of uterine horn ectopic excision.

Long-term oncological outcomes of the Agarwal loop-ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy.

To describe the Agarwal loop-ligation technique for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU) for upper tract urothelial carcinoma (UTUC) and report on long-term oncological outcomes. In the Agarwal loop-ligation technique, the distal ureteric stump is controlled using endoscopic Endoloop® or PolyLoop® ligation to ensure en bloc excision of the bladder cuff and prevent spillage of upper tract urine into the perivesical space. A retrospective review of the medical records of 76 patients who underwent the Agarwal loop-ligation technique for UTUC at participating centres from July 2004 to December 2017 was performed. Data collected included demographics, perioperative, and long-term oncological outcomes. Survival was calculated using Kaplan-Meier survival analyses. A total of 76 patients were included. The median age was 71.5years and median operative time was 4.3h. The intramural ureter and bladder cuff were completely excised in all patients. Distal surgical margins were clear in all, with only two patients found to have tumour extending to the circumferential surgical margin. There were no cases of perivesical recurrence or port-site metastasis. The 5-year bladder, local, and contralateral recurrence-free survival was 59.6%, 89.0% and 93.5%, respectively. Metastasis-free survival at 5-years was 73.5%. The 5-year overall survival and cancer-specific survival rates were 70.3% and 84.7%, respectively. We have described the Agarwal loop-ligation technique for the management of the distal ureter in LRNU. This technique complies with oncological principles outlined in the European Association of Urology guidelines, which minimises tumour spillage. Long-term oncological outcomes are satisfactory, with no cases of perivesical recurrence detected in this series.

MP61-02 DETAILED CADAVERIC ANALYSIS FOR PERIVESICAL LYMPH NODES WITH POTENTIAL IMPLICATIONS IN BLADDER CANCER

INTRODUCTION AND OBJECTIVE: Perivesical lymph nodes were added to the 8 edition of AJCC staging for bladder cancer. In pN+ patients, positive perivesical lymph nodes are associated with even worse overall survival. These nodes are inconsistently evaluated at the time of radical cystectomy (RC) and can be difficult to differentiate from perivesical fat. Currently, no studies have detailed the presence or anatomic location of perivesical lymph nodes. The objective was to provide a detailed anatomic evaluation of perivesical lymph nodes. METHODS: Six unembalmed cadavers with no prior pelvic malignancy or surgery were utilized. An open RC was performed on all specimens with wide resection of perivesical tissue and meticulous care to separate the pelvic lymph nodes (e.g.obturator, external iliac) from the specimen. The specimens were fixed in a previously validated lymph node revealing solution for 6 hours. Perivesical tissue dissection in 2 mm slices was performed. Lymph node identification and examination were performed by a board-certified pathologist. Perivesical lymph node size and location in relation to bladder wall was recorded. RESULTS: Gross lymph nodes were identified in the perivesical tissue in 50% (3/6) of the specimens, with a total of 6 lymph nodes identified. The mean lymph node size was 7.5 mm (2-16 mm). The mean distance from bladder wall was 9 mm (3-15 mm). Ten potential anatomic locations for perivesical nodes were developed: urachal, anterior bladder wall, posterior peritoneum, periprostatic/bladder neck, bilateral peripedicle, bilateral periseminal vesicle, bilateral lateral bladder wall. Nodes were identified in the: Right peripedicle (2 nodes), left lateral bladder wall (2 nodes), posterior peritoneum (1 node), anterior bladder wall (1 node) (Table). On histologic analysis, 4 of the 6 (66%) grossly identified lymph nodes had confirmed lymphoid tissue. CONCLUSIONS: In a cadaveric model with meticulous dissection, gross and histologically-confirmed lymph nodes were identified in the perivesical space in half of patients. When present, patients had an average of two nodes that were distributed around the bladder and within 15mm of the bladder wall. This data, as well as the inclusion of perivesical lymph nodes in AJCC staging, argues for thorough evaluation of the RC specimen for perivesical lymph nodes.Source of Funding: None

MP41-11 OUTCOMES AND TECHNIQUE FOR EXTRAPERITONEAL ROBOTIC YV-PLASTY FOR RECURRENT BLADDER NECK STENOSIS

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (MP41)1 Apr 2020MP41-11 OUTCOMES AND TECHNIQUE FOR EXTRAPERITONEAL ROBOTIC YV-PLASTY FOR RECURRENT BLADDER NECK STENOSIS Nadim Abo Youssef, Fabian Obrecht*, Jan Brachlow, Christian Padevit, and Hubert John Nadim Abo YoussefNadim Abo Youssef More articles by this author , Fabian Obrecht*Fabian Obrecht* More articles by this author , Jan BrachlowJan Brachlow More articles by this author , Christian PadevitChristian Padevit More articles by this author , and Hubert JohnHubert John More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000890.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To demonstrate the outcomes and the technique of robot assisted Y-V (RAYV) plasty bladder neck reconstruction with preferable extraperitoneal approach for recurrent bladder neck stenosis (BNS). METHODS: We present our results and the technique of 22 patients who underwent RAYV March 2016 to July 2019 in our department. 22 cases of BNS emerged after transurethral resection of the prostate. The indications were residual volume, dysuria and attenuated urinary stream. Following an extraperitoneal approach with a three arm Da Vinci Si system, the perivesical space is cleaned. The bladder neck is located and the ventral part of the prostate is exposed. An anterior longitudinal incision is performed starting from the bladder neck over the ventral vesico-prostatic junction down through the stenotic area to the external sphincter. The incision is enlarged to an inverted Y-shaped opening and an indwelling catheter is inserted. The tip of the V-shaped bladder flap is brought to the base of the inverted Y and closed with a running barbed suture. RESULTS: 22 patients with BNS underwent RAYV (table 1). All patients had undergone at least 2 transurethral procedures for the initial treatment. No conversion to open surgery had to be performed. The median operative time (skin to skin) was 133 min (range 69-180), the estimated blood loss was median of 5 (range 0-200) ml. There were no intraoperative and four patients with Clavien Dindo III as postoperative complications. The transurethral indwelling catheter was removed after 8 (4-25) days. The hospitalization period was median 5 (3-14) days, as patients preferred to leave the hospital without an indwelling catheter. Most of the patients showed six weeks postoperative a significant improvement of dysuria and residual volume as well as an increasing uroflowmetry (table 2). There was no recurrence of BNS with a median follow-up of 19.4 (2-42) months. CONCLUSIONS: The extraperitoneal robotic YV-plasty is a feasible and minimally invasive approach for recurrent bladder neck stenosis. Still, long-term results must confirm the efficacy in the future. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e598-e599 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nadim Abo Youssef More articles by this author Fabian Obrecht* More articles by this author Jan Brachlow More articles by this author Christian Padevit More articles by this author Hubert John More articles by this author Expand All Advertisement PDF downloadLoading ...

Angiomyofibroblastoma of scalp: a rare soft tissue tumour at an unusual site

Angimyofibroblastoma is a very rare, benign mesenchymal soft tissue tumour which involves the vulvovaginal area of females of reproductive age group. These tumours are usually slow growing and painless which has a very low tendency for local recurrence. In women it is common in female genital tract, vulva, and posterior perivesical space. In men it occurs in spermatic cord. Here a report of 47 year old male patient from VMKV Medical College and Hospital, Salem was presented with a swelling in the posterior aspect of scalp from 6 months with no any associated symptoms. A preoperative diagnosis of dermoid scalp was made and patient was subjected for excision.

Spontaneous bladder rupture: unusual presentation in a haemophilic child

A 4-year-old boy child presented with abdominal pain, haematuria, lower abdominal mass and urinary retention. There was no family history of bleeding. Ultrasound abdomen revealed an intravesical blood clot, rupture...

V6-12 TRANSVESCICOSCOPIC BLADDER CUFF EXCISION IN LAPAROSCOPIC NEPHROURETERECTOMY

You have accessJournal of UrologyMisc. GU Oncology and Transplant1 Apr 2017V6-12 TRANSVESCICOSCOPIC BLADDER CUFF EXCISION IN LAPAROSCOPIC NEPHROURETERECTOMY Young Eun Yoon, Sang Woon Kim, Hyung Ho Lee, Jang He Han, Seung Hwan Lee, Won Sik Ham, Koon Ho Rha, and Woong Kyu Han Young Eun YoonYoung Eun Yoon More articles by this author , Sang Woon KimSang Woon Kim More articles by this author , Hyung Ho LeeHyung Ho Lee More articles by this author , Jang He HanJang He Han More articles by this author , Seung Hwan LeeSeung Hwan Lee More articles by this author , Won Sik HamWon Sik Ham More articles by this author , Koon Ho RhaKoon Ho Rha More articles by this author , and Woong Kyu HanWoong Kyu Han More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1587AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To describe the management of the distal ureter during laparoscopic radical nephroureterectomy with the transvesical laparoscopic approach. METHODS The patient was placed in the modified lithotomy position with abducted thighs. The procedure started with cystoscopic examination of the bladder and ureteral orifices. After a small skin incision, a 5-mm-diameter trocar was introduced into the bladder dome. The anterior bladder wall was suspended to the abdominal wall to prevent the trocar from slipping out and 2 more 3-mm-diameter trocars were placed. The ureter was mobilized with hook electrocautery and dissected ureteral end was placed in extravesical space. Bladder was repaired with 4-0 vicryl. Then patient was placed in lateral position and conventional laparoscopic radical nephroureterectomy was performed. While dissection of distal ureter, the distal end of ureter was smoothly removed from perivesical space without any difficulty. RESULTS The patient was a 61-year-old female. The patient's CT scan showed right proximal ureteral mass and the result of previously performed ureteroscopic biopsy was transitional cell carcinoma, low grade. The operation time of transvesical bladder cuff excision was 50 minutes, and laparoscopic nephroureterectomy was performed for 120 minutes. Estimated blood loss of whole procedure was 300ml and there was no intraoperative or postoperative complication. Foley catheter was removed at 1 week. After 6 months postoperatively, there's no evidence of recurrence or metastasis. CONCLUSIONS Our initial experience with transvesicoscopic bladder cuff excision in laparoscopic radical nephroureterectomy demonstrated that the procedure is feasible and safe. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e682 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Young Eun Yoon More articles by this author Sang Woon Kim More articles by this author Hyung Ho Lee More articles by this author Jang He Han More articles by this author Seung Hwan Lee More articles by this author Won Sik Ham More articles by this author Koon Ho Rha More articles by this author Woong Kyu Han More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Simultaneous radical nephroureterectomy and transurethral distal ureter balloon occlusion and detachment.

BackgroundDistal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU) but there is no agreement on the ideal surgical technique to achieve it. We describe a novel technique for endoscopic DUBC excision during RNU that complies with the oncological principle of preventing spillage of tumor cells, by occluding the distal ureter before its excision, while shortening surgical time, and by avoiding repositioning the patient.MethodsBetween June 2010 and May 2012, 10 patients underwent simultaneous open RNU and transurethral distal ureter balloon occlusion and detachment using a flexible cystoscope (f-TUDUBOD) in lumbotomy position. After having ruled out the presence of a concomitant bladder tumor, one surgeon used a flexible cystoscope to occlude the affected ureter with a 5Fr Fogarty catheter and circumferentially incised the orifice until detaching it from the bladder with a boogie electrode or a Holmium laser; meanwhile, two other surgeons performed open RNU through a lumbotomic approach. Data were compared with those of patients who had previously undergone open RNU after TUDUBOD.ResultsMean surgical time for simultaneous open RNU and f-TUDUBOD was 113.4 ± 29.2 minutes, significantly shorter (P <0.01) than that for open RNU after TUDUBOD (154.2 ± 26.4 minutes). There were no complications. Surgical margins were always negative; at mean follow-up of 31.1 months, there was no recurrence in the perivesical space and a 20% (2/10) bladder recurrence rate comparing favorably with that (23.1%) observed at 30-month follow-up in patients who had undergone open RNU after TUDUBOD.ConclusionsSimultaneous open RNU and f-TUDUBOD proved to be feasible and to represent a safe and effective means of shortening surgical time, with obvious clinical and economical benefits.

Primary Extranodal Hodgkin's Lymphoma presenting with a Single Pelvic Mass

ABSTRACTIntroductionAlthough lymphomas can arise from a wide variety of tissues, primary extranodal presentation is predominantly a feature of non-Hodgkin's lymphomas. Primary pelvic extranodal Hodgkin's lymphoma is a rare malignancy. We presented a case of primer retroperitoneal Hodgkin's lymphoma initially presumed gynecologic malignancy. We discussed its rarity, staging and management.Case ReportA 75-year-old woman was referred to our hospital with persisting pelvic mass. Pelvic examination revealed an ill-defined immobile mass with hard in consistency. The mass 100 × 75 mm in diameter, invading right parametrium, perivesical space and bladder wall was detected in CT and there were no signs of metastases or enlarged lymph nodes. Diagnostic laparoscopy was suggested but the patient refused the surgery due to her advanced age. One year later, she presented with the symptoms of fever, sweats and fatigue. Hodgkin's lymphoma was diagnosed via laparoscopic biopsy of the mass located at retroperitoneal space anteriorly to the uterus. CT examination revealed multiple swollen lymph nodes and a pulmonary nodule; thus, stage 4 disease was established. International prognostic score was 2, indicating 67% progression free survival; however, patient died due to respiratory failure after the first course of ABVD chemotherapy.ConclusionAlthough gynecologists rarely experience primary extranodal lymphomas particularly Hodgkin's disease, lymphoid malignancies should be kept in mind in differential diagnosis of pelvic masses. This disease can rarely arise adjacent to gynecologic organs in retroperitoneal space, and this presentation can be misinterpreted as a gynecological malignancy.How to cite this articleKiran G, Canaz E, Sayar H, Serin S, Balakan O. Primary Extranodal Hodgkin's Lymphoma presenting with a Single Pelvic Mass. J South Asian Feder Obst Gynae 2014;6(3):183-186.

Transurethral Distal Ureter Balloon Occlusion and Detachment: A Simple Means of Managing the Distal Ureter During Radical Nephroureterectomy

Distal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU), but the technique to accomplish it remains controversial. We describe a novel technique of transurethral distal ureter balloon occlusion before detachment (TUDUBOD) whereby the affected ureter is occluded with a 5F Fogarty balloon catheter and circumferentially incised until the perivesical fat to detach it from the bladder. In the 13 patients who were treated between May 2005 and May 2010, mean surgical time for TUDUBOD was 21.3 minutes. Results for surgical margins were always negative; at mean follow-up of 39.8 months (range 16-74 mos), 4 (30.1%) patients had bladder recurrences but none occurred at the DUBC excision site or perivesical space. TUDUBOD seems to be a simple, cheap, and effective mean of managing the distal ureter during RNU that keeps with the oncologic principle of preventing tumor cell spillage outside the bladder.

Preperitoneal repair of inguinal hernia

From 2007 to date, fi ve boys with bladder exstrophy underwent this pre-emptive treatment of inguinal hernia at our institution. None has developed a recurrence after a median (range) follow-up of 29 (5 – 46) months. This approach avoids any manipulation of the inguinal canal, which is an advantage per se, but may be even more important in children with bladder exstrophy given the relatively high risk of hernia recurrence reported [ 1,2 ] . Furthermore, the presence of a pelvic diastasis makes the pelvic dissection of the cord easier than in normal children with a closed pelvic ring. The same procedure can also possibly be performed in children with a congenital inguinal hernia undergoing other procedures that require dissection of the perivesical space, e.g. ureteric re-implantation or ureterocoele repair.

A Rare Case of Female Bladder Spontaneous Rupture

Bladder spontaneous rupture in the woman represents an extremely rare urologic emergency; its cause can be iatrogenic, neoplastic or diabetic. Materials and Methods A 56-year-old woman was referred to our unit because of the presence of acute abdominal pain, oligoanuria and vomiting for two days. At physical examination, the patient presented with confusional state, acute urinary retention and gross hematuria after urethral catheterization. Laboratory data demonstrated important metabolic abnormalities: hyperglycemia (946 mg/dL), acute renal failure (serum creatinine: 3.25 mg/dL), hyponatremia (120 mEq/L) and metabolic acidosis. At the CT of her abdomen and pelvis, a suspected bladder rupture (right lateral wall) was revealed, and confirmed after performing a retrograde cystography. Personal history was negative for trauma; glycemia was never controlled despite an important familiarity for type I diabetes. An episode of painless gross hematuria had occurred one month before, treated by the physician with antibiotics. Firstly the metabolic and electrolyte imbalance was corrected and then an emergency explorative laparotomy was performed. An important urinary leakage in the pelvis and a mild peritoneal effusion were documented. Furthermore, an important leak of papillary-like neoplastic material from the vesical breach was detected. The neoplasm seemed to involve the whole bladder. The surgical treatment consisted in bladder raphia, accurate washing of perivesical space, difficult salvage cystectomy (tenacious adhesions due to the urinary leakage) and bilateral ureterocutaneostomy. During the postoperative stay, the patient showed a difficult glycemia control with insulin therapy and wound dehiscence healed by second intention. The hospital discharge was on day 30, with the patient in good health and acceptable glycemia control. Results The pathological diagnosis was a G2 non-invasive urothelial carcinoma, also involving a vesical diverticulum; the neoplasm was associated with an erosive chronic cystitis with aspects of transparietal micro-abscessual flogosis (pT1 G2 N0 Mx). The patient will perform a CT scan 3 months after surgery before possibly starting chemotherapy. Conclusions Bladder spontaneous rupture in the woman is an extremely rare pathology; in the reviews we analyzed, it is dealt with as a clinical condition that more often occurs in patients submitted to pelvic surgery followed by adjuvant radiotherapy. Invasive bladder neoplasms, predominantly the sarcomatoid ones, are the second more frequent cause mentioned in the literature. Diabetic uropathy of the bladder associated with purulent bacterial cystitis in the elderly is the third cause, which is mentioned in two articles only. At last, only one study indicates the superficial urothelial bladder cancer (pT1- G2) as the responsible for this dramatic event. In our case, the suspected bladder diabetic uropathy, characterized by reduced perception of micturition stimulus, the increase in vesical capacity and detrusorial hypocontractility, were probably an important concomitant cause of this dramatic clinic condition, in association with the large superficial urothelial neoplasm. Moreover, diabetic neuropathy could explain the delay of patient presentation to the physician. Urinary leak, probably occurred 2 days before diagnosis, created an important metabolic imbalance and remarkable surgical difficulties. The timely treatment allowed for the resolution of a clinical condition associated with an elevated mortality due to septic shock.

Obturator mononeuropathy caused by lipomatosis of the nerve: A case report

We report a patient who presented with the clinical features of obturator mononeuropathy. Abdomino-pelvic computed tomography revealed a fusiform mass in the right perivesical space; magnetic resonance imaging (MRI) showed characteristic "coaxial-cable-like" appearance in cross-section and "spaghetti-like" appearance in longitudinal section, pathognomonic of lipomatosis of the nerve. Nerve lipomatosis as the cause of obturator neuropathy has not been previously reported. MRI provides definite and graphic proof of the diagnosis.

Angiomyofibroblastoma Arising from the Posterior Perivesical Space: a Case Report with MR Findings

Angiomyofibroblastoma is a rare benign soft tissue neoplasm that predominantly occurs in the genital region of middle-aged women. We present a case of an angiomyofibroblastoma that involved the posterior perivesical space in a 48-year-old woman. We have documented the magnetic resonance imaging features of this case.

CT of pelvic extraperitoneal spaces: an anatomical study in cadavers

To evaluate the pelvic extraperitoneal compartments and communications with abdominal retroperitoneal spaces. Helical computed tomography (CT) was used to image the abdomen and pelvis after injection of 800 ml of dilute (1 in 25) contrast material into prevesical, perivesical and perirectal spaces in eight embalmed cadavers. Axial images and multiplanar reconstructions were reviewed to determine flow pathways. The prevesical space was injected in four cadavers, the perivesical space in two and the perirectal in two. After the four prevesical space injections, communication was seen with the perivesical (four of four), perirectal (one of four) and abdominal extraperitoneal spaces (posterior pararenal space in all, anterior pararenal space in two of four, and perirenal space in three of four). After the two perivesical injections, communication was seen with the prevesical (two of two), perirectal (two of two) and abdominal extraperitoneal spaces (posterior pararenal in two of two, anterior pararenal in two of two, and perirenal space in two of two). After the two perirectal space injections, communication was seen with the prevesical (two of two), perivesical (one of two) and abdominal extraperitoneal spaces (posterior pararenal in two of two, anterior pararenal in two of two, and perirenal space in one of two). The extraperitoneal spaces of the pelvis comprise three communicating compartments: the prevesical space, the perivesical space, and the perirectal space. The perirectal space, previously thought to be separate, communicates with the perivesical and the prevesical spaces. Intercommunication occurs both between the pelvic extraperitoneal spaces and with abdominal retroperitoneal spaces.

Percutaneous Wallstent Implantation to Rescue Failed Ureteropyelostomy for Massive Ureteral Necrosis after Renal Transplantation

A 44-year-old woman with end-stage renal disease underwent cadaver renal transplantation at another hospital. Two weeks after surgery, much clear fluid emerged from the operative wound. The patient visited our hospital and abdominal ultrasonography identified a fluid collection near the right perivesical space. A percutaneous nephrostomy was performed for urinary diversion. Antegrade pyelography showed renal pelvis distortion, an irregular surface along the entire ureter, and a severe stricture near the lower ureter, suggestive of massive ureteral necrosis of the graft. The initial treatment comprised resection of the necrotic ureter followed by an end-to-side pyeloureterostomy to join the graft renal pelvis to the middle portion of the ipsilateral native ureter. Although the postoperative period was initially unremarkable, delayed urine extravasation was noted on the fifth postoperative day. Antegrade pyelography revealed a 0.5-cm disruption gap between the graft renal pelvis and the native ureter (Fig. 1A). After discussion of the available treatment options with the patient, a metallic stent 6 mm in diameter and 30 mm in length (Wallstent; Schneider, Zurich, Switzerland) was inserted via a percutaneous antegrade approach to bridge the defect between the native ureter and graft renal pelvis. Subsequent recovery was uneventful, and antegrade pyelography showed that urine was no longer leaking from the disruption gap. The Wallstent was found to have remained in a good position (Fig. 1B) and the collecting system was patent without evidence of stone formation on three-dimensional computed tomography 10 months later. Over a 5-year follow-up period, the patient had stable renal function without sequelae.FIGURE 1.: (A) Antegrade pyelography showed a 0.5-cm ureteral disruption gap at the ureteropyelostomy anastomosis (black arrow) between the graft renal pelvis and native ureter (hollow arrow). (B) A metallic Wallstent (large arrow) was used to bridge the native ureter to the renal pelvis of the graft kidney. The small arrow indicates refluxing contrast medium in the upper portion of the right native ureter.With a reported incidence of 2.1%, ureteral necrosis is relatively uncommon after renal transplantation (1). Different techniques have been considered to repair the various types of ureteral injury. Pyeloureterostomy joining the graft pelvis to the distal portion of the native ureter is the preferred method when dealing with massive ureteral necrosis (1). Few reports have addressed further management when pyeloureterostomy fails. Antegrade or retrograde endourologic stent implantation may provide temporary relief of ureteral obstruction but can potentially lead to complications like stent encrustation or repeated urinary tract infections. Artificial ureteral replacement was successfully used in three patients with renal transplant ureteral necrosis in 1998 by Desgrandchamps et al. (2), who employed a minimally invasive technique originally described for the palliation of malignant ureteral obstructions. Based on a mean of 32-months of follow-up, the investigators concluded that the subcutaneous bypass is a simple and safe procedure, although late encrustation of the prosthesis remains a major concern. In our case, repeat operation of the disrupted pyeloureterostomy would have been difficult as a result of local inflammation. Likewise, a subcutaneous artificial ureteral replacement may not prevent persistent urine leakage from the disrupted anastomosis. Metal stents (e.g. Wallstents) are routinely used in the cardiovascular and biliary systems (3, 4) and have been deployed for malignant and benign ureteral obstruction with excellent results (5–7). The use of the technique presented in this case was able to bridge the defect caused by the disrupted pyeloureterostomy anastomosis, thereby avoiding further open surgery, with its associated morbidity. Because the presence of this new adynamic ureteral segment may cause morbidity such as stone formation in the future, regular follow-up of renal function and collecting system patency will remain crucial components in the ongoing management of this patient. Victor Chia-Hsiang Lin Division of Urology Department of Surgery E-Da HospitalI-Shou University Kaoshiung, Taiwan Alex Chien-Hwa Liao Division of Urology Department of Surgery Chi-Mei Medical Center Tainan, Taiwan Li-Ching Chang Division of Urology Department of Surgery E-Da HospitalI-Shou University Kaoshiung, Taiwan Wen-Sheng Tzeng Department of Radiology Chi-Mei Medical Center Tainan, Taiwan

Fat necrosis mimicking liposarcoma in a patient with pelvic lipomatosis: CT findings

Pelvic lipomatosis is a rare condition characterized by an overgrowth of normal fat in the perirectal and perivesical spaces. The most important differential diagnosis is liposarcoma. We present a case of pelvic lipomatosis associated with a mass, which was diagnosed radiologically as a liposarcoma, but surgical biopsy result revealed fat necrosis.