Journal of Endourology Case Reports最新文献

Background: Delayed proximal ureteral stricture (DPUS) after nephron-sparing treatment (partial nephrectomy [PN] and image-guided percutaneous ablation) of renal masses is a rare complication that occurs because of an unrecognized injury to the proximal ureter and/or its associated vascular supply. We present a multi-institutional series of patients who developed DPUS after nephron-sparing treatment and review relevant tumor characteristics, timing of DPUS presentation, presenting symptoms, and outcome of stricture management. Case Presentation: Between 2000 and 2019, nine patients (five PN and four ablation) were found to have DPUS diagnosed at an average of 9 (6-119) months after PN and 5.5 (1-6) after ablation. Average tumor size was 4.5 (2.9-7.3) cm and 3.6 (3-4.1) cm for those treated with PN and ablation, respectively. Nephrometry score was 8.3 (6-11) and 6.5 (5-8), respectively. For resected tumors, all were located in the lower pole, but uniformity was not found as far as medial vs lateral (3 vs 2), anterior vs posterior (2 vs 2, 1 N/A), and right vs left (3 vs 2). For ablated tumors, all four tumors were right sided, anterior, medial, and lower pole. Initial signs and symptoms include sepsis (2), flank pain (5), and asymptomatic hydronephrosis (2). Concomitant urinoma (2) and retroperitoneal abscess (1) was found on imaging. Initial management included ureteral stenting (5) and percutaneous nephrostomy tube (4). Three underwent nephrectomy. Two had spontaneous resolution of DPUS after a course of ureteral stenting. Conclusion: Potential risk factors associated with DPUS after nephron-sparing treatment, including medial and lower pole tumors, and particularly right-sided anterior masses for ablation and higher complexity nephrometry score for PN. Recognition of delayed symptoms and imaging abnormalities in the surveillance period should cue clinical suspicion to DPUS.

Background: Despite concomitant bladder and upper urinary tract cancers are present in 17% of cases, the simultaneous affection of the urethra, bladder, and both upper urinary tracts is extremely rare. Treatment decisions in this setting could be challenging because of the lack of evidence in the literature. Case Presentation: A 65-year-old Caucasian man with a history of nine low-grade (LG) and multifocal bladder tumor recurrences during the past 4 years is referred to our department with a newly diagnosed panurothelial carcinoma involving the bladder, urethra, and both upper urinary tracts. Because of the large and recurrent LG bladder tumor, the urethral involvement and the presence of bilateral pyelocaliceal tumors >4 cm the patient underwent a robot-assisted complete urinary tract extirpation (CUTE). Operating time was 360 minutes and blood loss 460 mL. No intraoperative complications were reported and blood transfusion was not required. The patient developed a surgical site infection in the glans that was solved with antibiotics without any other postoperative complication. He started renal replacement therapy and was discharged 6 days after the surgery. Pathologic analysis showed multifocal urothelial carcinomas; pTa LG involving the bladder and the prostatic-bulbar-membranous-penile urethra, pT3 high grade (HG) in right renal pelvis, pT1 HG in left renal pelvis, and pN0 in pelvic lymph node dissection. After a reasonable free-recurrence period of time the patient could be evaluated for a robot-assisted intracorporeal urinary diversion in preparation for a later renal transplantation. Conclusion: Robot-assisted CUTE could be a feasible and safe technique for selected patients with simultaneous panurothelial carcinoma. Further multicentric studies are warranted to determine the safety of this minimally invasive approach in patients with different comorbidities.

Background: SpaceOAR (organ at risk) hydrogel is a hydrogel matrix injected into the perirectal space posterior to the prostate for the purpose of mitigating radiation dose (and hence side effects of radiation) on the rectum. Manufacturer descriptions state that this material is reabsorbed 3 to 6 months after injection. Case Discussion: We encountered a 75-year old male patient who underwent SpaceOAR injection in anticipation for primary external beam radiation treatment for intermediate risk prostate cancer (Gleason score 7 = 4 + 3, prostate specific Antigen [PSA] = 2.32, cT2a). After initiation of androgen deprivation, but before radiotherapy, the patient decided to no longer undergo radiation but rather elected to proceed with surgery. Based on the presence of the SpaceOAR, we delayed his surgery to 6 months after SpaceOAR injection to allow for absorption of the material. A preoperative MRI showed persistent hydrogel matrix in the perirectal space. We performed a robotic radical prostatectomy effectively despite the persistent SpaceOAR hydrogel by modifying our dissection closer to the prostate posteriorly. Conclusion: SpaceOAR hydrogel may alter patient anatomy even 6 months after deployment, however, robotic prostatectomy would be feasible with proper knowledge of anatomy and by following the proper dissection planes above the perirectal space.

Introduction: Surgical management of long-segment radiation-induced distal ureteral strictures (RIDUS) is challenging. Pelvic radiation can damage the bladder, inhibiting the utilization of typical reconstruction techniques such as a psoas hitch and/or Boari flap. Also, radiation can cause scarring that can make ureterolysis difficult. Case Presentation: We present a case series of patients undergoing robotic ureteral bypass surgery with appendiceal graft for management of strictures in this setting. This novel procedure utilizes the patient's appendix as a bypass graft to divert urine away from the strictured portion of ureter and into the bladder; this technique does not require dissection of the strictured ureteral segment. Conclusion: Robotic ureteral bypass surgery can be effective for management of long-segment RIDUS.

Crossed fused renal ectopia (CFRE) is a rare fusion anomaly of the kidneys, with a predisposition to calculus disease. Management of renal calculi in CFRE is not standardized because of paucity of literature. We managed a 32-year-old man with left to right CFRE with multiple stones in both the kidneys by percutaneous nephrolithotomy for the right moiety and laparoscopic pyelolithotomy for the crossed moiety. Based on the stone burden and anatomy, we decided to go for a staged approach, to provide maximum clearance rate with least risk. We share our experience in this case, with regard to the use of two different but minimally invasive modalities for effective management of the patient. We also emphasize on the utilization of a staged approach whenever required for patient safety. We also reviewed the literature regarding the management of kidney stones in this rare anomaly.

Background: Percutaneous nephrolithotomy (PCNL) is an effective minimally invasive surgical modality for the management of renal calculi. It is generally considered safe with commonly encountered complications being urinary extravasation, fever, and bleeding. Injury to the biliary tract or puncture of the gallbladder is an extremely rare but a grave complication of PCNL. Case Presentation: We present a case of a 70-year-old man who underwent PCNL for an obstructing right renal pelvic calculus. Upon middle caliceal puncture to access the pelvicaliceal system, an unexpected green aspirate suggestive of bile was noted egressing through the puncture needle when stiletto was detached. The needle was swiftly withdrawn and percutaneous renal access was effective on the second puncture to complete the procedure. In the postoperative period, biliary ascites was confirmed on imaging, which was managed in a minimally invasive manner with an ultrasonography-guided abdominal drain insertion. The patient recovered well and was discharged home. Conclusion: Biliary ascites with or without peritonitis is a rare but potentially fatal consequence of biliary tract injury that can occur during PCNL. If there is recognition of biliary aspirate during a percutaneous renal procedure, aggressive management, including diverting the biliary fluid in appropriately selected cases, can obviate the need for emergent open or laparoscopic surgical intervention as highlighted in our case.

Background: An uncommon cause of recurrent renal colic is mucous tissue passage secondary to renal papillae necrosis. Because of its low prevalence, the correct management of recurrent obstructive uropathy produced by renal papillary necrosis (RPN) is not well defined. Case Presentation: We present a case of recurrent renal colic associated with the expulsion of mucous tissue in a young woman's urine with a history of excessive consumption of nonsteroidal anti-inflammatory drugs (NSAIDs). The patient required multiple admissions to the emergency department because of recurrent episodes of renal colic. A retrograde pyelogram and histopathologic study of the expulsed tissue supported the diagnosis of RPN. The patient was managed with Double-J stents for 12 months, complete withdrawal of NSAIDs, and large volume intake of water. A satisfactory outcome was seen radiologically and endoscopically after treatment. The patient stopped experiencing new renal colic episodes because of the passive ureteral dilatation despite still presenting the mucous tissue expulsion in the urine. Conclusions: Passive ureteral dilatation with Double-J stents could possibly be an effective treatment for patients with recurrent renal colic secondary to persistent renal papillae necrosis.

Background: Ganglioneuroma is a rare tumor derived from the neural crest that can occur in any sympathetic tissue. It corresponds to 0.3% to 2% of incidental adrenal tumors and <250 have been reported in the literature so far. Case Presentation: We present a case of a 30-year-old Caucasian woman presented with a large bilobed adrenal tumor found on a CT scan during the investigation of acute abdominal pain. The image also showed a rare anatomic variation of a left-sided inferior vena cava. Biochemical work-up for adrenal incidentaloma showed normal markers. Since we could not rule out malignancy, the patient was subjected to laparoscopic adrenalectomy and the pathology report showed an adrenal ganglioneuroma, a rare nonfunctioning tumor of the adrenal. Conclusion: Ganglioneuroma can present as a large bilobed adrenal tumor. The laparoscopic approach is feasible and safe. Preoperative planning is needed and vascular variations can be challenging during the procedure.

Background: Selective renal artery angioembolization is the first treatment option in case of significant bleeding after percutaneous nephrolithotomy. Migration of embolization material into the collecting system is extremely rare. The treatment of this condition is not standardized, but manual extraction, ultrasound fragmentation, and holmium laser lithotripsy have been described. Case presentation: We report the laser extraction of these coils in two patients at our center with two different approaches: retrograde intrarenal surgery (RIRS) and endoscopic combined intrarenal surgery (ECIRS). They were young male patients aged 25 and 29 years at the time of surgery, and they were 2-5 years postembolization when they presented to our center for symptoms such as hematuria and passage of small stone fragments. The first patient was managed solely with RIRS, whereas the second patient required ECIRS because of significant bleeding after coil removal, which necessitated hemostasis using a resectoscope. Conclusion: For patients who present with recurrent stones or other symptoms such as pain, hematuria, or flank pain, the diagnosis of migrated embolization coils should be considered. Management can be via the retrograde or percutaneous approach, but in the setting of significant amount of migrated coils or significant bleeding after their removal, percutaneous access may allow more definitive hemostasis.