Villous adenoma of the renal pelvis: a common entity at an uncommon location

Villous adenoma is uncommonly seen in the urogenital tract and is even more rarely seen in the upper urinary tract and renal pelvis. Like colorectal adenomas, these neoplasms can transform into adenocarcinoma. The preoperative diagnosis is challenging due to their frequent association with hydronephrosis. Herein, we present the case of a villous adenoma of the renal pelvis in a 62-year-old man presenting with recurrent urinary tract infection. The computed tomography scan showed marked hydronephrosis but no suspicious mass in the right kidney. A laparoscopic right nephrectomy was performed. Gross examination revealed a dilated renal pelvis with an irregular exophytic lesion in the renal pelvis's upper surface. The histopathological examination showed slender, elongated villi with thin fibrovascular cores, consistent with villous adenoma morphology. Isolated villous adenomas have a favorable prognosis. However, the pathologist should undertake a search for an invasive component.

Pionefrose unilateral em cão - relato de caso / Unilateral pyonephrosis in a dog - case report / Pionefrosis unilateral en perro - relato de caso

A pionefrose consiste em uma hidronefrose contaminada, associada à destruição do parênquima renal. Tem como causas o bloqueio ureteral ou uretral por urólitos, inflamação crônica, neoplasia e ureter ectópico, seguidos de contaminação. O diagnóstico é realizado através de exames de imagem, principalmente a ultrassonografia e também através de urinálise e urocultura. Em casos avançados o tratamento preconizado é a nefrectomia. O presente trabalho tem como objetivo relatar um caso de um cão com suspeita inicial de hidronefrose. O paciente passou por nefrectomia, no pós-operatório observou-se melhora do seu quadro clínico, porém permanecendo a anemia. O diagnóstico definitivo, realizado por exame histopatológico, revelou pionefrose, entretanto sua causa não foi estabelecida.(AU)

Pyonephrosis consists of a contaminated hydronephrosis associated with the destruction of the renal parenchyma. Its causes include ureter or urethra blockage by uroliths, chronic inflammation, neoplasm, and ectopic ureter, followed by contamination. The diagnosis is made through image exams, mainly ultrasound, and also through urinalysis and uroculture. In advanced cases, nephrectomy is the recommended treatment. The objective of this study is to report a case of a dog with initial suspicion of hydronephrosis. The patient underwent nephrectomy, and during the postoperative period, an improvement in the clinical scenario was observed, despite the persistent anemia. The definitive diagnosis, carried out by histopathological examination, revealed pyonephrosis; however, its cause was not established.(AU)

La pionefrosis es una hidronefrosis contaminada, asociada con la destrucción del parénquima renal. Sus causas son el bloqueo ureteral o uretral por urolitos, inflamación crónica, neoplasia y uréter ectópico, seguido de contaminación. El diagnóstico se realiza mediante exámenes de imágenes, principalmente ultrasonografía y también mediante análisis de orina y urocultivo. En casos avanzados el tratamiento recomendado es la nefrectomía. Este artículo tiene como objetivo informar un caso de un perro con sospecha inicial de hidronefrosis. El paciente se sometió a nefrectomía; después de la operación, su estado clínico mejoró, pero la anemia permaneció. El diagnóstico definitivo realizado por el examen histopatológico reveló pionfrosis, sin embargo, su causa no se ha establecido.(AU)

Laparoscopic nephrectomy outside gerota fascia and en bloc ligation of the renal hilum for management of inflammatory renal diseases

ABSTRACT Objectives This study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications. Materials and Methods Thirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined. Results Among 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery. Conclusions In laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.

Pyonephrosis caused by Salmonella sp. in a patient with polycystic kidney disease undergoing hemodialysis / Pionefrose causada por Salmonella sp. em um paciente com doença renal policística submetido a hemodiálise

AIMS: This article reports a case of pyonephrosis caused by Salmonella sp. in a patient with polycystic kidney disease undergoing hemodialysis treatment. CASE DESCRIPTION: An elderly male patient previously diagnosed with polycystic kidney disease undergoing standard hemodyalitic treatment presented uronephrosis, evolving to pyonephrosis caused by Salmonella sp., and was successfully treated with ciprofloxacin. CONCLUSIONS: The polycystic kidney disease may have contributed to the bacteria's attachment to the kidney, due to increase of permeability of the intestinal mucosa, easier bacterial translocation to bloodstream and its subsequent accommodation in the infected organ.

OBJETIVOS: Este artigo relata um caso de pionefrose causada por Salmonella sp. em paciente com doença renal policística em tratamento por hemodiálise. DESCRIÇÃO DO CASO: Um paciente idoso do sexo masculino, previamente diagnosticado com doença renal policística, em tratamento convencional por hemodiálise, apresentou uronefrose, evoluindo a pionefrose causada por Salmonella sp., sendo tratado com sucesso com ciprofloxacino. CONCLUSÕES: A doença renal policística pode ter contribuído para a instalação da bactéria no rim, visto o aumento da permeabilidade da mucosa intestinal e maior facilidade de translocação da bactéria para a corrente sanguínea e seu posterior alojamento no órgão infectado.

Ureteral Stent Insertion in the Management of Renal Colic during Pregnancy / 전남의대학술지

To determine an optimal invasive intervention for renal colic patients during pregnancy after conservative treatments have been found to be unhelpful. Among the available invasive interventions, we investigated the reliability of a ureteral stent insertion, which is considered the least invasive intervention during pregnancy. Between June 2006 and February 2015, a total of 826 pregnant patients came to the emergency room or urology outpatient department, and 39 of these patients had renal colic. The mean patient age was 30.49 years. In this retrospective cohort study, the charts of the patients were reviewed to collect data that included age, symptoms, the lateralities and locations of urolithiasis, trimester, pain following treatment and pregnancy complications. Based on ultrasonography diagnoses, 13 patients had urolithiasis, and 13 patients had hydronephrosis without definite echogenicity of the ureteral calculi. Conservative treatments were successful in 25 patients. Among these treatments, antibiotics were used in 15 patients, and the remaining patients received only hydration and analgesics without antibiotics. Several urological interventions were required in 14 patients. The most common intervention was ureteral stent insertion, which was performed in 13 patients to treat hydronephrosis or urolithiasis. The patients' pain was relieved following these interventions. Only one patient received percutaneous nephrostomy due to pyonephrosis. No pregnancy complications were noted. Ureteral stent insertion is regarded as a reliable and stable first-line urological intervention for pregnant patients with renal colic following conservative treatments. Ureteral stent insertion has been found to be equally effective and safe as percutaneous nephrostomy, which is associated with complications that include bleeding and dislocation, and the inconvenience of using external drainage system.

Ureteral Stent Insertion in the Management of Renal Colic during Pregnancy / 전남의대학술지

To determine an optimal invasive intervention for renal colic patients during pregnancy after conservative treatments have been found to be unhelpful. Among the available invasive interventions, we investigated the reliability of a ureteral stent insertion, which is considered the least invasive intervention during pregnancy. Between June 2006 and February 2015, a total of 826 pregnant patients came to the emergency room or urology outpatient department, and 39 of these patients had renal colic. The mean patient age was 30.49 years. In this retrospective cohort study, the charts of the patients were reviewed to collect data that included age, symptoms, the lateralities and locations of urolithiasis, trimester, pain following treatment and pregnancy complications. Based on ultrasonography diagnoses, 13 patients had urolithiasis, and 13 patients had hydronephrosis without definite echogenicity of the ureteral calculi. Conservative treatments were successful in 25 patients. Among these treatments, antibiotics were used in 15 patients, and the remaining patients received only hydration and analgesics without antibiotics. Several urological interventions were required in 14 patients. The most common intervention was ureteral stent insertion, which was performed in 13 patients to treat hydronephrosis or urolithiasis. The patients' pain was relieved following these interventions. Only one patient received percutaneous nephrostomy due to pyonephrosis. No pregnancy complications were noted. Ureteral stent insertion is regarded as a reliable and stable first-line urological intervention for pregnant patients with renal colic following conservative treatments. Ureteral stent insertion has been found to be equally effective and safe as percutaneous nephrostomy, which is associated with complications that include bleeding and dislocation, and the inconvenience of using external drainage system.

Infecção do trato urinário / Urinary tract infection

A infecção do trato urinário corresponde a uma resposta inflamatória do urotélio em consequência à invasão bacteriana, geralmente acompanhada de bacteriúria e piúria. No mundo, a Escherichia coli uropatogênica causa 80% das cistites não complicadas. O principal fator de virulência bacteriana para a infecção do trato urinário é a adesão bacteriana que promove a fixação na superfície do epitélio tecidual. Originalmente a cultura de urina com o crescimento de um número superior a 100.000 unidades formadoras de colônias indicam a infecção, porém algumas condições especiais são apontadas tanto em pacientes com infecção crônica como em crianças. Neste trabalho apontamos, de acordo com os tipos de infecção do trato urinário bacteriana, as opções de tratamento com alguns dos principais antimicrobianos da atualidade.

Solitary mucormycosis in renal allograft: a case report

Mucormycosis is a known infection in renal transplantation responsible for mortality and morbidity in this group of patients. However, solitary mucormycosis in renal allograft is uncommon. We present a patient with solitary mucormycosis in the renal allograft suspected as pyonephrosis. Graft nephrectomy at one and half months after diagnosis and two and half months post-transplant was performed. The patient is clinically stable and on maintenance dialysis, without evidence of any infection subsequently

Fragmented Pigtail Percutaneous Nephrostomy Tubes: Etiology and Management

PURPOSE: To review our experience with the management of fragmented and retained pigtail percutaneous nephrostomy (PCN) tubes and to explore the reasons for the fragmentation. MATERIALS AND METHODS: We retrospectively reviewed our institute database from January 2006 to December 2011 for patients who had undergone retrieval of fragmented PCN tubes. We assessed the preoperative factors, operative technique, and post-operative outcomes. RESULTS: A total of seven patients (4 males and 3 females) had been diagnosed with fragmented PCN tubes. The mean age of the patients was 41.5 years. Of the seven patients, five required antegrade instrumentation by way of a percutaneous tract to remove the foreign body, mostly along with stone retrieval. One patient underwent ureterorenoscopy and pneumolithotripsy for a ureteric stone along with ureteroscopic removal of the PCN fragment. Another patient underwent nephrectomy of the kidney containing the PCN fragment because it had become nonfunctioning. All patients were free of stones and symptoms on follow-up. CONCLUSIONS: A prolonged waiting period for definitive surgery, urinary infection, and associated stone disease are significant factors causing fragmentation of PCN tubes. Proper insertion techniques, regular timed changes of the PCN tube, appropriate care of the PCN tube, and early surgery for underlying stone disease are required to avoid this complication. Patients with retained PCN tubes can be managed effectively with antegrade or retrograde endoscopic techniques while definitive management of the primary pathology is carried out, without any additional morbidity.

Endoscopic placement of double-J ureteric stents in children as a treatment for primary obstructive megaureter

To determine the efficacy and potential complications of double-J ureteric stents in the treatment of persistent or progressive primary obstructive megaureter in pediatric patients within our institution. A retrospective case-note review of all patients with double-J ureteric stents, between 1997 and 2004, was performed. In all, 38 stents were inserted in 31 patients aged between 2 months and 15 years of age. Complications and results of follow-up investigations and the need for follow-up investigations were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion. Endoscopic placement of double-J ureteric stents in childhood is straightforward and complications are uncommon [8/38 insertions]. In non-resolving or progressive primary non-refluxing megaureter, double-J ureteric stenting alone is effective with resolution of primary non-refluxing megaureter in 66% of cases [25/38 insertions]. Ureteric stenting provides an alternative to early surgery in patients with primary non-refluxing megaureter. The youngest patient in our series was 2 months old at the time of endoscopic ureteric double-J stent insertion. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of persistent or progressive non-refluxing megaureter leading to progressive hydronephrosis or pyonephrosis

Treatment of calculous pyonephrosis with percutaneous nephrolithotomy via the standard access / 南方医科大学学报

<p><b>OBJECTIVE</b>To investigate the feasibility of treatment for calculous pyonephrosis with first stage percutaneous nephrolithotomy under the standard access.</p><p><b>METHODS</b>Thirty-six cases of calculous pyonephrosis and 36 cases of urolithiasis with no pyonephrosis were treated by percutaneous nephrolithotomy. In the nephrostomy, the caliber was dilated to F24. All the operations were preformed through the EMS lithotrity system. The intrapelvic pressure was detected in the operation. The hemoculture before and after operation, the germi culture of urine, and the temperature and blood leucocyte changes after operation were recorded. All the patients were treated by antibiotics before and after the operation.</p><p><b>RESULTS</b>All the patients were treated successfully. The average intrapelvic pressure were 23.2 cmH(2)O in non-pyonephrosis group and 22.8 cmH(2)O in pyonephrosis group. Both of the groups had 1 case of transient bacteremia after the operation. No significant difference was found in the other indices between the two groups.</p><p><b>CONCLUSION</b>EMS lithotrity system is safe and feasible for treating calculous pyonephrosis with stage I percutaneous nephrolithotomy via the standard access.</p>

A case of spontaneous ureteral rupture in a patient on hemodialysis / 대한내과학회지

Spontaneous ureteral rupture is rare, and refers to leakage in the absence of prior ureteral manipulation, external trauma, previous surgery, or any destructive kidney disease. It presents a major diagnostic challenge due to the diversity at presentation. Here, we present a rare case of spontaneous ureteral rupture in a 62-year-old man with a history of fungal pyonephrosis (Candida) on maintenance hemodialysis, causing a large infected urinoma and abscess and a review the literature.

[Squamous cell carcinoma of the pelvis presenting as pyonephrosis. A case report and review of the literature]

Squamous cell carcinoma of the renal pelvis is a rare tumor with a poor prognosis, mainly occurring in patients with neglected and secondarily infected pyelocalyceal stones. We report a new case of a 45-year old man who presented with features of pyonephrosis and was subjected to nephrectomy. Post-operative histological evaluation revealed an unsuspected squamous cell carcinoma of the renal pelvis. The patient died 3 months after the operation. Based on our observation and a review of the literature, we discuss the etiopathogenesis, histological, clinical and therapeutic aspects of this pathology

Mucinous adenocarcinoma of the renal pelvis presenting as pyonephrosis: a case report.

Tumours of the renal pelvis are rare. We present a case of primary mucinous adenocarcinoma of the renal pelvis masquerading as pyonephrosis clinically and diagnosed on histopathologic examination. Patient presented with pyonephrosis of the left kidney due to a large staghorn calculus and was treated with tube nephrostomy followed by nephrectomy.

Pionefrose em paciente comcálculo ureteral infectado sem comprometimento do estado geral / Pyonephrosis in a patient with infected ureteral calculus without general state deterioration

Relatamos o caso de uma paciente de 34 anos que apresentou há 2 anos episódios de cólica renal, sendo diagnosticada litíase renal. Há 1 mês houveintensificação dos episódios de dor lombar à esquerda com irradiação para genitália, disúria, polaciúria, urgência urinária, febre alta e calafrios. IniciouCiprofloxacina sem melhora significativa dos sintomas, tendo sido internada para investigação diagnóstica e tratamento. Ao exame físico encontrava-sehipocorada, taquicárdica e febril. Abdômen doloroso à palpação e presença de massa palpável em hipocôndrio esquerdo. Os exames da admissãomostraram Hemoglobina 6,5g/dL, Leucócitos 17.100/mm3, Plaquetas 656.000/mm3, Creatinina 1,0mg/dL. A ultrassonografia abdominal evidenciounefrolitíase e hidronefrose à esquerda. Foi realizada nefrectomia do rim esquerdo. Na cirurgia o rim esquerdo estava aumentado e com consistênciacística, sem áreas de parênquima normal, com ureter dilatado e grande quantidade de secreção purulenta espessa e esverdeada. No examemicroscópico foram vistos glomérulos retraídos, atrofia tubular, intenso infiltrado inflamatório misto no interstício e áreas abscedadas atingindo inclusivea pelve renal. A paciente apresentou evolução favorável, recebendo alta com função renal normal e sem complicações no seguimento.

We report the case of a 34 years-old woman who had episodes of renal colic and a diagnosis of renal calculi. One month before admission she notedexacerbation of left-side lumbar pain, which irradiated to genital region, dysuria, polacyuria, urinary urgency and high degree fever, with chills. Treatmentwas started with Ciprofloxacin, but she had no clinical improvement and was admitted to investigation. At physical examination she was pale, tachycardicand febrile. Her abdomen was tender, with a palpable mass on left hypochondrium. The laboratorial tests showed hemoglobin 6.5g/dL, white blood cells17100/mm3, platelets 656,000/mm3, and creatinine 1.0mg/dL. The abdominal ultrasound showed left-side nephrolitiasis and hydronephrosis. It wasperformed left nephrectomy. The surgical description was: left kidney with increased size, with cystic consistence, without areas of normal parenchyma, withdilated ureter and large amount of thick and greenish secretion. At microscopic examination, protracted glomeruli, tubular atrophy and intense interstitialinflammatory infiltrate were observed, with areas of abscesses reaching renal pelvis. The patient had a favorable course and was dismissed with a normalrenal function. She did not present any complication during the follow-up.

A Case of Nephrocolic Fistula Associated with Staghorn Calculi / 대한신장학회잡지

A nephrocolic fistula is uncommon complication resulting from chronic inflammatory processes in the kidney. We report here a case of nephrocolic fistula associated with staghorn calculi. A 61-year-old female with known renal stones for three years was admitted to our hospital because of left flank pain and gross hematuria. Abdominal CT scan showed pyonephrosis with staghorn calculi in the left kidney. We performed percutaneous nephrostomy because of pelvocaliceal dilatation and high fever. Leakage of contrast dye was also detected in antegrade pyelogram, and drainage of fecal contents from nephrostomy was noted, suggesting fistulous formation between left kidney and colon. Clinical and laboratory findings of the patient deteriorated rapidly in spite of conservative management including antibiotics administration, so we performed nephrectomy with excision of the fistulous tract and partial colectomy. However, she showed delirium and had several attacks of generalized seizure, and she died of sepsis and multiple organ failure on the 33rd hospital day. In conclusion, when a nephrocolic fistula develops in patient with renal stone, prompt investigation and appropriate surgical treatment should be considered to improve the clinical outcome.

Usefulness of Unenhanced Helical CT in Patients with Suspected Ureteral Colic

PURPOSE: To determine the usefulness of unenhanced helical CT in patients with suspected renal colic. MATERIALS AND METHODS: One hundred and fourteen patients with suspected ureteral colic, referred by physicians, underwent unenhanced helical CT. Two radiologists prospectively interpreted the results, determining the presence or absence of ureter stone and other diseases that arise outside the urinary tract. In cases of ureteral stone, we retrospectively sought secondary signs of hydronephrosis, perinephric fat stranding, thickening of renal fascia, renal enlargement, and the tissue rim sign. RESULTS: Among the 114 patients, 57 were confirmed as having ureter stones. Unenhanced helical CT depicted 57 of 58 stones in 57 patients, producing one false-negative and one false-positive result. Overall, the results showed 98% sensitivity, 95% specificity, 98% positive predictive value, 95% negative predictive value, and 97% accuracy. The frequencies of secondary signs were as follows: hydronephrosis, 95% (54/57); perinephric fat stranding, 81% (46/57); thickening of renal fascia, 77% (44/57); renal enlargement, 65% (37/57); and the tissue rim sign 72% (21/29). In 20 patients, the diagnoses were not related to stone disease and included one falsenegative diagnosis of pyonephrosis. CONCLUSION: Unenhanced helical CT provides information which is valuable in the accurate diagnosis of ureteral stone as well as other diseases that arise outside the urinary tract in patients with suspected renal colic.

Clinical Studies of Xanthogranulomatous Pyelonephritis / 대한비뇨기과학회지

PURPOSE: Because the preoperative diagnosis of xanthogranulomatous pyelonephritis (XGP) is difficult due to its similarities to other renal diseases, the diagnosis is made postoperatively in most patients. The aim of this study was to improve preoperative diagnosis of this disease. MATERIALS AND METHODS: We reviewed clinical characteristics, laboratory and radiological findings, preoperative diagnoses, and operative methods of 6 patients with XGP who underwent operation from March 1991 to July 1998. Mean age was 49.8 years (range 28 to 80) and male to female ratio was 1 to 2. RESULTS: All 6 patients had flank pain and urinary tract infection. Among 6 patients, there were 3 patients (50%) with renal staghorn stone and 1 (16.7%) with ureteropelvic junction stricture. No patient was diagnosed as XGP preoperatively. Three patients (50%) diagnosed as pyonephrosis with staghorn stone preopratively underwent simple nephrectomy and 2 patients diagnosed as renal mass preoperatively underwent radical nephrectomy. One patient diagnosed as renal abscess extended to retroperitoneum and psoas muscle preoperatively was diagnosed as XGP through intraoperative frozen section biopsy of renal tissue and underwent partial nephrectomy and drainage. CONCLUSIONS: Preoperative diagnosis of XGP will be raised through better understanding of the clinical characteristics and radiologic findings of this disease.