Emphysematous pyelonephritis: our experience with conservative management in 14 cases

Emphysematous pyelonephritis [EPN] is a rare, severe, acute, necrotizing infection of the kidney. In this study, we present the clinical details, the management strategies, and the outcome of fourteen patients of EPN managed at our center. A retrospective analysis of the hospital records was done. A total of fourteen patients with EPN were admitted in our hospital from August 2007 to February 2011. All the patients were managed conservatively. Follow-up ranged from six months to one year. Of the fourteen patients, four belonged to class I, five to class II, four to class III A and one to class III B. All the patients had history of fever, 43% had localized flank pain while 36% had vague abdominal discomfort. Renal angle tenderness was the most common sign, seen in 86% of the patients. E. coli was the most common bacteria, which was isolated from urine in 57% of the patients. On the risk factor stratification, three patients had simultaneous presence of 2 or more risk factors [thrombocytopenia-2 patients; renal function impairment-7 patients; shock-1 patient]. All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad spectrum antibiotics. Intervention, in the form of percutaneous drainage or DJ stenting, was done in six patients. One patient failed to respond to this minimally invasive modality of treatment and had to undergo an open drainage. Thus, the acute episode was managed with conservative management strategies in all the patients; however, three patients underwent nephrectomy due to poorly-functioning kidney during follow-up. EPN is now being more readily diagnosed, at an early stage, making conservative management of EPN a safe, effective, and feasible option.

Urinary tract endometriosis: review of 19 cases

The aim of our study was to evaluate the treatment outcomes of medical and surgical management of urinary tract endometriosis. Urinary tract endometriosis patients enrolled between Jan 2006 and May 2010 were retrospectively reviewed. Preoperative datas [mode of presentation, diagnosis, imaging], intraoperative findings [location and size of lesion], postoperative histopathology and follow-up were recorded and results were analyzed and the success rate of different modalities of treatment was calculated. In our study, of nineteen patients, nine had vesical involvement and ten had ureteric involvement. Among the vesical group, the success rate of transurethral resection followed by injection leuproide was 60% [3/5], while among the partial cystectomy group, the success rate was 100%. Among patients with ureteric involvement, success rate of distal ureterectomy and reimplantation was 100%, laparoscopic ureterolysis with Double J stenting followed by injection leuprolide was 75% while that of Gonadotropin- releasing hormone [GnRh] analogue alone was 67%. One should have a high index of suspicion with irritative voiding symptoms with or without hematuria, with negative urine culture, in all premenopausal women to diagnose urinary tract endometriosis. Partial cystectomy is a better alternative to transurethral resection followed by GnRh analogue in vesical endometriosis. Approach to the ureter must be individualised depending upon the severity of disease and dilatation of the upper tract to maximise the preservation of renal function

Upper gastro-intestinal bleeding - rare presentation of renal cell carcinoma

Renal cell carcinoma [RCC] constitutes 2-3% of all adult malignancies and often diagnosed incidentally. Classical tried of RCC now rarely seen, it behaves unpredictably and having diverge range of clinical manifestation including paraneoplastic syndromes. Upper gastrointestinal [GI] bleeding due to stomach metastasis of RCC is uncommon and to the best of our knowledge, only few cases are reported in world literature and most of them were diagnosed during follow-up after complete treatment of RCC but in our case, it was the primary manifestation of disease. Our case also demonstrates the importance of imaging in undiagnosed cases of upper GI bleeding

Laparoscopic ureteroneocystostomy for management of lower ureteric strictures

We assessed the results of laparoscopic transperitoneal ureteroneocystostomy with or without a psoas hitch for management of lower ureteral strictures. Between October 2005 and August 2008, 16 patients with lower ureteric strictures underwent laparoscopl uretroeocystostomy with or without a psoas hitch. Etiology of strictures was gynecological surgery in 11, surgery for stone disease in 3, ureterovaginal fistula in 1 and primary obstructive megaureter in 1. Transperitoneal 3- or 4-port laparoscopic ureteroneocystostomy was performed with or without psoas hitch. 1. All operations were successfully completed without any need for conversion to open. Mean operative time was171.56 min [range 130 to 260 min], mean blood loss was 93.44 cc [range 30 to 200 cc] and total hospital stay was 3.73 days [range 3 to 6 days]. Mean time to resume oral intake was 12.5 h [range 8 to 22 h]. Mean follow-up period was 21.83 months [range 6-39 months]. Postoperative follow-up investigations revealed successful outcome in all 16 patients, success being defined as relief of symptoms and radiological improvement, irrespective of the refluxing status. Non-refluxing status was achieved in 15 out of 16 patients as determined by micturition cystography. Laparoscopic ureteroneocystostomy is a safe and effective procedure, with inherent advantages of laparoscopic surgery