Perivascular epithelioid cell tumour (PEComa) of the inferior vena cava presenting as an adrenal mass.

A 54-year-old woman had a mass located in the right suprarenal area. On imaging, this mass appeared to be infiltrating the inferior vena cava (IVC). Exploratory laparotomy was undertaken and excision of the tumour was done with the sleeve of the involved IVC. The mass turned out to be a perivascular epithelioid cell tumour (PEComa) on histopathological examination. This report describes previously reported cases of PEComa in brief and highlights the problems associated with the management of this tumour.

Fracture of the penis: a radiological or clinical diagnosis? A case series and literature review.

INTRODUCTION: Fracture of the penis is rare and needs a surgeon's attention for appropriate management. The exact role of diagnostic investigations has not been established. We studied the role of these investigations and the results of surgery. CASE SERIES: Seventeen patients with median age of 36 years (range, 27-72 years) presented to us between 2002 and 2007 with suspected fracture of the penis. The mode of injury was sexual intercourse (15 patients), masturbation (1 patient), and rolling over in bed (1 patient). The median time from injury to presentation was 10 hours (range, 1-144 hours). Clinical evaluation included patient history and examination for all patients, ultrasonography in 6 patients, retrograde urethrography in 6 patients, and magnetic resonance imaging in 1 patient. Fifteen patients underwent immediate surgical exploration, 1 patient was kept under observation, and 1 patient refused surgical exploration. DISCUSSION: Patient history and clinical examination were highly sensitive and accurate in predicting a cavernosal tear, and retrograde urethrography was highly sensitive and accurate in detecting urethral injury. Ultrasonography was highly specific but not sensitive for detecting a cavernosal tear. Radiological investigations did not influence patient management in any of the cases. On surgical exploration, 15 patients had cavernosal tears and 4 also had urethral injuries; all injuries were repaired successfully. One patient had a negative surgical exploration and was diagnosed as having a superficial dorsal vein rupture. One patient had a history suggestive of penile fracture but had a normal clinical examination and was kept under observation. At follow up in a mean of 7.5 months, no patient had erectile dysfunction or penile deformity. CONCLUSION: Further evaluation beyond taking a patient history and performing a clinical examination is not necessary in most cases for managing patients with suspected penile fracture. Retrograde urethrography may be omitted before surgical exploration, even in cases with suspected urethral injury. Early surgical repair is associated with a good outcome with minimal complications.

Giant retrovesical epithelioid hemangioendothelioma presenting with acute urinary retention: a case report.

Epithelioid hemangioendothelioma (EH) is a very rare vascular tumor of intermediate biological behavior. It can arise from various sites including bone, liver, spleen, pleura, lung, skin, or soft tissue. We report a case of a 24-year-old man who presented with a history of acute urinary retention and a palpable lump in the lower abdomen. Imaging showed a large pelvic mass displaying heterogeneous texture with solid and cystic components compressing and displacing adjacent structures. The patient underwent exploratory laparotomy with excision of the pelvic mass. Histopathological examination confirmed the diagnosis of EH. Pelvic soft tissue origin of EH is extremely rare. The diagnosis of EH may be suggested by characteristic magnetic resonance imaging (MRI) findings.

Endourologic management of forgotten encrusted ureteral stents: can ureteroscopic lithotripsy be avoided?

We present endourologic management strategies and tricks to minimize instrumentation and complications in long-indwelling encrusted stents. Seventeen patients presented with 19 retained ureteral stents (median indwelling time 3.0 y; 0.25 to 17 y). Investigations included x-ray, ultrasound, noncontrast computed tomography, excretory urography, magnetic resonance imaging, Tc diethylenetriaminepenta-acetic acid scan, and retrograde ureterography. Incrustation was present in all stents, encrustation 16, stone formation 11, and spontaneous fragmentation 3. All patients had gaping of ureteric orifices and dilated capacious ureters with no stent impaction. Management included extracorporeal shock wave lithotripsy (2), simple pull under fluoroscopy cystoscopically (2) and ureteroscopically (2), cystolithotripsy (10), percutaneous nephrolithotripsy (6), nephrectomy (2), and no intervention (2). In 3 patients with large encrustation burden, tubular encrustation in ureteral segment of stent could be removed intact without lithotripsy. To conclude, encrusted ureteral stents can be successfully managed using endourologic interventions. Owing to capacious ureter and nonimpacted stent, a careful attempt of pulling can be made under fluoroscopic guidance to minimize the time of ureteroscopic lithotripsy and complications thereof.

Acute pyelonephritis with renal vein and inferior vena cava thrombosis in a case of hyperhomocysteinemia.

Acute pyelonephritis is not considered a common cause of renal vein (RVT) and inferior vena caval thrombosis (IVCT). Apart from malignancy, RVT is not an uncommon condition amongst patients with nephrotic syndrome, most commonly seen in patients with membranous glomerulonephritis. However, RVT occurring in association to acute pyelonephritis is rare. Clinically, it is difficult to distinguish between acute pyelonephritis and RVT because both present with fever, flank pain, and hematuria. We report a case of acute pyelonephritis with RVT and IVCT with underlying hyperhomocysteinemia. The patient was treated with systemic anticoagulation, antibiotics, and B complex therapy. At 3 months follow-up, there was complete resolution of thrombus but the left kidney was nonfunctioning.

Lactose intolerance in prostate cancer patients: incidence and associated factors.

OBJECTIVE: Osteoporosis is common in prostate cancer (CaP) patients both before and after institution of androgen deprivation therapy and is associated with significant morbidity. Lactose intolerance (LI) can affect bone mass but has not been studied in this group of patients. The objective of this study was to compare the incidence of LI in CaP patients with that in the general population and to identify factors affecting lactose intolerance in CaP patients. MATERIAL AND METHODS: Fifty-five men with CaP planned for bilateral orchidectomy were enrolled in the study and their baseline characteristics including age, weight, height, body mass index (BMI), prostate-specific antigen, serum calcium profile, lactose tolerance status, physical activity, alcohol intake and smoking, bone mineral density and calcium intake were registered. The data on lactose tolerance in these patients were compared with those of 81 age-matched controls (data taken from the available database). RESULTS: The incidence of LI in CaP patients was significantly less than that in the control group (36.2% and 58.3%, respectively, p = 0.027). A significantly greater number of CaP patients in the lactose-tolerant group had a calcium intake of >1500 mg/day (p = 0.03) and that of milk >500 ml/day (p = 0.05) than those in the intolerant group. Age >70 years, BMI <25 kg/m2, height >163 cm, lower physical activity and co-abuse of alcohol and smoking significantly correlated with the presence of LI (p < or = 0.05). Patients with serum calcium <9 mg/dl had higher fasting breath H2 levels and a higher proportion had a BMI >25 kg/m2 and weight >65 kg. CONCLUSIONS: The incidence of LI in CaP patients is less than that in the general population despite a higher incidence of osteoporosis, indicating a complex etiology of CaP-related osteoporosis. Certain physical characteristics and personal habits are important in determining lactose-tolerant status.

Implication of the cystic fibrosis transmembrane conductance regulator gene in infertile family members of Indian CF patients.

Cystic fibrosis (CF) is an autosomal recessive disease caused by mutations in the CFTR gene. Among males with CF, 95% are infertile due to congenital absence of the vas deferens. We investigated the role of family history of infertility among CF subjects and characterized mutations in them. Among 50 CF subjects, four had a family history of infertility. A homozygous c.1521_1523delCTT mutation was detected in one, two had a compound heterozygous genotype (c.1521_1523delCTT/c.3717 + 10 kbC>T), and c.1521_1523delCTT mutation was identified on one allele of fourth CF subject. Genetic analysis of each infertile family members of CF subjects revealed the c.1521_1523delCTT mutation on one allele; however, no mutation could be identified on other allele. Haplotype analysis of the infertile family members showed that at least one of the alleles shared the same haplotype as that of the index case. It is suggested that the CFTR gene is implicated in the infertile members of the CF families. Failure to detect mutations on the other allele by SSCP analysis demands direct gene sequencing to detect mutations in the intronic or promoter region.

Tamsulosin facilitates earlier clearance of stone fragments and reduces pain after shockwave lithotripsy for renal calculi: results from an open-label randomized study.

OBJECTIVES: To evaluate the role of tamsulosin in the clearance of fragments after extracorporeal shock wave lithotripsy (ESWL) to treat renal calculi. METHODS: In this open-label prospective randomized study conducted at our institute from 2006 to 2007, 139 patients with normal renal function and a single radiopaque renal calculus, 5-20 mm, undergoing ESWL were enrolled. All patients underwent ESWL every 3 weeks until success or for

Laparoscopic nephron-sparing surgery for metanephric adenoma.

A 47-year-old patient presented with hematuria of 3-month duration. Computed tomography revealed right lower polar exophytic mass. Laparoscopic nephron-sparing surgery was performed. The macroscopic examination of the mass showed encapsulated tumor with soft pultaceous material. Histologic examination of the mass was consistent with metanephric adenoma. We are reporting this case of metanephric adenoma, being treated with laparoscopic partial nephrectomy.

Laparoscopic pyeloureterostomy in ureteral duplication with lower polar ureteropelvic junction obstruction: easy and effective.

Ureteropelvic junction (UPJ) obstruction in ureteral duplication is not uncommon. Ureteropyelostomy is a safe, easy surgical option when the adequate length of the distal ureter is not available for pyeloplasty. In this paper, we present the case of a 26-year-old male who was treated with laparoscopic ureteropyelostomy for a symptomatic lower moiety UPJ obstruction.

Laparoscopic ureterocalicostomy for salvage of giant hydronephrotic kidney: initial experience.

Reconstructive surgery for salvage of giant hydronephrosis is associated with unique challenges. We introduce the surgical technique of laparoscopic ureterocalicostomy for giant hydronephrosis. A transperitoneal five-port access was created and, after reflecting the colon, the lower pole of the hydronephrotic sac was excised. A wide, spatulated end-to-end ureterocaliceal anastomosis was performed. The sac was decompressed slowly in a controlled manner, which helped during dissection. At 3 months of follow-up, the patient was symptom free, and retrograde ureterography showed a wide, patent anastomosis. Laparoscopic ureterocalicostomy is technically feasible for the salvage of a giant hydronephrotic kidney and duplicates the results of open surgery.

Non-interventional management of obstructive acute renal-failure in hormone-naïve prostate cancer.

Advanced carcinoma prostate (CaP) commonly presents as bilateral ureteric obstruction. The management often requires androgen ablation along with temporary urinary diversion (percutaneous nephrostomy or ureteric catheterization) which is not infrequently associated with complications. Two patients of hormone-naïve CaP presented to our emergency department with oliguric renal failure due to bilateral ureteric obstruction and were treated with dialysis, ketoconazole (for androgen ablation) and corticosteroids; urinary diversion was not feasible in either at the time of presentation. Brisk diuresis occurred within 48 hours obviating the need of urinary diversion. Follow-up of these cases is presented and justification of this approach is discussed.

Superior mesenteric artery injury during en bloc excision of a massive left adrenal tumor.

Superior mesenteric artery (SMA) injury is a rare event during abdominal surgery. We report the first case of inadvertent injury of the superior mesenteric artery during surgery of a large malignant adrenocortical tumor with inferior vena cava thrombus. The cause of inadvertent injury was anatomical distortion of the great vessels due to the massive nature of the tumor. The case was managed successfully by immediate end-to-end anastomosis of the superior mesenteric artery.

Congenital vesicovaginal fistula with transverse vaginal septum and ectopic ureter opening in proximal vagina: case report and brief review.

Congenital vesicovaginal fistula is an extreme rarity. We report on a case of a 22-year-old lady who presented with menouria and infertility. On evaluation, she was found to have congenital vesicovaginal fistula, a nonfunctioning right kidney with ectopic ureter and transverse vaginal septum. Abdominal repair of the fistula, right nephroureterectomy, and excision of the vaginal septum was performed.

Comparison of outcomes in patients undergoing coronary bypass of patent versus restenosed bare metal stented coronary arteries.

It is unclear whether bypass of a patent stented artery affects clinical outcomes. We sought to compare the survival of patients who, as part of multisystem coronary artery bypass grafting, underwent revascularization of arteries with patent stents (<50% stenosis) or in-stent restenosis (>50% diameter stenosis). Of 550 consecutive patients with previously placed stents who underwent coronary artery bypass grafting from May 1995 to October 2003, we studied 399 who had only 1 stented vessel bypassed at surgery. Of these, 128 had coronary bypass to an artery with a patent stent and 271 had bypass to an artery with in-stent restenosis. Nonparametric survival estimates were obtained using the Kaplan-Meier method. A propensity-adjusted multivariate hazard model of group differences was generated using variables identified by bootstrap bagging. The unadjusted survival rate at 1 month, 1 year, and 5 years was 99.7%, 97.3%, and 89.1%, respectively, for the patent stent group and 96.6%, 93.9%, and 86.2%, respectively, for the in-stent restenosis group, a result of high early risk in the latter group. After adjusting for clinical variables, neither stent patency (p = 0.9) nor interval (p = 0.3) from stent placement was a risk factor, although advanced age, increased blood urea nitrogen, and preoperative atrial fibrillation were associated with poorer survival. In conclusion, survival after bypassing a patent stented coronary artery is comparable to that after bypassing a stented restenotic coronary artery.

Relation of homocysteine and C-reactive protein to urinary albumin loss.

This study shows that elevated high-sensitivity C-reactive protein and plasma total homocysteine contribute independently to the likelihood of an increased urinary albumin:creatinine ratio. This result suggests that total homocysteine and C-reactive protein may be acting by separate mechanistic pathways.

Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era.

BACKGROUND: Since the advent of percutaneous coronary interventions (PCIs), technological advances, adjunctive pharmacotherapy, and increasing operator experience have contributed to lowering the occurrence of major complications. However, emergency coronary artery bypass surgery (CABG) for failed PCI is still associated with important morbidity and mortality, even in the era of coronary stenting. We sought to determine the prevalence, indications, predictors, and complications of emergency CABG after PCI in the past decade. METHODS AND RESULTS: We reviewed 18 593 PCIs performed from 1992 through 2000. There was a need for emergency CABG in 113 (0.61%) cases. The major indications were extensive dissection (n=61, 54%), perforation/tamponade (n=23, 20%), and recurrent acute closure (n=23, 20%). Prevalence of emergency CABG decreased from 1.5% of PCIs in 1992 to 0.14% in 2000 (P<0.001). Independent predictors of the need for emergency CABG included the worst ACC/AHA scoring of the intervened lesion (P<0.001) and female sex (P= 0.028), whereas history of prior bypass surgery and use of stents resulted in a decreased need for emergency CABG (P<0.001 for both). In patients undergoing emergency CABG, there were 17 (15%) in-hospital deaths, 14 (12%) perioperative Q-wave myocardial infarctions, and 6 (5%) cerebrovascular accidents. CONCLUSIONS: The need for emergency CABG has considerably decreased over time. Risk factors include female sex and a higher ACC/AHA score of the intervened lesion. However, morbidity and mortality of emergency CABG remain high even in the new millennium.