Alternating Biplanar Fluoroscopy in Percutaneous Nephrostomy to Approach Stones in Patients With Horseshoe Kidney: An Institutional Experience.

This case series aims to evaluate the use of alternating perpendicular biplanar fluoroscopy in percutaneous nephrostomies/percutaneous nephrolithotripsies (PCNs/PCNLs) to approach renal stones in patients with horseshoe kidneys. Between January 2012 and December 2019, PCNs/PCNLs were done for six patients with horseshoe kidneys having renal stones. Skin and renal calyceal entry points were determined by alternating perpendicular biplanar fluoroscopy using a portable C-arm machine in the conventional fluoroscopy unit. The site of renal access, postoperative complications, and residual stones was assessed. The mean age of the patients was 36.8 years. The mean stone size was 6.1 cm (2.1-16.05cm). In five out of six (5/6; 83%) patients, there was one access site. Four patients had their access site through the upper calyx, and one patient had it through the lower calyx. The stone-free rate was four out of six (4/6; 66.6%). One patient had a mild drop in hemoglobin postoperatively. There were no major complications reported. The implementation of alternating biplanar fluoroscopy was found safe and helpful in providing a better appreciation of renal anatomy and stone location in patients with horseshoe kidneys. This technique helps in approaching horseshoe kidney stones in PCN/PCNL without moving the patient or fluoroscopy machine, with a potential decrease in operation time and radiation exposure.

Metastatic hepatocellular carcinoma to parotid glands.

PATIENT: Male, 66. FINAL DIAGNOSIS: Hepatocellular carcinoma. SYMPTOMS: Abdominal distension • painful right facial swelling • weight loss. MEDICATION: -. CLINICAL PROCEDURE: -. SPECIALTY: -. OBJECTIVE: Rare disease. BACKGROUND: Hepatocellular carcinoma is a common cancer, but it rarely metastasizes to the salivary glands. A review of the literature revealed only 5 reported cases of hepatocellular carcinoma metastatic to parotid glands. We here report an additional case of this rare association. CASE REPORT: A 66-year-old male with a background of type 2 diabetes mellitus and post-alcoholic decompensated liver cirrhosis presented with a progressively enlarging painful right facial swelling for 2 months that was eventually found to be due to hepatocellular carcinoma metastatic to the right parotid gland. Fine needle aspiration from the right parotid showed sheets and single malignant cells that were interpreted as carcinoma not otherwise specific. However, biopsy showed metastatic hepatocellular carcinoma into the right parotid gland. CONCLUSIONS: We report an additional case of the rare metastasis of hepatocellular carcinoma to the parotid glands. It should therefore be considered in a patient with decompensated liver cirrhosis presenting with a parotid swelling. Furthermore, the present case demonstrates the importance of the tissue biopsy for obtaining an accurate final diagnosis.

Peritoneal tuberculosis in Qatar: a five-year hospital-based study from 2005 to 2009.

There is limited information about peritoneal tuberculosis in Qatar. This retrospective study aimed to review our experience with peritoneal tuberculosis in patients admitted to Hamad general hospital over a period of 5 years, from 2005 to 2009, with emphasis on presentation, investigation, diagnosis and therapeutic outcome. Fifty-four patients with peritoneal tuberculosis identified during the study period were included. The mean age of them was 31.85 years and 96.3% (52/54) of them were non-Qataris with male predominance. The main symptoms and signs at the time of presentation were abdominal pain and ascites respectively. Underlying diseases were described in 24% (13/54) and history of contact with tuberculous cases was present in 31.5% (17/54) of patients. Tuberculin test was positive in 66.7% (36/54). The ascitic fluid smear showed acid fast bacilli in 2% (1/53), and culture was positive in 39.6% (21/53) of cases. Laparoscopically obtained peritoneal biopsy showed caseating granulomas in 93% (40/43) and mycobacteria were identified by acid fast staining and culture in 58.5% (24/41) and 98% (40/41) of the tested specimens respectively. Most of the patients (84%; 37/44) who had completed their therapy in Qatar improved with antituberculosis therapy, and only one patient died. In conclusion, the clinical features and the imaging findings of the disease were non-specific. A high index of suspicion is essential for early diagnosis. Culture of ascitic fluid delayed the diagnosis in clinically suspected cases, whereas laparoscopically guided peritoneal biopsy provided rapid and correct diagnosis. A Six-month course with antituberculous therapy was effective and improved the outcome.

Primary leiomyosarcoma of the inferior vena cava: report of a case diagnosed by fine needle aspiration cytology and confirmed by histopathologic examination.

BACKGROUND: Leiomyosarcoma is a malignant neoplasm and can originate within major abdominal veins, including the inferior venacava (IVC). CASE: A 45-year-old woman presented with upper abdominal pain and a mass lesion in the liver and within the lumen of the IVC. A diagnosis of primary leiomyosarcoma of the IVC was made by using imaging techniques,fine needle aspiration cytology and histopathologic examination of the resected specimen. CONCLUSION: In patients presenting with vague upper abdominal pain and radiologic features of a hepatic mass extending to major veins, the rare possibility of primary leiomyosarcoma of the IVC shoald he considered and investigated by both fine needle aspiration cytology and intraoperative histology. Early surgical intervention and/or postoperative chemotherapy and radiotherapy are associated with improved survival.

Is the 10th and 11th intercostal space a safe approach for percutaneous nephrostomy and nephrolithotomy?

The aim of this study was to determine the rate of complications in percutaneous nephrostomy (PCN) and nephrolithotomy (PCNL) performed through the 11th and 10th intercostal spaces using our monitoring technique and to discuss the safety of the procedure. Out of 398 PCNs and PCNLs carried out during a 3-year period, 56 patients had 57 such procedures performed using an intercostal approach. The 11th intercostal route was used in 42 and the 10th in 15 cases. One patient had two separate nephrostomies performed through the 10th and 11th intercostal spaces. The technique utilizes bi-planar fluoroscopy with a combination of a conventional angiographic machine to provide anterior-posterior fluoroscopy and a C-arm mobile fluoroscopy machine to give a lateral view, displayed on two separate monitors. None of the patients had clinically significant thoracic or abdominal complications. Two patients had minor chest complications. Only one developed changes (plate atelectasis, elevation of the hemi-diaphragm) directly related to the nephrostomy (2%). The second patient had bilateral plate atelectasis and unilateral congestive lung changes after PCNL. These changes were not necessarily related to the procedure but rather to general anesthesia during nephrolithotomy. The authors consider PCN or PCNL through the intercostal approach a safe procedure with a negligible complication rate, provided that it is performed under bi-planar fluoroscopy, which allows determination of the skin entry point just below the level of pleural reflection and provides three-dimensional monitoring of advancement of the puncturing needle toward the target entry point.