Perioperative management of phaeochromocytoma with stress cardiomyopathy and aberrant vascular drainage.

The following case discusses the surgical considerations for a patient presenting with cardiogenic shock secondary to a phaeochromocytoma crisis with stress cardiomyopathy. The patient underwent an interval laparoscopic adrenalectomy. Pneumoperitoneum insufflation was performed at lower pressures; manipulation of the adrenal tumour was minimised, and the adrenal vein was ligated early. However, as intraoperative blood pressure (BP) remained elevated and rising, further gentle dissection revealed an aberrant inferior phrenic vein draining the adrenal nodule. BP was finally reduced following ligation of the inferior phrenic vein, demonstrating the clinical significance of an unusual dual venous drainage from the adrenal nodule in this patient.

Elevated HCG and retroperitoneal adenopathy after clomiphene therapy for infertility.

In the context of an elevated human chorionic gonadotropin (HCG) with enlarged retroperitoneal nodes and absent testicular tumours, clinicians will consider a diagnosis of extragonadal germ cell tumours. We report the case of a man in his thirties who while on treatment for subfertility with clomiphene citrate was noted to have enlarged retroperitoneal nodes and elevated HCG levels of 75 IU/L. Chemotherapy with bleomycin, etoposide and cisplatin originally planned was deferred when two separate retroperitoneal nodal biopsies returned as benign fibroadipose tissue and HCG levels spontaneously down-trended to 4 IU/L within 4 months of clomiphene citrate discontinuation. Follow-up imaging revealed regression of the retroperitoneal nodes.

Case of flank pain from ureteral injury after lumbar laminectomy.

We present a case of an iatrogenic complete left proximal ureteric injury after a lumbar 1 laminectomy and intradural tumour excision and lumbar 4/5 transforaminal lumbar interbody fusion. Initial management included a percutaneous nephrostomy for urinary diversion followed by definitive urinary reconstruction with an ileal ureter.

Primary renal synovial sarcoma presenting with a retroperitoneal bleed.

Synovial sarcomas are most commonly localised in extremities, especially in the lower thigh and knee areas. Comprising less than 1% of all malignancies, retroperitoneal synovial sarcoma is very rare with primary synovial sarcoma of the kidney being even more infrequent and difficult to diagnose. We describe a case report of a renal synovial sarcoma in a young adult who was initially managed as a case of Wunderlich's syndrome secondary to what was believed to be a ruptured renal angiomyolipoma. After biopsy confirmation, the patient was eventually managed with neo-adjuvant chemotherapy followed by a right radical nephrectomy and right hepatectomy. Despite its rarity, synovial sarcoma should be considered as differential diagnosis of a bleeding retroperitoneal soft tissue mass detected in young adults.

Unusual finding after treatment for testicular cancer.

In the context of a post-treatment testicular germ cell tumour, an abdominal lesion found on surveillance CT studies led to a differential diagnosis, including recurrent germ cell tumour. We report the case of a 48-year-old man who was noted to have a new interval soft tissue lesion on a surveillance CT scan, 5 years after initial orchidectomy and chemotherapy. Excision of this lesion and histopathological review revealed an intra-abdominal desmoid.

The optimal management of variant histology in muscle invasive bladder cancer.

Bladder cancer is a heterogenous disease that is associated with tangible mortality in muscle invasive disease. The WHO 2016 classification of urothelial tumours reflects the contemporary approach towards histological variants in bladder cancer, including variants of urothelial carcinoma (UC) and non-urothelial variants. This review focuses on variant histology in UC, and discusses the importance of accurate histological diagnosis, and subsequent risk stratification and therapeutic decision making based on proper variant recognition. Most urothelial variants are associated with poorer outcomes compared to conventional UC, although some perform reasonably better. However, high quality evidence detailing optimal treatment and survival outcomes are still lacking in literature, due to the rarity of these cases.

Role of computed tomography-calculated intraparenchymal tumor volume in assessment of patients undergoing partial nephrectomy.

OBJECTIVES: To determine the complexity of renal masses by using an objective novel imaging parameter (intraparenchymal tumor volume) based on computed tomography scans, to correlate this parameter to perioperative outcomes and to the RENAL nephrometry score. METHODS: After institutional review board approval, 87 patients who underwent partial nephrectomy between 2012 and 2016 at Singapore General Hospital, Singapore, were retrospectively analyzed. Preoperative computed tomography intravenous pyelogram scans were reviewed by a single senior radiologist who calculated the intraparenchymal tumor volume. Once the intraparenchymal tumor volume scores were obtained, they were compared with perioperative renal and surgical outcomes, and nephrometry scores. Furthermore, intraparenchymal tumor volume was subdivided into two categories, low and high intraparenchymal tumor volume, both using the 89th percentile. RESULTS: The mean patient age was 60 years, and the mean tumor size was 2.9 cm. The mean nephrometry score was 7.8, and the mean intraparenchymal tumor volume score was 12.7 cm³. The cut-off for high intraparenchymal tumor volume was >27.26 cm³. As a continuous variable, intraparenchymal tumor volume showed a significant relationship with the percentage of creatinine change (P = 0.009) and nephrometry scores (P < 0.001). As a categorical variable, high intraparenchymal tumor volume showed significance when compared with absolute creatinine change (P = 0.018), percentage of creatinine change (P = 0.004) and nephrometry score (P < 0.001). CONCLUSIONS: Intraparenchymal tumor volume represents a novel objective tool based on computed tomography imaging to determine the complexity of a renal mass. This tool correlates with renal functional outcomes of partial nephrectomy, and it also shows good correlation with RENAL nephrometry score.