The Problem of Occult Pyelonephritis: Acute Pyelonephritis in Patients Presenting Only with Lower Urinary Tract Symptoms.

Pyelonephritis is a prevalent diagnosis of emergency department visits. It commonly presents as flank pain and costovertebral tenderness with urinary symptoms. However, some cases occur without typical symptoms. Our study highlights the dubious presentation of pyelonephritis with lower urinary tract symptoms (LUTS) only. This study was conducted at a tertiary care hospital, where charts and files were reviewed from January 11, 2018 to February 28, 2019 for all the patients with a diagnosis of acute pyelonephritis from medical records. In our study, 521 patients were included and 492 (94%) of the participants were suffering from pyelonephritis. Approximately 22.8% of the patients showed the absence of both flank pain and costovertebral tenderness but were diagnosed with pyelonephritis based on computed tomography (CT) and magnetic resonance imaging (MRI). Moreover, 27% of the patients reported upper urinary tract symptoms only and were diagnosed by CT or MRI findings. Out of that only 24% and 16% of the patients reported flank pain and costovertebral tenderness, respectively. Insignificant associations with pyelonephritis were found for age, gender and other comorbidities. Our study showed a significant number of patients with pyelonephritis without any upper urinary tract symptoms. Patients with LUTS should be evaluated further by imaging if they belong to the high-risk population.

Antireflux Ureteral Stent Improves Stent-Related Symptoms and Quality of Life: A Prospective Randomized Controlled Trial.

Objectives: To compare the effectiveness of antireflux ureteral stents on improving symptoms and quality of life of patients with ureteral stents. Materials and Methods: We randomized 120 patients with ureteral stone who required ureteral stent placement after ureteroscopic lithotripsy, of which 107 (56 in standard ureteral stent group and 51 in antireflux ureteral stent group) entered the final analysis. Severity of flank pain and suprapubic pain, visual analog scale (VAS), analgesic used after hospitalization, back soreness during micturition, gross hematuria, creatinine abnormality, hydronephrosis grade, symptomatic urinary tract infection (UTI), and quality of life were compared between the two groups. Results: There were no serious complications after operation in all 107 cases. The antireflux ureteral stent group had less flank pain and suprapubic pain (p < 0.05), analgesic used after hospitalization (p < 0.05), back soreness during micturition (p < 0.05), and lower VAS (p < 0.05). The health status index scores (p < 0.05), dimensions of usual activities, and pain/discomfort (p < 0.05) in the antireflux ureteral stent group were statistically better than those in the standard ureteral stent group. There were no significant differences between the groups in creatinine abnormality, hydronephrosis grade, gross hematuria, and symptomatic UTI. Conclusions: The antireflux ureteral stent has the same safety and efficacy as the standard ureteral stent, and is significantly better than the standard ureteral stent in flank pain and suprapubic pain, VAS, analgesic used after hospitalization, back soreness during micturition, and quality of life.

The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments.

INTRODUCTION: The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs. METHODS: All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated. RESULTS: NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3 mg/L, and 1 mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95 mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95 mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%. CONCLUSIONS: WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting.

Predictors of renal infarction in patients presenting to the emergency department with flank pain: A retrospective observational study.

OBJECTIVES: Flank pain is a common symptom in the emergency department and can be caused by a variety of diseases. Renal infarction (RI) is a very rare disease, and many RI patients complain of flank pain. However, there is no definitive predictor of RI when patients complain of flank pain. This study aimed to identify the clinical factors for predicting RI in patients with flank pain. METHODS: This retrospective single-center study was conducted on patients complaining of flank pain from January 2016 to March 2020 at a South Korean tertiary care hospital. Exclusion criteria included patients who did not undergo contrast-enhanced computed tomography, age < 18 years, and trauma. Demographic and laboratory data were obtained from medical records. Logistic regression analysis was conducted to identify predictors of RI occurrence. RESULTS: In all, 2,131 patients were enrolled, and 39 (1.8%) had RI. From a multivariable logistic regression analysis, an age ≥ 65 years (odds ratio [OR], 3.249; 95% confidence interval [CI], 1.366-7.725; p = 0.008), male sex (OR, 2.846; 95% CI, 1.190-6.808; p = 0.019), atrial fibrillation (OR, 10.386; 95% CI, 3.724-28.961; p < 0.001), current smoker (OR, 10.022; 95% CI, 4.565-22.001; p < 0.001), and no hematuria (OR, 0.267; 95% CI, 0.114-0.628; p = 0.002) were significantly associated with the occurrence of RI. CONCLUSIONS: Five clinical factors, i.e., age ≥ 65 years, male sex, atrial fibrillation, current smoker, and no hematuria, were significantly associated with the occurrence of RI in patients with flank pain.

Treatment and Management of Loin Pain Hematuria Syndrome.

PURPOSE OF REVIEW: Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS: LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Nutcracker Syndrome with the Superimposition of Thin Basement Membrane Syndrome.

A 21-year-old woman was referred to our hospital because of proteinuria and hematuria. She had occasional flank pain. A renal biopsy was performed and revealed a thin basement membrane. Therefore, she was diagnosed with thin basement membrane disease. However, the frequency of her flank pain increased. Since her left kidney was slightly larger than the right, nutcracker syndrome (NCS) was suspected. Renal vein ultrasonography and venography were performed, and NCS was confirmed. Her hematuria was multifactorial, and NCS can go unnoticed if there is a comorbidity that also causes hematuria.

Robot-assisted Kidney Autotransplantation: A Minimally Invasive Way to Salvage Kidneys.

BACKGROUND: Kidney autotransplantation (KAT) is the ultimate way to salvage kidneys with complex renovascular, ureteral, or malignant pathologies that are not amenable to in situ reconstruction. A minimally invasive approach could broaden its adoption. OBJECTIVE: To describe operative technique, perioperative complications, and early functional outcomes of robot-assisted kidney autotransplantation (RAKAT). DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of prospectively collected data regarding consecutive patients undergoing RAKAT between March 2017 and February 2018 at two university hospitals. INTERVENTION: RAKAT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Technical feasibility, perioperative complications, and early functional results. RESULTS AND LIMITATIONS: Seven patients underwent RAKAT (three male and four female; five left and two right; one totally intracorporeal) for complex ureteral strictures (n=5), severe left renal vein nutcracker (n=1), and loin pain hematuria syndrome (n=1). Two patients underwent bench vascular reconstruction and one patient underwent ex vivo flexible ureterorenoscopy. No patient needed open conversion. Median operative and console time was 370 and 255min, respectively, with median vascular and ureteral anastomosis time of 28 and 23min, respectively. Median warm, cold, and rewarming ischemia time was 2, 178, and 44min, respectively. One major postoperative complication occurred-wound dehiscence needing wound revision (grade 3b). Median hospital stay was 5 d. At 3 mo, all patients were free of indwelling stents, pain, or hematuria. Median serum creatinine at 3 mo was 0.80mg/dl and median calculated autotransplant glomerular filtration rate did not drop significantly. CONCLUSIONS: RAKAT is feasible, safe, and results in good functioning of the autotransplant in selected patients with complex ureteral strictures, loin pain hematuria, or severe nutcracker syndrome. Larger studies with longer follow-up are needed to confirm these findings and to test whether RAKAT is feasible for other KAT indications. PATIENT SUMMARY: We describe the first series worldwide of a minimally invasive technique for kidney autotransplantation. Robot-assisted kidney autotransplantation is a safe and feasible approach to prevent nephrectomy for intractable symptoms in selected patients with complex ureteral or renal pathology.

Concurrent Preoperative Presence of Hydronephrosis and Flank Pain Independently Predicts Worse Outcome of Upper Tract Urothelial Carcinoma.

OBJECTIVES: To investigate the impact of preoperative hydronephrosis and flank pain on prognosis of patients with upper tract urothelial carcinoma. METHODS: In total, 472 patients with upper tract urothelial carcinoma managed by radical nephroureterectomy were included from Kaohsiung Medical University Hospital Healthcare System. Clinicopathological data were collected retrospectively for analysis. The significance of hydronephrosis, especially when combined with flank pain, and other relevant factors on overall and cancer-specific survival were evaluated. RESULTS: Of the 472 patients, 292 (62%) had preoperative hydronephrosis and 121 (26%) presented with flank pain. Preoperative hydronephrosis was significantly associated with age, hematuria, flank pain, tumor location, and pathological tumor stage. Concurrent presence of hydronephrosis and flank pain was a significant predictor of non-organ-confined disease (multivariate-adjusted hazard ratio = 2.10, P = 0.025). Kaplan-Meier analysis showed significantly poorer overall and cancer-specific survival in patients with preoperative hydronephrosis (P = 0.005 and P = 0.026, respectively) and in patients with flank pain (P < 0.001 and P = 0.001, respectively) than those without. However, only simultaneous hydronephrosis and flank pain independently predicted adverse outcome (hazard ratio = 1.98, P = 0.016 for overall survival and hazard ratio = 1.87, P = 0.036 for and cancer-specific survival, respectively) in multivariate Cox proportional hazards models. In addition, concurrent presence of hydronephrosis and flank pain was also significantly predictive of worse survival in patient with high grade or muscle-invasive disease. Notably, there was no difference in survival between patients with hydronephrosis but devoid of flank pain and those without hydronephrosis. CONCLUSION: Concurrent preoperative presence of hydronephrosis and flank pain predicted non-organ-confined status of upper tract urothelial carcinoma. When accompanied with flank pain, hydronephrosis represented an independent predictor for worse outcome in patients with upper tract urothelial carcinoma.

A patient with loin hematuria syndrome and chronic flank pain treated with pulsed radiofrequency of the splanchnic nerves.

INTRODUCTION: Chronic abdominal and flank pain can be multifactorial and difficult to treat. Loin pain hematuria syndrome (LPHS) is a rare clinical cause of chronic abdominal and flank pain and is a diagnosis of exclusion with limited treatment options, ranging from medications to renal autotransplantation or even nephrectomy in resistant cases. CASE DESCRIPTION: A 50-year-old man with a history of recurrent nephrolithiasis secondary to hypercalcemia presented to the pain clinic with bilateral flank pain. After failed conservative medical management, the decision was made to proceed to interventional modalities. He responded for a short duration to a splanchnic nerve block and subsequently had a longer analgesic response to pulsed radiofrequency (PRF) ablation to the splanchnic nerves. DISCUSSION: LPHS is a difficult clinical scenario to diagnose and treat. Conservative options are often unsuccessful, but the more extreme interventions such as renal autotransplantation and nephrectomies are invasive and not always effective. In this case report, we describe the novel use of PRF to the splanchnic nerves as an alternative treatment modality for patients with LPHS.Although the exact mechanism of action of PRF on nerve tissue is unclear, its indication in pain management requires further research and discussion. Our patient experienced substantial and sustained relief of his flank pain. PRF may be a viable option for patients with LPHS.

Infarto renal derecho. Presentación de un nuevo caso / Right renal infarction: a new case report

OBJETIVO: Presentar un nuevo caso de infarto renal. MÉTODOS: Se presenta el caso de una mujer de 84 años con dolor cólico en flanco derecho de 24 horas de evolución y con antecedente de infarto agudo de miocardio cuatro meses antes. CONCLUSIÓN: El infarto renal es una patología rara, dando lugar en la mayoría de los casos a una sintomatología inespecífica y solapable a otros procesos urológicos más frecuentes, lo que implica un retraso en su diagnóstico y en su tratamiento. Las pruebas de imagen más concluyentes son la Tc con contraste o la Eco-Doppler pero el diagnóstico de certeza es por angiografía o angio-Tc. Su tratamiento es conservador, anticoagulación parenteral y oral, el manejo invasivo es infrecuente (AU)

OBJECTIVE: To present a new case of renal infarction. METHODS: We report the case of an 84-year-old woman presenting with right flank colic pain of 24 hours of evolution and past history of acute myocardial infarction four months before. CONCLUSION: Renal infarction is a rare condition; in most of the cases it does not show specific symptoms and usually overlap with other more common urologic procedures, which results in a delay in diagnosis and treatment. The most conclusive imaging tests are i.v contrast CT scan or Doppler ultrasound but definitive diagnosis is achieved by angiography or CT angiography. Treatment is conservative, with parenteral and oral anticoagulation; invasive management is rare (AU)

Left kidney: an unusual site of cocaine-related renal infarction. A case report.

Acute renal infarction is a well known, although relatively unfrequent, cause of flank pain resistant to administration of spasmolytic and nonsteroidal anti-inflammatory drugs. We present an original case of a 41-year-old man, complaining of acute severe left flank pain, resistant to common analgesic therapy, who was diagnosed of segmental renal infarction of a branch of left renal artery. Pathophysiology of renal damage in cocaine users is multifactorial, and it has been postulated that the right kidney was more prone to ischaemia. Left kidney represents an extremely unusual site of cocaine-related renal infarction.

Formation of obstructing blood clot in the ureter in a patient with Glanzmann's thrombasthenia.

Glanzman thrombasthenia is a rare hematologic disorder characterized by qualitative thrombocyte abnormality. Patients present with episodic mucocutaneous bleeding. Thrombosis is a paradox phenomenon observed in patients with Glanzman thrombasthenia and generally considered as a treatment complication. We present a 16-year-old girl referred for severe flank pain beginning after treatment of hematuria due to Glanzman thrombasthenia. The patient underwent endoscopy for further diagnosis and treatment because of the failure of radiologic evaluation. Although the resolution of the large clots was obtained with streptokinase instillation via the ureteral catheter, clot was mobilized with gentle insertion of ureteral catheter in the present case.

Embolización de aneurisma calcificado de arteria renal en paciente monorreno / Calcified renal artery aneurism embolization in a solitary kidney

OBJETIVO: Revisar la presentación, diagnóstico y tratamiento de una entidad poco frecuente como los aneurismas de la arteria renal.MÉTODOS: Presentamos el caso de un paciente monorreno con un aneurisma renal calcificado sintomático.RESULTADOS: Los aneurismas de la arteria renal pueden provocar hipertensión, hematuria, dolor en flanco, o ser totalmente asintomáticos. Las causas más frecuentes son laarteriosclerosis y la displasia fibromuscular y el diagnóstico se basa en la tomografía computerizada y en la angiografía. El tratamiento puede ser quirúrgico, endovascular o expectante.CONCLUSIONES: Los aneurismas de la arteria renal son una patología sobre la que, por su baja prevalencia, no existen pautas claras de actuación. El número de casos diagnosticados ha aumentado en las últimas décadas y el tratamiento endovascular se muestra como una buena opción(AU)

OBJECTIVE: To review presentation, diagnosis and treatment of renal artery aneurysms, a very uncommon disease.METHODS: We report the case of a male with a calcified renal artery aneurysm in a solitary kidney.RESULTS: Symptomatic effects may be hypertension, hematuria or flank pain. Arteriosclerosis and medial dysplasia are the most frequent causes and diagnosis is based on CT scan and angiography.CONCLUSIONS: The renal artery aneurysm is a disease with low prevalence and there is no clear protocol for management. The number of cases has increased over the last decades and endovasculrar treatment is a good therapeutic option(AU)

[Angiomyolipoma and Lenk syndrome: case report]. / Triada de Lenk como presentación clínica del angiomiolipoma.

Angiomyolipoma (AML) is a benign clonal neoplasm that consists of varying amounts of mature adipose tissue, smooth muscle, and thick-walled vessels. Approximately 20% of AMLs are found in patients with tuberous sclerosis syndrome (TS), an autosomal-dominant disorder characterized by mental retardation, epilepsy, and adenoma sebaceous, a distinctive skin lesion. Massive retroperitoneal hemorrhage from AML, also known as Wunderlich's syndrome, has been found in up to 10% of patients and represents the most significant and feared complication. The presence of even a small amount of fat within a renal lesion on CT scan (confirmed by Hounsfield unit's < or = 10) is considered diagnostic of AML. Intervention should be considered for larger tumors, particularly if the patient is symptomatic, taking into account patient age, comorbidities, and other related factors. A nephron-sparing approach, via either partial nephrectomy or selective embolization, is clearly preferred. We present the case of a fifty-nine-year old patient with an angiomyolipoma and massive retroperitoneal hemorrhage with Lenk syndrome.

Hipertensión secundaria a Síndrome de Cushing / Hypertension secondary to Cushing syndrome

En un pequeño grupo de hipertensos puede identifi carse una causa, responsable del aumento de las cifras de presión arterial, como el Síndrome de Cushing, que supone el 0,2-0,6% de los casos. Presentamosel caso de un paciente diagnosticado de hipertensión secundaria a Síndrome de Cushing

In a small group of hypertensive patients a cause of elevated blood pressure levels can be identifi ed,such as Cushing syndrome, which corresponds to 0.2-0.6% of cases. We present the case of a patient diagnosed with hypertension secondary to Cushing Syndrome