Detection of two synchronous histologically different renal cell carcinoma subtypes in the same kidney: a case report and review of the literature.

INTRODUCTION: Renal cell carcinoma (RCC) is the dominant primary renal malignant neoplasm, encompassing a significant portion of renal tumors. The presence of synchronous yet histologically distinct ipsilateral RCCs, however, is an exceptionally uncommon phenomenon that is rather under-described in the literature regarding etiology, diagnosis, management, and later outcomes during follow-up. CASE PRESENTATION: We aim to present the 9th case of a combination chromophobe RCC (ChRCC) and clear cell RCC (ccRCC) in literature, according to our knowledge, for a 69-year-old North African, Caucasian female patient who, after complaining of loin pain and hematuria, was found to have two right renal masses with preoperative computed tomography (CT) and underwent right radical nephrectomy. Pathological examination later revealed the two renal masses to be of different histologic subtypes. CONCLUSION: The coexistence of dissimilar RCC subtypes can contribute to diverse prognostic implications. Further research should focus on enhancing the complex, yet highly crucial, preoperative detection and pathological examination to differentiate multiple renal lesions. Planning optimal operative techniques (radical or partial nephrectomy), selecting suitable adjuvant regimens, and reporting long-term follow-up outcomes of patients in whom synchronous yet different RCC subtypes were detected are of utmost importance.

Newly modified 'pseudo flap' without compromising vascularity to enhance repair of long distal ureteral loss: A retrospective analysis of a prospective database.

Objective: To present an alternative technique called pseudo-flap for reconstructing long ureteral defects as an alternative to Boari flap. Despite being used for more than 70 years by urologists for tension-free reconstruction of distal and mid-ureteral defects, the Boari flap exhibits high complication rates, with an average of 27% (range 5.5%-30.4%). These complications arise from compromised blood supply, attributed to incisions made on all three sides of the flap and dependence on the flap base as the sole source of blood supply. Methods: We retrospectively reviewed patients who underwent our modified technique by a single surgeon between 2008 and 2021. We used a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspects of the bladder after complete release from adhesions and sacrificing the superior vesical pedicle, if necessary. The innovative part of the technique involved making short relaxing incisions at different levels on both sides of a pseudo-flap while pushing the bladder dome upward to reach the healthy ureter in a tension-free manner, followed by anastomosis with a non-refluxing or refluxing technique. Results: Fifteen patients underwent the pseudo-flap technique with a mean follow-up of 16.9 months. Four had prior radiation, three had hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis, and one had a ureteral stricture in a transplanted kidney. Eight procedures were performed during intraoperative consultations.Only one patient (7%) developed a major complication (Clavien-Dindo grade ≥2). This patient developed postoperative leak, and none developed obstructive hydronephrosis, suggesting stricture or flap ischemia. The mean length of the flap was 9.3 cm. Conclusion: Our pseudo-flap technique has lower complication rates than the traditional Boari flap. It is not technically challenging, minimally compromises blood supply and is thus especially suitable for complex, highly morbid patients with decreased tissue vascularity, such as those with prior radiation and peritoneal carcinomatosis.

Superfetation and heterotopic pregnancy: Case report of two rare phenomena coexisting and implications in the era of assisted reproductive technologies.

Key Clinical Message: To raise awareness about the increasing incidence of superfetation and heterotopic pregnancy in patients with ovarian induction, their insidious symptoms of abdominal pain, anemia, and hemodynamic instability in early pregnancy, and the usefulness of transvaginal ultrasound (TVUS) and quantitative beta human chorionic gonadotrophin (b-hCG) for diagnosis. Abstract: Superfetation, occurrence of ovulation, fertilization, and implantation during an ongoing pregnancy and heterotopic pregnancy (HP) simultaneous presence of intrauterine and extrauterine pregnancies are infrequent phenomena. We report a case where both coexisted, challenges in diagnosis and management and association with the widespread use of assisted reproductive technologies (ARTs). A 32-year-old woman, who previously underwent ovulation induction therapy, presented with abdominal pain at 8 weeks pregnancy according to her last menstrual period. The patient had high quantitative serum beta-human chorionic gonadotropin (b-hCG) (30,883 mIU/mL). She was vitally stable and not anemic. Transvaginal ultrasound (TVUS) revealed two pregnancies at different gestational ages: an intrauterine pregnancy at 5 weeks and 3 days, and a right intact tubal ectopic pregnancy at 10 weeks and 5 days. Superfetation resulting in HP was then diagnosed. Subsequently, the patient underwent right laparoscopic salpingectomy. The intrauterine pregnancy progressed normally, resulting in delivery of a healthy full-term neonate via Cesarean section at 38 weeks. Superfetation is typically rare from suppression of follicular development and ovulation during pregnancy. Various theories have been proposed to explain its etiology, including polyovulation, delayed blastocyst implantation, and abnormal estrogen and b-hCG surges. In superfetation, an embryo resulting from a previous conception coexists with another embryo, either intrauterine, resulting in diamniotic dizygotic twins with significantly different gestational ages, or extrauterine resulting in HP. Despite being particularly challenging to diagnose because its presenting symptoms can overlap with those of other more common clinical conditions in early pregnancy, HP is increasingly seen with ARTs. In addition, the treatment of HP is versatile, ranging from expectant management to laparoscopic surgery. High level of suspicion for HP and superfetation is crucial in patients who, after ART, present with abdominal pain, hemodynamic instability, or anemia. Additionally, patients planning to undergo subsequent ART cycles should be thoroughly screened with b-hCG and TVUS to exclude an ongoing intrauterine or extrauterine pregnancy.

Neglected ureteral stent in a patient with chronic kidney disease and solitary functioning kidney: case report and review of literature.

Introduction: A ureteral stent is crucial for managing urinary flow obstruction, ureteral reconstructive surgeries, and iatrogenic ureteral injuries. The authors aim to report a case of forgotten double-J stent for 17 years, the longest time reported in literature in a patient with solitary kidney and no typical long-term complications as stones formation and encrustation. Case presentation: A 58-year-old male with chronic kidney disease and solitary left kidney presented with left loin pain. With creatinine higher than baseline (6.2 mg/dl), he reported a neglected double-J stent placed 17 years ago in a different hospital. In addition, non-contrast computed tomography and cystoscopy revealed hydronephrosis, cystitis, and an element of infra-vesical obstruction, evident by high bladder neck. Treatment included left percutaneous nephrostomy, but he was readmitted few weeks later for cystoscopy, ureteroscopy, and a new double-J insertion. Due to worsening renal function, he was readmitted four weeks later for cystoscopic removal of the new double-J stent and Transurethral Resection of the Prostate, after which creatinine returned to baseline. Discussion: Double-J stents are vital in urological procedures, but neglecting their presence can lead to severe complications like encrustations, stone formation, stent fractures, hydronephrosis, infections, and renal function loss. Treatment of long-term complications is difficult and should consider many factors, including the type and severity of associated complications and the patient's preoperative status. Conclusion: Preventing complications from neglected or forgotten double-J stents through patient education and follow-up is crucial, especially in those with solitary functioning kidneys due to the imminent loss of renal function.