Bilateral emphysematous pyelonephritis and emphysematous cystitis with autosomal-dominant polycystic kidney disease: is conservative management justified?

OBJECTIVE: To report a case of bilateral emphysematous pyelonephritis (EPN) and emphysematous cystitis in a 64-year-old diabetic male with autosomal-dominant polycystic kidney disease (ADPKD). CASE PRESENTATION AND INTERVENTION: A 64-year-old diabetic male presented with worsening of renal function and fluid overload. Diagnosis was confirmed by computerized tomography (CT scan) and conservative management with broad-spectrum antibiotics was instituted. There was good clinical response and repeated CT scan showed complete resolution. CONCLUSION: This case shows that conservative management is an acceptable alternative to surgery in EPN occurring with ADPKD. However, it is recommended that patients should be closely monitored, both clinically and radiologically, and percutaneous catheter drainage or surgical intervention carried out whenever deemed necessary.

Intact specimen extraction in laparoscopic nephrectomy procedures: Pfannenstiel versus expanded port site incisions.

OBJECTIVES: Laparoscopic nephrectomy is considered the standard of care for most Stage T1 and T2 renal tumors. Most centers perform intact extraction rather than morcellation. The extraction incision location varies, with no consensus on the best site. We compared the operative and perioperative parameters after transperitoneal laparoscopic nephrectomy procedures with intact specimen extraction through a Pfannenstiel (PFN) or expanded port site (EPS) incision. METHODS: The consecutive charts of 150 patients (March 2001 to October 2003) undergoing laparoscopic radical nephrectomy (LRN), laparoscopic nephroureterectomy, or laparoscopic donor nephrectomy with intact specimen extraction were reviewed. The specimens were extracted by way of a PFN or an EPS incision. Two analyses were completed. The first included only LRN, and the second included LRN, laparoscopic nephroureterectomy, and laparoscopic donor nephrectomy. RESULTS: In the LRN-only analysis, the PFN group had a shorter hospital stay (2.84 versus 3.37 days, P <0.05). This group also used significantly less morphine (23.7 versus 47.3 mg, P <0.006). The PFN group in the second analysis also used less morphine (26.3 versus 51.1 mg, P <0.002). Four extraction site complications were found; 1 patient in the PFN group developed cellulitis, and 3 patients in the EPS group developed an incisional hernia. CONCLUSIONS: This evidence suggests reduced morbidity with intact specimen extraction through a PFN incision compared with an EPS incision during laparoscopic nephrectomy procedures. Our practice has been modified on the basis of these data, and all specimens are now removed through a PFN incision when suitable. Urologists should consider PFN incisions for specimen extraction with laparoscopic nephrectomy procedures.

Laparoscopic management of advanced renal cell carcinoma with level I renal vein thrombus.

OBJECTIVES: To present our series of laparoscopic radical nephrectomy in patients with level I tumor thrombus. The existence of renal vein tumor thrombus presents a technical challenge in securing hilar control during the resection of a renal mass. To our knowledge, this experience represents one of the largest series of laparoscopic nephrectomy for renal cell carcinoma associated with a macroscopic renal vein thrombus. METHODS: From April 2002 to June 2004, 12 patients (8 men and 4 women) were diagnosed with renal masses. In addition to computed tomography, cavography and magnetic resonance imaging were used to determine the levels of tumor thrombi preoperatively in those who had suspicious involvement of the renal vein on computed tomography. RESULTS: Laparoscopic nephrectomy was performed in a standard fashion. Hand-assisted laparoscopic nephrectomy was used in 6 cases involving large tumors with bulky hilar adenopathy. All renal veins were stapled using an endoscopic vascular stapler. Intraoperative laparoscopic ultrasonography was used to delineate the extent of the vein thrombus in 4 cases to enable proper stapler positioning. No intraoperative complications occurred, and 2 cases were electively converted to open nephrectomy. The postoperative narcotic requirements and hospitalization times were low. Pathologic examination of the tumor specimens demonstrated negative resection margins in all patients. CONCLUSIONS: In carefully selected patients, laparoscopic resection of renal masses with level I renal vein thrombi is feasible. Because of technical considerations that may be identified intraoperatively, early conversion to open nephrectomy should be anticipated. Long-term results regarding oncologic control continue to be assessed.

McMaster experience with laparoscopic pyeloplasty.

PURPOSE: Laparoscopic pyeloplasty has been developed as a minimally invasive alternative to open pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO). Several series have been published with similar success rates for the two procedures. We present our initial experience with laparoscopic pyeloplasty. MATERIAL AND METHODS: A retrospective review of 29 consecutive patients (mean age 37 years) who underwent Laparoscopic dismembered Hynes-Anderson pyeloplasty in our institution between January 2001 to April 2003 was performed. All patients had flank pain with radiologic findings consistent with ureteropelvic junction obstruction and impaired drainage on diuretic renal scan. Patients were assessed at 6 weeks with an ultrasound and assessment of pain, then an intravenous pyelogram (i.v.p.) and diuretic renogram were completed at 6 months along with a repeat clinical assessment. RESULTS: Twenty-nine patients underwent the procedure with one patient converted to an open procedure due to difficulties with the anastomosis. Mean operating time was 225 minutes, which decreased with experience. Mean blood loss was 50 cc and no patient required transfusion. Mean hospital stay was 2.5 days. Mean follow-up was 12 months. Twenty-six patients had complete resolution of their pain and an improvement on ultrasound was demonstrated, but only six patients showed improvement in function on i.v.p. or renogram at 6 months. In five patients with 25% or less differential renal function preoperatively, the function was worse or negligible despite complete resolution of symptoms. One patient developed stent migration requiring repositioning and another developed calcification on the distal end of the stent requiring cystolithalopaxy prior to stent removal. CONCLUSIONS: In our experience, laparoscopic pyeloplasty offers excellent symptomatic relief in a minimally invasive fashion with low morbidity for adult patients with ureteropelvic junction obstruction. In patients with borderline function (25% or less) preoperatively and with a normal functioning contralateral kidney, nephrectomy should be a consideration.

The unsuspected nonpalpable testicular mass detected by ultrasound: a management problem.

Ultrasound is recognized as a valuable method of detecting testicular masses. Rarely, ultrasound will detect a testicular mass that was not clinically suspected. We present the case of a 43-year old man who presented with an unsuspected testicular mass detected by ultrasound. He underwent inguinal orchiectomy. The pathology showed a Leydig Cell tumor with cytological atypia. A review of the literature suggests that most incidentally discovered testicular masses are tumors, but there is disagreement as to whether they are usually benign or malignant. In view of the fact that many of these lesions are benign, if tumor markers are not elevated, inguinal exploration and excision of the lesion with frozen section examination is an acceptable management approach.