Transplant renal vein thrombosis in a recipient with aberrant venous anatomy.

Renal vein thrombosis in a transplanted kidney is an uncommon but critical complication that can result in graft loss if management is delayed. A 31-year-old male with known atresia of the inferior vena cava who received a deceased donor renal transplant 7 years previously presented to hospital with severe graft site pain and a week of nausea, vomiting, and chills. Serum creatinine was markedly elevated from baseline. Sonographic examination revealed external iliac vein thrombosis with extension of the thrombus into the transplant renal vein. Urgent angiographic administration of tissue plasminogen activator and suction thrombectomy was performed, then followed by heparin and clopidogrel post procedure. Within 24 h, his serum creatinine improved, and within 2 weeks returned to his baseline. He was started on lifelong warfarin anti-coagulation to reduce the risk of rethrombosis secondary to his uncorrectable aberrant venous anatomy. Due to the turbulent and sometimes reversed flow in the major veins, lifelong anticoagulation should be strongly considered for such transplant patients with recipient aberrancy of the large veins.

Pathological nature of renal tumors - does size matter?

INTRODUCTION: We examined the relationship between the size and nature of renal masses in term of malignant potential, histological grading, pathological staging and presence of necrosis and sarcomatoid changes. MATERIALS AND METHODS: Retrospectively, we reviewed 323 consecutive nephrectomies between 2000 and 2010. Final pathology was correlated with tumour size. The renal tumours were stratified into three groups according to the largest diameter, defined as 4 cm or smaller, greater than 4 cm to 7 cm, and greater than 7 cm. We recorded the proportion of benign tumours, tumour grade and stage, presence of necrosis and sarcomatoid change. RESULTS: Small renal masses ≤4 cm (SRMs) were more likely to be localised to the kidney (90%) and of lower histological grade (75%). The proportion of benign tumours in SRMs (15%) was higher than other two groups with the majority of benign tumours being oncocytomas. There was a statistically significant trend with greater necrosis and sarcomatoid change for the large size group. CONCLUSIONS: SRMs are likely to be low grade and organ confined with little or no adverse pathological features. There is increased likelihood of benignity in SRTs with the majority of benign tumours being oncocytomas.

Suprapubic catheter insertion using an ultrasound-guided technique and literature review.

What's known on the subject? and What does the study add? The conventional 'blind' technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life-threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US-guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.