Amer Hanano

Risks, Advantages, and Complications of Intercostal vs Subcostal Approach for Percutaneous Nephrolithotripsy

OBJECTIVES To establish the efficacy of nephrolithotripsy via intercostal access route vs subcostal access route with respect to attained stone-free status, operating time, and complications. METHODS Percutaneous nephrolithotripsies via the upper pole were performed in 142 patients (93 male, 49 female, age 24-78 years) from 1998 to 2005 at our 4 academic medical centers. Selection criteria for nephrolithotripsy via upper pole access were staghorn calculi > or = 5.5 cm(3), upper pole calyx calculi > or = 2.5 cm, and abnormal or high lying kidney, often in combination with obesity. Of 68 staghorn calculi, 49 were accessed via intercostal and 19 via subcostal route. Of 57 upper calyx calculi 38 were accessed via intercostal and 19 via subcostal route; all calculi in the upper ureter considered easily accessible via the intercostal route. RESULTS Of 103 patients with intercostal access, 91 attained a stone-free status. There were 4 major and 6 minor complications. Depending on stone location, mean operating times varied from 42 to 152 minutes. Of 39 patients in whom a subcostal access route was chosen, 29 were made stone-free. There were 3 major and 8 minor complications. The mean operating time varied from 108 to 145 minutes. CONCLUSIONS The significantly higher rate of achieving stone-free status, lower rate of complications, and markedly reduced operating time when using intercostal access make this the route of choice for upper pole nephrolithotripsy.

Complex left fetal ovarian cyst with subsequent autoamputation and migration into the right lower quadrant in a neonate: case report and review of the literature.

We present a case of a neonate who presented with a right lower quadrant cystic mass. This mass represented a hemorrhagic cyst arising from the left ovary, in which the ovary had undergone torsion, autoamputation, and migration prenatally into the right lower quadrant.

Risks and benefits of the intercostal approach for percutaneous nephrolithotripsy

OBJECTIVE The objective of our retrospective study was to provide evidence on the efficacy of the intercostal versus subcostal access route for percutaneous nephrolithotripsy. MATERIALS AND METHODS 642 patients underwent nephrolithotomy or nephrolithotripsy from 1996 to 2005. A total of 127 had an intercostal access tract (11th or 12th); 515 had a subcostal access tract. RESULTS Major complications included one pneumothorax (1.0%), one arterio-calyceal fistula (1.0%) and three arteriovenous fistulae (2.7%) for intercostal upper pole access; two pneumothoraces (1.7%), one arteriovenous fistula (1.0%), one pseudoaneurysm (1.0%), one ruptured uretero-pelvic junction (1.0%), 4 perforated ureters (3.4%) for subcostal upper pole access; one hemothorax (1.6%), one colo-calyceal fistula (1.6%), one AV fistula (1.6%), and two perforated ureters (3.2%) with subcostal interpolar access. Diffuse bleeding from the tract with a subcostal interpolar approach occurred 3.2% of the time compared with 2.4% with a lower pole approach. Staghorn calculi demonstrated similar rates of complications. CONCLUSION Considering the advantages that the intercostal access route offers the surgeon, it is reasonable to recommend its use after proper pre-procedural assessment of the anatomy, and particularly the respiratory lung motion.

Computerized Tomography Reveals Variable Aggressiveness of Transitional Cell Carcinoma of the Bladder and Bladder Diverticulum

A 58-year-old white male presented with gross hematuria. At hospitalization hematocrit was 26, hemoglobin was 9.6 gm and urinalysis revealed greater than 100 red blood cells per high power field with multiple clots. Cytology identified abnormal cells consistent with transitional cell carcinoma, cellular debris and bacteria on high power field. Serum albumin was low, creatinine was 1.4 mg/dl and blood urea nitrogen was 24 mg/dl. History included a benign bladder papilloma which had been removed by fulguration 6 years earlier. However, the local medical doctor could not provide a pathology report. Cystoscopy revealed a large 3 cm tumor on the right side of the bladder floor with areas of surface necrosis. The entire bladder mucosa was infiltrated by tumor with multiple areas of necrosis and ulcerations. A narrow neck diverticulum was seen on the left side. Biopsy confirmed the diagnosis of infiltrating transitional cell carcinoma with involvement of all layers of the muscularis. Four-phase multidetector computerized tomography demonstrated massive circumferential tumor involvement of all layers of the muscularis and extension along the left lateral bladder wall into the perivesical fat (part A of figure). Tumor neovascularity extended into the central lobe of the prostate (part B of figure). Prominent tumor mass involved the mucosa and submucosa. In contrast, mucosal and submucosal involvement in the diverticulum appeared minimal, with minimal extension into the inner third of the muscularis but none into the peridiverticular fat (part C of figure). After 48 Gy external radiation therapy, radical cystoprostatectomy with resection of components of the membranous urethra was performed with reimplantation of the ureters into an ileal loop. Histopathology of the specimen confirmed unusually thick tumor elements in the mucosa and submucosa of the bladder with areas of necrosis and permeation through all layers of muscularis into the perivesical fat. The findings in this case are in line with the literature, which indicates noninvasive neoplasms confined to the mucosa and submucosa in 44% of diverticula and invasive neoplasms in 56%, the latter often associated with less common bladder cancer subtypes with pT3 disease and risk of progression. 1

Computerized Tomography of Fournier's Gangrene

A 49-year-old white male presented with fever, leukocytosis, pain, scrotal swelling and hyperemia. Physical examination failed to reveal crepitus. CT clearly showed gas extending anteriorly along the dartos fascia to the scrotum in juxtaposition to the penis (see figure). Prompt surgical drainage and appropriate antibiotics controlled the process within 1 week without late sequelae. The mortality rate of Fournier’s gangrene is currently between 7.5% and 40%, whereas it was as high as 88% in older series. 1 Fever, hyperemia, swelling, pain and crepitus of the involved perineum and scrotum are the telltale clinical manifestations. Thrombocytopenia, leukocytosis, anemia hypocalcemia and tachycardia are presenting symptoms in two-thirds of patients, and anaerobic bacteria (often polymicrobial) produce gas in the tissues causing crepitus in two-thirds. 2 Pathologically Fournier’s gangrene is a rapidly progressing polymicrobial necrotizing fasciitis of the perineal, perianal and genital regions. 3 The accompanying massive edema impedes the vascular supply, and promotes thrombosis and, thus, progression to tissue necrosis. Gas in soft tissue

Inferior Vena Cava Tumor Thrombus (Renal Cell Carcinoma) Extending Into Hepatic Veins

A 56-year-old white male presented with complaints of fatigue, weight loss, edema in the lower extremities, shortness of breath and several bouts of transient gross hematuria during the last 2 months. Physical examination revealed grade 1 pitting edema of the lower extremities and the liver was tender to palpation. Laboratory findings at hospital admission revealed red blood cell count 4.1 million, white blood cell count 6,400, hematocrit 38, hemoglobin 11.2, alkaline phosphatase 73, serum glutamic-oxaloacetic transaminase 16, bilirubin 0.7, creatinine 3.8 mg/dl, blood urea nitrogen 42 mg/dl, serum albumin 3.6 and serum globulin 3.8. Urinalysis showed a slightly turbid urine with a pH of 7.4, 15 red blood cells per high power field, 1 to 2 white blood cells per high power field and clusters of bacteria. The arterial phase of enhanced multidetector computerized tomography revealed a 4.8 cm enhancing tumor in the right kidney with neovascularity extending into the perinephric space. An arterialized tumor thrombus was seen in the right renal vein extending into the intrahepatic segment of the inferior vena cava (IVC). Tumor neovascularity extended into the hepatic veins and there was contiguous invasion of liver parenchyma sector V (see figure). In addition, there was a small 1 1⁄2 cm negative defect in the IVC segment above the obvious tumor thrombus reflecting an adherent bland thrombus. Tumor neovascularity was also seen in the renal hilar nodes (8 to 10 mm in size) and nodes at the level of the porta hepatis. Computerized tomography of the lungs and brain as well as radionuclide bone scans showed no other metastatic tumor. Following superselective embolization of the renal cell carcinoma and the arterialized tumor thrombus (augmented by adrenaline flow modulation) with 355 mc embologold spheres the primary neoplasm was removed with radical nephrectomy. Embolization had resulted in slight retraction of the tumor thrombus in the IVC, facilitating its removal. The intrahepatic tumor extension was managed using segmental hepatectomy. The patient survived with a cancer-free status as ascertained by followup computerized tomography for 11 months, and then

Duodenal-Renal Fistula

A 54-year-old white male presented with a 3-month history of right flank pain. Onset of pain was in the mid abdomen and for 2 consecutive days the patient noticed blood in stool. During the next 2 months he had several episodes of low grade fever with temperatures up to 38.5C. At hospital admission percussion of the right flank elicited pain. Patient temperature was normal at 36.5C. White blood cell count was 9,800, red blood cells 4.1 million, hematocrit 41, hemoglobin 14.3, creatinine 1.8, blood urea nitrogen 27, amylase 140 U/l and lipase 180 U/l. Urinalysis revealed cloudy urine. Specific gravity was 1,024, with 10 to 12 white blood cells and 15 to 20 red blood cells per high power field, abundant bacteria on high power field, as well as some mucoid (eosinophilic staining) globules. Urine culture was positive for Escherichia coli. A 3-phase contrast enhanced computerized tomogram revealed a large extrarenal right kidney pelvis. The wall of the pelvis appeared thickened, and there was prominent striation in the periduodenal fat of the second and junction segment third portion of the duodenum (fig. 1). The excretory phase computerized tomogram demonstrated densely opacified urine in the ureteropelvic junction of the right kidney with identical dense material in the second portion of the duodenum. The right ureteropelvic junction, left ureter and duodenal lumen contained

Myceleal emphysematous cystitis complicating a renal transplant kidney

This 44 year old Caucasian male presented acutely ill with chills, fever and pain over the renal allograft. The symptoms had intensified over the past 3 days. At admission his temperature was 100.8 F, pulse-rate 110/min, BP 185/110, Hb 10.2, Hct 28, WBC 16200 (66% polymorphs). BUN 140 mg/dL, CR 3.8 mg/dL, blood sugar 121 mg%. The patient had a history of poorly controlled hypertension for eight years and received a renal transplant for endstage renal disease some 10 months ago. The postoperative period was complicated by several episodes of LUTIs which were treated with amoxicillin and ciprofloxacin. Two months prior to this admission the patient had been treated for acute rejection and was still on maintenance immunosup-pressive therapy. Foley catheterization yielded only 100 mL of purulent urine; analysis revealing 60 WBC/hpf, bacteria, mycelia and debris. Urine culture grew E Coli and identified Aspergillus Niger. Enhanced computed tomograms revealed massive gas in the bladder, dissecting in the submu-cosal layer and extending into the space of Retzius. Debris is outlined by the gas. A shaggy mass engulfes the tip of the Foley catheter. The mass and shaggy debris are caused by a myceliatomas (Figure-1). A CT section at a slightly higher level demonstrated lateral extension of the gas-dissection in the pre-vesi-cal space. It also shows the site of implantation of the transplant ureter, which is edematous (Figure-2). A coronal reconstruction shows the massively edema-tous ureter, with some gas dissecting into the ureter (Figure-3). There is however, still some parenchymal phase enhancement of the transplant kidney, suggest-ing viability. Open surgical drainage of the space of Retzius was immediately undertaken. Aggressive antibi-otic therapy with ciprofloxacin and amphotericin B, parenteral, as well by infusion into the bladder was pursued for 3 weeks. The necrotic transplant ureter was resected. The transplant kidney was drained by percutaneous nephrostomy, ultimately a uretero-pyelostomy, using the still intact native ureter was performed to reestablish drainage to the bladder. Only a few cases of emphysematous cystitis in renal transplant recipients have been reported (1,2).

Cirrhosis With Microscopic Hematuria and Pelvic Congestion Syndrome

A 42-year-old white male presented with microscopic hematuria and 5 to 10 red blood cells per high power field on 3 consecutive examinations. History revealed advanced cirrhosis of the liver secondary to ethanol abuse. Aspartate transaminase was increased, aspartate transaminase-to-alanine transaminase ratio was 2.6, alkaline phosphatase was increased, white blood cell count was 12,000, creatinine was 1.9, blood urea nitrogen was 30 and cystoscopy was negative. Ultrasound showed no abnormalities of the upper urinary tract. Multiphase computerized tomography confirmed the presence of massive esophageal varices but also revealed hugely dilated collateral splenic veins (fig. 1) and massive splenorenal shunts, resulting in significant dilatation of the left renal vein (fig. 2). The pathophysiology of this process causes increased left renal vein pressure similar to that seen

Colon caliceal fistula: a complication of percutaneous nephrolithotripsy.

A 41-year-old black male was admitted to the hospital with pyuria, fever and left flank pain after undergoing percutaneous nephrolithotripsy for a calculus in a caliceal diverticulum of the anterior superior calix of the left kidney. The diverticulum had been accessed 10 days earlier under fluoroscopic guidance via a subcostal approach. The location of the calculus, spleen, liver, lung, pleural deflection and colon had been established on computerized tomography with the patient in a supine position. Injection into the caliceal diverticulum revealed a narrow, almost occluded neck. Thus, neither guide nor working wire could be advanced into the pelvis or bladder but was instead coiled in the caliceal diverticulum. The tract was dilated to 26Fr in the customary fashion and the calculus was extracted. A 12Fr drain was placed and then removed after 4 days because there was no drainage. Within 1 week the patient was readmitted to the hospital with flank pain, fever and pyuria. Urinalysis revealed 40 white blood cells per high power field, 5 red blood cells per high power field and vegetable fibers. Culture yielded greater than 100,000 coliform organisms per ml. Temperature was 100.8F, blood urea nitrogen 30 (18 before percutaneous nephrolithotripsy), creatinine 1.1 and white blood cell count 8,200. Red blood cell count, hemoglobin, hematocrit, sodium, potassium and chloride were within normal limits. A delayed film of a left retrograde urogram revealed a caliceal diverticulum of the anterior superior calix of the left kidney with a fistulous tract communicating with the left colon (see figure). This was clearly a complication of the access procedure, and failure to identify its presence earlier was likely due to the tamponading effect of the 12Fr catheter. Only after removal of the diverticulum was there open communication from the calix to the colon. Although computerized tomography with the patient in the supine position showed the colon to be at the level of and lateral to the kidney, it is well-known that the topography of the kidney, pleural deflection, lungs and colon change with respiration and with the patient in the prone, supine and upright positions.