Journal of Endourology Case Reports

Published by Mary Ann Liebert
Online ISSN: 2379-9889
Nephrostogram identifying the Double-J stent outside the course of the ureter (A) (arrow). Followed by effective rendezvous insertion of a Double-J polymeric stent across the ureteral defect (B). 
Background: The use of ureteroscopy in the management of urolithiasis is well established. Ureteral avulsion is a rare but challenging complication of the procedure. Postureteral injury strictures are a common result of such injuries and are typically managed with reconstructive surgery or endoscopically with polymer stent. This case represents the first effective management of ureteral avulsion and subsequent ureteral stricture using a Memokath ureteral stent. Case Presentation: A 54-year-old gentleman presented to the Department of Urology with right loin pain as a result of right renal calculi, previously treated with extracorporeal shockwave lithotripsy. The patient was investigated with ultrasonography and noncontrast CT of his urinary tract, revealing mild right-sided hydroureteronephrosis and two right proximal ureteral stones, measuring 9 and 4 mm, respectively. He underwent a right semirigid ureteroscopy and laser stone fragmentation with complete stone clearance, but on withdrawal of the ureteroscope, a right ureteral injury occurred with ureteral mucosal avulsion extending from the L3/L4 vertebrae to the right vesicoureteral junction. Upon consideration of several options for management of this ureteral avulsion, the patient opted for endourologic stenting. After 10 months, the patient developed a ureteral stricture as a result of the avulsion. He was troubled with stent-related symptoms and wanted to avoid reconstructive surgery and, therefore, opted for a Memokath ureteral stent. The patient recovered well with excellent renal function and drainage on subsequent mercaptoacetyl-triglycyl renogram. Conclusion: Ureteral avulsion is a rare but important complication of ureteroscopy with numerous options available for management. Discussions should be had with the patient to weigh the various options, and metallic stents should be considered in the long-term management of such injuries and their sequel.
Background: There are limited data about urolithiasis in young infants, especially in class age younger than 2 years. Case presentation: We report the case of a child <2 years old (13 months) affected by metabolic urolithiasis (cystinuria), and renal hypertension. He was admitted to our ward from the pediatric emergency room for fever, lack of appetite, irritability, and abdominal pain crisis. Ultrasonography (US) described a huge stone (15 mm) in dilated left renal pelvis (20 mm) associated with distal ureteral ectasia (7 mm). Urine and blood diagnostic assessments were performed. Hydropenic therapy and urine alkalization were started without success. The child underwent an ureteroscopy (URS) with a 4.5-6.5F rigid ureteroscope aiming to reach the renal pelvis and perform holmium: yttrium-aluminum-garnet laser stone disintegration. During the procedure, the ureter presented two unexpected stones in the distal portion (missed on US). A laser ureteral lithotripsy was effectively performed extracting smaller stone fragments. Ureteral kinking, confirmed by ascending pyelography, made it impossible to reach renal pelvis with the ureteroscope. The child was further studied with a CT scan that revealed a massive stone involvement of the left excretory pathway. Metabolic and urine assessment revealed a metabolic disease: cystinuria. To remove renal stones, an operative retroperitoneoscopy (RP) was performed. During the procedure was identified a lesion of the pelvis (secondary to stone decubitus) with urine tearing and massive perirenal inflammation. The stone was removed and pelvis was sutured. Postoperatively, the patient was stone free without major complications. Conclusions: In particular cases (younger patients, ureteral kinking, and renal failure risk), a totally combinated minimally invasive access (URS, laser stone fragmentation, and RP) can be a valid alternative to micro percutaneous nephrolithotomy or to massive open treatment. In fact, rigid URS represents a valid minimally invasive approach either for examination or for laser treatment of pediatric urinary tract stones. With important ureteral kinking, RP must be considered by experienced pediatric urologists.
Background: Localized prostate cancer rarely undergoes a shift in metabolism towards aerobic glycolysis, a process known as the Warburg Effect. Because of this, positron emission tomography (PET)/CT imaging using 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG) is uncommonly used to evaluate patients with early-stage prostate cancer. However, men undergoing an 18F-FDG PET/CT for unrelated reasons will on occasion be found to have radiotracer uptake within the prostate gland. The appropriate work-up of these patients is poorly defined. Case Presentation: We present the case of a 61-year-old man with a history of tonsillar squamous cell carcinoma who was incidentally found on 18F-FDG PET/CT to have a hypermetabolic nodule within the prostate. The patient's prostate-specific antigen level was 2.1 ng/cc and digital rectal examination revealed no abnormalities. The patient underwent a targeted prostate biopsy of the lesion using the KOELIS Trinity biopsy platform, which uniquely allows for the real-time overlay of transrectal ultrasonography and PET/CT images. Targeted biopsy revealed Gleason score 4 + 3 = 7 (grade group 3) prostate cancer. Conclusion: Although the incidental detection of 18F-FDG uptake within the prostate is uncommon, more than half of all patients will be found to have prostate cancer. Based on this case and our review of the available medical literature, it is our belief that men with incidentally detected uptake of 18F-FDG within the prostate should undergo further evaluation with a prostate biopsy. This recommendation is supported by data suggesting that 18F-FDG-avid prostate cancer represents a more aggressive clinical phenotype.
Axial CT scan images of the bilateral stones. (A) Right stone (B) left stone.
Background: Because of the fear of being infected with coronavirus disease 2019 (COVID-19), patients with nephrolithiasis, who choose to stay home, may suffer serious complications such as obstructive uropathy, deterioration of renal function, sepsis, and death. We present such a case that led to renal failure and necessitated emergent urologic intervention. Case Presentation: A 60-year-old Caucasian man presented with right flank pain, dizziness, and dyspnea at the emergency room. History was significant for a previous diagnosis of right renal pelvic stone that was scheduled for retrograde intrarenal surgery before the pandemic lockdown. Upon evaluation, he was found to have an elevated creatinine of 40.2 mg/dL, bilateral hydronephrosis, pericardial and pleural effusion. The patient underwent emergency hemodialysis, followed by preliminary bilateral percutaneous nephrostomy, and subsequently by ureteral stenting. He was discharged stable with the future plan for endoscopic stone management. Conclusions: In the midst of the COVID-19 pandemic, urologists should follow up all known kidney stone patients, regularly assess their condition, and prioritize those who need urgent care. Patient education and telemedicine are useful tools for this purpose and may help minimize the risk of complications during a community lockdown.
Background: Ureteral stent encrustation poses a distinct challenge to urologists. The purpose of our study is to present a patient with one of the oldest retained ureteral stents reported in the literature, effectively treated at our institution with a multimodal endourologic approach. Case Presentation: After IRB approval and patient's consent, we present the case of a 47-year-old man who was referred to our institution for gross hematuria and a right retained ureteral stent, incidentally found on imaging. This patient had a history of traumatic stab wound 22 years prior, requiring an exploratory laparotomy and a ureteral stent insertion. Preoperative CT scan revealed a fragmented and heavily encrusted right ureteral stent. The patient was effectively treated with a multimodal endourologic approach, including a cystolitholapaxy, a right retrograde flexible ureteroscopy (URS), and a prone split-leg right percutaneous nephrolithotomy combined with a right retrograde URS. The patient was rendered stone and stent free. Conclusion: To our knowledge, this 22-year-old retained stent is one of the oldest reported in the literature. As observed in our patient, multimodal endourologic techniques are safe and effective in patients with retained ureteral stents to render then stent and stone free.
Background: Retained and subsequently encrusted stents can lead to a number of complications, the most dire being deterioration of renal function. Limited literature exists concerning endourologic management of stents retained for extreme durations and few that concerns patients with abnormal renal anatomy. Case Presentation: A 70-year-old man with history of Crohn's disease and partially duplicated collecting system presented with rising creatinine and was found to have bilateral retained Double-J stents, originally placed before small bowel resection 22 years prior. The patient underwent staged bilateral percutaneous nephrolithotomy with ultimate effective removal of both stents. The patient has had subsequent improvement in renal function and has not required dialysis. Conclusion: Removal of ureteral stents in a timely manner is paramount to prevent long-term retention and complication, but when required retained stents can be safely managed with a well-planned endourologic approach, even if significant deterioration in renal function has occurred.
Atrophic and ectopic right kidney. (A) A coronal cut of the CT scan showing the atrophic right pelvic kidney (yellow circle). (B) On this coronal cut of the CT scan, the ureter and seminal vesicle complex can be seen (yellow ellipse). 
Intraoperative view of right pelvic kidney. (A) A view of the pelvic kidney (yellow arrow) before dissection. (B) Shows the ureter inserting into the right seminal vesicle. 
A 24-year-old male was found to have recurrent epididymitis secondary to ectopic ureteral insertion to the seminal vesicle. His ipsilateral kidney was atrophic and ectopic in the pelvis, suggesting a complex failure of embryological development. He was successfully treated with robot-assisted laparoscopic nephroureterectomy.
Diagnostic laparoscopy showed Müllerian remnants in the form of uterus (U), cervix, two fallopian tubes (F), and two gonads (G). 
First stage Fowler Stephen procedure, in which clipping (C) of the gonadal (G) vessel was done allowing the testis (T) to receive blood supply from the artery of the vas only. 
Prentiss's maneuver, the uterus (U) appeared in the midline without splitting with the cord and fallopian tube (C) getting out lateral to the medial umbilical ligament (M) with the testis (T) attached. 
Background: Persistent Müllerian duct syndrome (PMDS) is not a common form of disorder of sex development in which Müllerian duct derivatives (fallopian tubes, uterus, and the proximal vagina) are present in an otherwise normally differentiated 46 XY male. In most of cases, the challenge comes in the procedure of orchiopexy. Case Presentation: We report a case of a 26-year-old man with PMDS. It was accidentally discovered when the patient presented to our outpatient clinic concerning about his empty scrotum as a premarital check. Diagnostic laparoscopy discovered Mullerian remnants in the form of uterus, cervix, and fallopian tubes with two attached testes to the fallopian tubes. Staged laparoscopic orchiopexy was done. We discuss the presentation, the management of this case in the literature, and our intervention. Conclusion: PMDS is not a common condition. Several concerns present in the management of these cases. Malignant transformation of the testis is the main risk facing those patients. Few literature studies discussed the risk of changing of these remnants into malignant tissue. Thus discussion with the patient, tissue histopathology, expert opinions, and literature review are the main clues in management of such cases.
Background: The injection of hydrogel in between the anterior rectal wall and prostate protects the rectum from the radiation field in men undergoing radiotherapy for prostate cancer. Multicenter prospective trials have demonstrated safety of the material, and that liquefication and reabsorption of the material occur roughly 12 weeks after injection. Other studies have noted the presence of the hydrogel up to 24 weeks after injection and documented significant complications with its use. In this study we discuss a patient in whom hydrogel was discovered in the anterior rectal wall who was undergoing radical cystoprostatectomy 32 weeks after injection, and how this precluded creation of a neobladder. Case Presentation: A 64-year-old Caucasian man with a history of diabetes mellitus and hypertension was diagnosed with unfavorable intermediate risk prostate cancer. He underwent injection of hydrogel followed by radiotherapy. He subsequently developed hematuria and carcinoma in situ and high grade T1 nonmuscle invasive bladder cancer were diagnosed. Thirty-two weeks later, he underwent robot-assisted radical cystoprostatectomy. The patient was originally planned for neobladder creation but intraoperative findings of persistent hydrogel in between rectum and prostate precluded this reconstruction and necessitated construction of an ileal conduit. Conclusion: Urologists should be aware of the fact that SpaceOAR hydrogel can persist beyond the expected 12- to 24-week dissolution period. In a patient who requires a radical cystectomy, the persistent presence of that gel may preclude the creation of a neobladder. Preoperative imaging to identify persistence vs dissolution of the gel would facilitate better preoperative patient counseling.
LithoVue out of the package reliable 270° deflectability at the start of each case. 
Scout photo, on left, and retrograde ureteropyelogram, on right, revealing renal calculi in lower pole of left kidney (white arrow) located at the infundibular pelvic angle requiring roughly a 180° ureteroscope approach. 
Background: Since the development of the first flexible ureteroscope, in 1964, technological advances in image quality, flexibility, and deflection have led to the development of the first single-use digital flexible ureteroscope, LithoVue™ (Boston Scientific, Marlborough, MA). With respect to reusable fiber-optic and now digital ureteroscopes, there is an initial capital cost of several thousand dollars (USD) as well as, controversy regarding durability, the cost of repairs and the burdensome reprocessing steps of ureteroscopy. The single-use LithoVue eliminates the need for costly repairs, the occurrence of unpredictable performance, and procedural delays. Renal stones located in the lower pole of the kidney can be extremely challenging as extreme deflections of greater than 160° are difficult to maintain and are often further compromised when using stone treatment tools, such as laser fibers and baskets. This case describes an initial use of the LithoVue digital disposable ureteroscope in the effective treatment of lower pole calculi using a 365 μm holmium laser fiber. Case Report: A 35-year-old female, with a medical history significant for chronic bacteriuria, and recurrent symptomatic culture proven urinary tract infections, underwent localization studies. Retrograde ureteropyelography demonstrated two calcifications adjoining, measuring a total of 1.4 cm, overlying the left renal shadow. Urine aspirated yielded clinically significant, >100,000, Escherichia coli and Streptococcus anginosus bacteriuria, which was felt to be originating from the left lower calix. This case used the newly FDA-approved LithoVue flexible disposable ureteroscope. The two stones were seen using the ureteroscope passed through an ureteral access sheath in the lower pole calix. A 365 μm holmium laser fiber was inserted into the ureteroscope and advanced toward the stones. There was no loss of deflection as the ureteroscope performed reproducibly. The laser was used for more than 4000 pulses at 15 W, producing mucoid debris and fragments. A 1.9F nitinol basket was, then, used to extract the fragments, and the patient was rendered stone free. Treatment success was confirmed by plain abdominal film obtained 1 week after stent removal. Conclusion: The LithoVue system single-use digital flexible ureteroscope provides an economical advantage over both reusable digital and fiber-optic ureteroscopes. The LithoVue system uses the enhanced image resolution of the digital complementary metal oxide semiconductor imager, similar to other reusable digital ureteroscopes, while maintaining the small ureteroscope size of a flexible fiber-optic ureteroscope, allowing for consistent and effective lower pole access. Deflection characteristics are maintained even when thicker laser fibers are passed through the working channel.
Preoperative contrast-enhanced CT scan of the kidney. (A) A mass in the right kidney and a mass in the upper pole of the left kidney. (B) A mass in the right kidney and a mass in the middle pole of the left kidney. (C) One mass in the lower pole of the left kidney. (D) Another mass in the lower pole of the left kidney. The dotted circles indicate the tumor before surgery. 
Laparoscopic internal scenes of intraoperative operation. (A) Puncture biopsy of the tumor in the upper pole of the right kidney. (B) A 2-mm cold knife is put into the tumor in the upper pole of the right kidney. (C) The ice hockey is advanced to the upper pole of the kidney and covers the entire tumor. (D) Puncture biopsy of the tumor in the middle pole of the right kidney. (E) A 2-mm cold knife is put into the tumor body in the middle pole of the right kidney. (F) The ice hockey is advanced to the middle pole of the kidney and covers the entire tumor. 
Laparoscopic external scenes of intraoperative operation. (A) Port position. (B) Intraoperative cryoablation (location). (C) A postoperative gross specimen. (D) A view of the postoperative incision. 
Background: Unilateral renal tumor cryoablation and contralateral radical nephrectomy of bilateral renal tumors were performed by transumbilical three-dimensional (3D) multichannel laparoendoscopic single-site (LESS) surgery, in an attempt to verify the feasibility and safety of the procedure, sum up the operational experience, and evaluate the surgical outcome. Case Presentation: This was a 47-year-old female patient with a body mass index of 27.34 kg/m² without backache, low back pain, hematuria, urinary urgency, frequent urination, dysuria, and other symptoms. Contrast-enhanced CT scan of the kidney on admission showed four masses in the left kidney and two masses in the right kidney. Preoperative serum creatinine (SCr) was 87 μmol/L. Operation was performed under general anesthesia by first laying the patient in a left lateral position. A 2-cm longitudinal transumbilical skin incision was made to expose the right kidney for complete dissection of the two tumors. First, puncture biopsy was performed, and then two freeze–thaw cryoablation cycles for the two tumors were performed. At last, the patient was laid in a right lateral position for radical nephrectomy of the left kidney. The operative duration, cryoablation time, and estimated blood loss were 200 minutes, 40 minutes, and 100 mL, respectively. Postoperative pathological examination revealed clear-cell renal cell carcinoma. The right glomerular filtration rate tested was 42.36 mL/minute and SCr was 131 μmol/L at day 5 after surgery. There was no evidence of contrast enhancement at the cryoablative region as shown by renal contrasted CT scan performed 4 days after surgery and renal contrasted MRI scan performed 6 weeks after surgery, indicating that there was no tumor remnant or recurrence. Conclusion: Our preliminary experience shows that the treatment of bilateral renal tumors with unilateral renal tumor cryoablation and contralateral radical nephrectomy by transumbilical 3D LESS is safe, feasible, and effective. It may prove to be a viable option for patients with significant comorbidities and an insensitive treatment intention.
The modality of choice in the surgical management of benign prostatic hyperplasia for large prostates has traditionally been open prostatectomy. Advances in minimally invasive techniques have begun to challenge this notion with advantages such as lower bleeding and transfusion rates and shorter hospital stay. In this case report, we illustrate the use of holmium laser enucleation of the prostate (HoLEP) in a gland measuring more than 400 cc. We describe the case of a 71-year-old man with persistent voiding urinary symptoms despite two previous transurethral resections of his prostate. With greater experience in HoLEP and declining experience in open prostatectomy, there may be a shift toward HoLEP as the preferred treatment choice for large prostate glands.
Background: Chronic pain in the region of varicocele embolization is not well described and can be a challenging symptom to manage, with limited options for treatment after failing conservative measures. It is important to counsel patients of this potential complication when determining the best option for varicocele repair. To our knowledge, there are no reported cases of gonadal vein excision for chronic abdominal pain after coil embolization. Case Presentation: A 63-year-old Caucasian male presented to our urology clinic after coil embolization. His testicular pain resolved but he reported new left-sided abdominal pain after coil embolization for a large left varicocele. After failing conservative measures including nonsteroidal anti-inflammatory drugs, antibiotics, and prednisone, he was referred for further work-up and to discuss treatment options. On presentation, the patient reported pain on the left side of his abdomen consistent with the location of gonadal vein. After extensive counseling that surgical removal may not alleviate his pain, robotic gonadal vein excision was offered, and the patient elected to proceed. Intraoperatively, the coils were easily seen through the wall of the vessel. This segment of the gonadal vein containing the coil was excised in its entirety. The patient was discharged on postoperative day 1 with only nonsteroidal pain medications. Six weeks postoperatively, the patient reported no complications, and almost complete resolution of his preoperative pain. Conclusions: To our knowledge, this is the first case report demonstrating the surgical removal of the gonadal vein for treatment of chronic abdominal pain after varicocele embolization. After failing conservative measures, this may present another viable treatment option to address this difficult complication in a select group of patients.
Coronal section of CT showing perforation (arrow) of the bladder wall with surrounding fluid collection.
Coronal section of CT showing right nonfunctioning kidney (cross) with left retroperitoneal collection (arrow).
We present a unique case of simultaneous rupture of the bladder and left renal pelvis after blunt trauma to the lower abdomen. To the best of our knowledge, this has not yet been reported in the literature. Another unusual aspect of this case was that the bladder rupture was bilateral, with both an extra- and intraperitoneal component. The management of this case was challenging. This involved an emergency laparotomy to repair the bladder tear, followed by a nephrostomy. This was followed by left ureteral stent insertion using a rendezvous technique. The case also highlights the role of expectant conservative management relating to the concurrent left renal pelvic rupture.
Background: Straight catheters are usually used for clean intermittent catheterization (CIC). Patients perform CIC without much difficulty. Spontaneous knotting of catheter is rare in large bore straight catheters and female patients. Case Presentation: A 50-year old lady, case of neurogenic bladder on CIC inserted a 14F straight catheter, drained some urine but was unable to remove the catheter. She presented in emergency with retention of urine. Her X-ray and ultrasound examination revealed a knotted catheter. Conservative measures to remove the catheter such as forceful injection of radio-opaque contrast and passage of hydrophilic guidewire did not work. She was taken in the operating room. The knot was ablated using holmium laser through transurethral passage of an 8F ureteroscope. Conclusions: Spontaneous knotting of urethral catheter is rare in adults. It should be suspected whenever a straight catheter cannot be removed. Inserting excessive length of catheter is an important risk factor. Holmium laser is an excellent tool to cut the catheter in a least invasive way when conservative measures have failed.
Voiding cystourethrogram. 
Urethrocystoscopic image. 
After ablation. 
Pathology analysis ''squamous metaplasia.'' 
Background: Urethral polyps are rare benign pathologies seen in the male posterior urethra, more frequently originating from verumontanum. In this article, we aimed to discuss diagnosis and treatment of a urethral polyp causing hematuria and urinary infection in a 3-month-old male infant. This is the first case in the literature in which a urethral polyp is treated with Holmium yttrium-aluminum-garnet (YAG) laser. Case Presentation: The patient was a 3-month-old male infant, and complains were hematuria and crying during micturition. Ultrasonography and voiding cystourethrogram were used for diagnosis. Urethral polyp was observed on urethrocystoscopy. Ablation was performed with a newborn cystoscope. Conclusion: Urethral polyp can cause hematuria and urinary obstruction and should be considered in the differential diagnosis of pathologies such as posterior urethral valve and cecoureterocele that could cause infravesical obstruction. Holmium-YAG laser is a good choice of treatment with easy application possibilities using a newborn cystoscope, especially for newborns and infants who have thin urethra.
Large left central region renal cyst with adjacent 8 mm calculus in upper pole calix. 
CT scan-coronal plane showing large renal cyst with renal calculus. 
Pigtail catheter radiologically inserted into renal cyst cavity. Note staple line from previous bowel surgery. 
Renal cyst cavity ablation using 26F resectoscope and roller ball diathermy. 
Renal cysts are common and most often are discovered incidentally, but may require intervention if associated with pain, hypertension, or hematuria. Minimally invasive treatment options are preferred with numerous modalities available, including renal cyst ablation. This case report of a 61-year-old female describes the effective percutaneous drainage and endoscopic ablation of a simple parapelvic renal cyst for management of symptomatic renal calculus. Current literature regarding this surgical intervention and alternative methods is discussed.
Background: We describe a patient who underwent waterjet ablation of the prostate after an unsuccessful prostatic urethral lift (PUL) procedure. Case Presentation: After PUL, our patient had incomplete bladder emptying with a postvoid residual of 600 mL. Urodynamic study of the bladder suggested detrusor underactivity. Our patient was motivated to undergo a salvage bladder outlet surgery. At 3 months after Aquablation, he reported complete resolution of bothersome lower urinary tract symptoms (LUTS). Conclusion: This case report illustrates return of volitional voiding and significant improvement in LUTS after salvage bladder outlet treatment with waterjet ablation of the prostate.
Patients with severe skeletal deformities are a challenging group to treat. A female, white, 35-year-old presented with right kidney stones located in renal pelvis, lower calyx, and upper ureter. She was affected by severe spinal deformity with restrictive respiratory obstruction, caused by kyphoscoliosis. Percutaneous nephrolithotomy in supine position was performed, achieving complete removal of kidney stones. The treatment of renal stones in this patient was complex, so special attention to respiratory function was mandatory; this was a challenging but feasible situation.
Suspect protrusion of the abscess to the cyst by MRI. 
Percutaneous insertion of two drains into the abscess (A), filiform leakage of contrast to the urinary system (B), insertion of a new Single-J stent; persistent communication between urinary system and abscess (C), no more signs of communication between urinary tract and abscess (D). 
We report a 50-year-old female patient with a left-sided renal abscess caused by extended-spectrum β-lactamase-producing bacteria. According to the ORENUC classification she had phenotype N. The course was complicated by a perforation to an adjacent cyst and later to the renal pelvis. A primarily conservative approach of intravenous antibiotics had to be changed to an ultrasonography-guided percutaneous drainage of the lesion and insertion of a ureteral stent to stem a high volume of urine leakage. Drainage of a renal abscess is indicated if the size is larger than 3 cm according to EAU guidelines (relative size) or when the resolution does not occur after antibiotics. One-year follow-up showed the patient made a full recovery with no recurrence of a urinary tract infection or of any abscess.
Incidentally found contrast enhancement of solid tumor or left kidney. Contrast enhancement of left renal tumor of 4.3 cm in length, middle portion, posterior aspect, 50% endophytic, and near collecting system. 
In precontrast phase, one 0.5 cm upper calix stone was found. One 0.5 cm intracollecting system stone at left upper calix (arrow). 
Patient went to emergency department with fever, chillness, left flank pain, and turbid discharge from previous drainage hole. CT revealed multilocular abscesses formation around left kidney, mainly in posterior peri-and pararenal spaces. 
URSL and retrograde pyelography were arranged and performed 1 week later after infection control. (A) URSL revealed one ureteral stone at upper third ureter and measured about 0.5 cm. (B) Retrograde pyelography was performed that revealed patent collecting system without filling defect or contrast extravasation. URSL, ureter renal scopy lithotripsy. 
Background: Nephron-sparing surgery has been shown to achieve oncological results equivalent to those of radical nephrectomy in patients with compromised renal function who have renal tumors <4 cm. However, technical difficulties and potential surgical complications remain challenges to the surgeon. Various factors, such as tumor size and location, collecting system invasion, and patient's expectations, are major concerns that may affect the feasibility of performing an effective partial nephrectomy. We report a patient with renal cell carcinoma who underwent open partial nephrectomy and suffered from complications of perirenal abscess because of stone migration, obstruction, and subsequence urine leakage. Case Presentation: A 63-year-old female with an incidental finding of a 4-cm renal tumor on the left kidney underwent an effective open partial nephrectomy at our institute. There were no intraoperative complications and the drainage tube was removed 3 days later. The patient visited our emergency department 1 month later with high fever. She was diagnosed with severe sepsis and perirenal abscess formation. Percutaneous nephrostomy was performed for prompt decompression. A sequential imaging study with CT and antegrade pyelography revealed one 0.5-cm stone, which migrated from the calix to proximal ureter postoperatively and subsequently caused obstruction and dramatic urine leakage. Ureteroscopic lithotripsy was performed with ureteral stenting. Postoperatively, the urinary leakage and abscess formation resolved. Conclusion: Nephron-sparing surgery is one of the most challenging procedures in the management of renal cancer. Urine leakage after partial nephrectomy may occur when a large tumor involves the collecting system. Postoperative ureteral obstruction is also a risk factor of urinary leakage. Watertight repair with a Double J catheter before operation may be required.
Redness and swelling of the left abdominal and lumbar area.
Sagittal section of CT of the abdomen showing large retroperitoneal and subcutaneous pus collection arising from the left kidney.
Coronal section of CT of the abdomen showing large retroperitoneal collection around the left kidney infiltrating the ipsilateral psoas muscle.
CT of the abdomen 4 days after surgical debridement, showing significant reduction of the collection with a Double-J stent in the left renal pelvis.
Background: Renal rupture and retroperitoneal abscess formation after extracorporeal shock wave lithotripsy (SWL) is a rare and potentially life-threatening complication if left untreated with a high morbidity rate. In this study, we present a rare case of renal rupture after SWL, with formation of an extensive retroperitoneal abscess extending to the left abdominal and lumbar area. Case Presentation: A 48-year-old Caucasian woman presented to the outpatient department with left abdominal and lumbar redness and swelling caused by renal rupture and massive perinephric abscess formation, 10 days after SWL treatment of her left renal pelvic stones. She was treated first with drainage of the retroperitoneal abscess and simultaneous Double-J stent placement in her left kidney. A left open nephrectomy was subsequently performed because of persistence of kidney infection. Conclusion: Retroperitoneal abscess formation after SWL is a serious and highly morbid complication, which should be early diagnosed and timely treated.
Background: Malakoplakia is a rare benign lesion, usually associated with deficient intralysosomal degradation of microorganisms, more commonly, Escherichia coli. Malakoplakia occurs in various organ systems, the most frequently affected site being the urinary bladder. We report a rare case of isolated extensive malakoplakia involving the prostate, diagnosed on transurethral resection performed for radiologically suspected prostatic abscesses. Case Presentation: A 61-year-old African American male presented with symptoms of urinary obstruction for the past 2 months. His medical history was significant for immunosuppression (liver transplantation 3 months prior and diabetes mellitus). He reported four episodes of E. coli-associated urinary tract infection after his liver transplantation. Serum prostate specific antigen was 1.83 ng/cc (normal inferior to 4 ng/cc), and urine culture was positive for E. coli sensitive to ceftriaxone. Pelvic magnetic resonance imaging was suggestive of prostatitis with prostatic abscesses; cystoscopy was unremarkable. The patient was started on intravenous ceftriaxone therapy. A standard bipolar transurethral resection of the prostate was performed, and purulent-like material was encountered in the resected tissue. Histologic examination demonstrated extensive infiltration and replacement of the prostatic tissue by sheets of pink histiocytes with targetoid inclusions consistent with Michaelis-Gutmann bodies, ultimately confirming malakoplakia of the prostate. Conclusion: Prostatic malakoplakia is an unexpected diagnosis in patients suspected of having malignancy or prostatitis. Its exact pathogenesis is unknown, but it involves defective bacterial degradation after phagocytosis. E. coli is often cultured from the patients' urine. Immunosuppression, present in our patient, is a well-known associated factor. Prostatic malakoplakia can radiologically masquerade as prostatic adenocarcinoma, despite the use of cutting-edge imaging technology. With the growing use of multiparametric 3T prostate magnetic resonance imaging to screen for prostate cancer, it is possible that urologists, radiologists, and pathologists will encounter prostatic malakoplakia more frequently in the future.
Background: Extrinsic compression of the ureter can result from multiple different malignancies, typically in the presence of known or disseminated disease. Rarely, hydroureteronephrosis and flank pain can occur as the presenting sign and symptom of lymphoma. In this study, we present two cases of primary ureteral obstruction in patients without a prior diagnosis of lymphoma and without bulky retroperitoneal lymphadenopathy. Case Presentation: Case #1 was a healthy 58-year-old man who presented with acute left flank pain. He was found to have left hydroureteronephrosis secondary to a proximal periureteral mass. Diagnostic ureteroscopy demonstrated this to be an extrinsic compression on the ureter and preoperative imaging was negative aside from one enlarged periaortic node. Laparoscopic ureterolysis and biopsy were remarkable for periureteral dystrophic tissue concerning for lymphoma. Case #2 was a 47-year-old woman with a solitary kidney secondary to prior left nephrectomy who presented with hydronephrosis of her solitary kidney and acute kidney injury. Retrograde pyelogram showed high-grade obstruction at the junction of the mid- and distal ureter. Periureteral thickening was noted, but no definitive masses were seen on cross-sectional imaging. Robotic ureterolysis showed dense fibrosis around the ureter. Pathology report from Cases #1 and #2 were both remarkable for marginal zone lymphoma and both patients received bendamustine and rixuximab with resolution of ureteral obstruction and their lymphoma. Conclusion: Ureteral compression as the primary presentation of periureteral lymphoma is a rare but important etiology of extrinsic malignant ureteral obstruction. These cases emphasize that malignant obstruction can occur even in the absence of disseminated disease.
Background: Obstructing ureteral stones are a rare cause of anuria, which is typically from prerenal or renal etiologies. Classically, obstructive stones cause moderate to severe renal colic. Urolithiasis is rarely considered during evaluation of painless anuria. Case Presentation: We present an unusual case of a 73-year-old Caucasian female who presented with anuria and was found to have large bilateral obstructing ureteral stones in the absence of renal colic. Conclusion: Given that patients with obstructive anuria can be asymptomatic, urolithiasis should be considered in all patients presenting with anuria.
Background: Retrograde intrarenal surgery (RIRS) has become the preferred treatment option for selected renal stones <20 mm. However, laser fragmentation of stones often results in residual small fragments that may prompt subsequent stone events. We describe a simple technique to facilitate removal of these fragments. Case Presentation: A 68-year-old woman underwent elective RIRS for a 13 mm right renal pelvic stone. After laser fragmentation of the stone there were numerous <2 mm fragments too small to allow removal by a standard retrieval basket (i.e., NCircle® and NCompass® Nitinol Stone Extractors, Cook Medical, Bloomington, IN). A smaller ureteral access sheath (UAS) was advanced into the kidney within the preexisting larger UAS and, using a connecting piece from a Foley catheter, stone fragments were suctioned out through the smaller sheath. Stone-free status was corroborated endoscopically and with postoperative CT. Conclusion: Stone fragments were flushed from the kidney using a simple irrigation technique through a coaxial UAS.
Insertion of the nephrostomy needle through the previously created nephrostomy tract. (A) The laser fiber was used as a guide to pass the needle over it. (B) Fluoroscopic image showing the nephrostomy puncture tract. (C) Direct endoscopic view of nephrostomy needle insertion, which was guided by the laser fiber (blue wire). (D) The laser fiber is removed and clear urine is observed to confirm access into the calix.
Nephrostomy access dilation. (A) Insertion of 10F doublelumen catheter to pass a secondary safety wire. (B) Dilatation of the tract was performed with sequential metal dilators. (C) Amplatz sheath insertion.
Background: Percutaneous nephrolithotomy (PCNL) serves as the gold standard minimally invasive procedure to remove large renal stones. The puncture is made from the skin to the chosen calix under fluoroscopic guidance, although this remains a challenging technique. We describe the initial case of retrograde holmium laser acquired nephrostomy access. Case Presentation: In this study, we present the case of a 48-year-old woman with right renal colic with imaging revealing a 2.6 cm staghorn stone. With institutional approval, we performed a new technique utilizing retrograde access with a flexible ureteroscope and a holmium laser fiber to achieve nephrostomy access for PCNL in the prone position. With the ureteroscope confirmed in the desired calix, the ureteroscope and laser fiber were aimed and fired toward the flank and thus creating a subcostal nephrostomy tract. PCNL was then carried out per standard of care lithotripsy techniques utilizing the holmium laser. Conclusion: In this initial case, percutaneous retrograde laser access allowed for desired caliceal nephrostomy access under direct vision.
Background: During percutaneous nephrolithotomy (PCNL) and endoscopic combined intrarenal surgery (ECIRS), obtaining renal access is the most critical step to achieving effective treatment without major intraoperative complications. Among a variety of methods attempted to improve the access, robot-assisted fluoroscopy-guided (RAFG) renal access has been introduced to mitigate technical human errors and overcome challenging learning curves. In this study, we present our first experience with an automated needle targeting with an X-ray (ANT-X) device for minimally invasive (mini-) ECIRS. Case Presentation: A 75-year-old healthy woman with a 6.0 cm3 left kidney stone was referred to our hospital for surgical treatment. The patient underwent mini-ECIRS utilizing RAFG renal access without complication, and the stone was completely removed. The ureteral stent and transurethral catheter were removed on postoperative day 2, and the patient was discharged on postoperative day 3. There were no residual fragments detected by CT as of 3 months after the surgery. Conclusion: To our knowledge, this is the first report of the effective use of RAFG mini-ECIRS for a kidney stone. The overall outcome was positive, indicating the feasibility of ANT-X use for PCNL and ECIRS.
Background: Instrument-related complications occur occasionally with the use of flexible ureteroscopes. In this study, we present a unique problem related to instrument malfunction of flexible ureteroscope during retrograde intrarenal surgery. Case Presentation: A 60-year-old male patient with a 1.2 cm left upper ureteral stone initially underwent semirigid ureteroscopic laser lithotripsy and during the procedure the stone got retropulsed into middle calix of the kidney. Subsequently, a 9.5F (internal diameter) ureteral access sheath was placed and using URF P6R flexible ureteroscope (Olympus) the stone was completely dusted with holmium laser. At the end of the procedure, the operating surgeon was unable to remove the ureteroscope out of the ureteral access sheath as it was getting stuck inside. On careful inspection under fluoroscopy, it was noticed that there was a partial break in the outer surface of the flexible ureteroscope at the level of the junction of the distal flexible part of the ureteroscope with the shaft. Since multiple attempts to retrieve the ureteroscope into the access sheath failed, a decision was made to pull the ureteroscope and ureteral access sheath as a whole over a 0.035″ terumo guidewire. Gentle traction was applied on the entire assembly and the instrument was withdrawn out of ureter over the guidewire under fluoroscopic guidance. A lateral angulation of the distal flexible portion with the shaft of the flexible ureteroscope caused by breakage of the fiber-optic cables led to this problem intraoperatively. Conclusion: Breakage of fiber-optic cables caused by excessive manipulation of flexible ureteroscope during retrograde intrarenal surgery can lead to entrapment of the ureteroscope within the ureteral access sheath. This problem might be solved by gently withdrawing the whole assembly out of the ureter over a guidewire.
Representative selection of CT abdomen and pelvis images showing location of obstructing proximal ureteral stone, including axial (A) and coronal (B) cuts. 
Representative selection of intraoperative fluoroscopic images showing contrast extravasation at initial ureteroscopy (A) and resolution of ureteral injury after stent placement 6 weeks postoperation (B). 
Background: The ureteral access sheath (UAS) has revolutionized the management of urinary pathology in the upper tract by providing rapid repeatable access to the upper urinary tract. However, in many practices, it remains a controversial tool in endourology given concerns of possible ureteral injury and presumed long-term sequela from those injuries. This case suggests that these concerns may be more hypothetical than real. Case Presentation: A 32-year-old female with a history of recurrent nephrolithiasis presented with left-sided symptomatic renal colic. She was found to have bilateral nephrolithiasis plus a left 6 × 5 mm proximal ureteral stone with associated moderate hydroureteronephrosis. The patient failed a trial of passage and as such was taken to the operating room for an elective ureteroscopy (URS) during which she sustained a Grade 3 ureteral splitting injury, measuring ∼2–3 cm, to the distal ureter from passage of the 16F UAS. At the end of the procedure a 7/10F endopyelotomy stent was placed. On follow-up URS at 6 weeks, there was no visual evidence of ureteral injury. A Lasix renal scan obtained 8 weeks after stent removal showed no evidence of obstruction. Conclusion: High-grade ureteral injuries sustained from UAS passage are rare. However, when injuries of this nature occur, the concern over long-term damage to the ureter may well be overstated.
Background: Management of renal calculi in a patient with kidney malrotation can be difficult because of complexity and alteration of collecting system anatomy. Pyelolithotomy, whether open, laparoscopic, or robotic, has been shown to be an effective method of stone removal in this patient population; however, it is not always ideal because of its invasiveness and increased morbidity. Ideally, a percutaneous approach may be less invasive, and if feasible, it can optimize patient safety and stone-free status. Case Presentation: Here we present a case of a 68-year-old Caucasian female who presented with 2.7 cm stone in the renal pelvis of a severely malrotated left kidney, which was managed using a combination of fluoroscopy and ultrasound (US)-guided percutaneous nephrolithotomy. Conclusion: US-guided access properly delineates the anatomic complexities of a severely malrotated kidney and permits safe percutaneous management of large stones. This is because fluoroscopic guidance alone may lead to inadvertent adjacent visceral organ trauma and increased risk of parenchymal and intrarenal vascular injury.
CT imaging illustrating renal calculi with skin-to-stone distance. (A) Axial view measuring 79.7 mm. (B) Sagittal view measuring 72.6 mm.
Lawson retrograde needle-catheter preparation. (A, B) Luer lock loosened. (C, D) Needle advanced and secured inside sheath. (E, F) Luer lock secured with needle just inside sheath to prevent damage to ureteroscope.
Lawson retrograde endoscopic-assisted access. (A) Retrograde pyelogram. (B, C) Identifying posterior upper pole calix. (D-F) Posterior calix and Lawson rocket wire exiting ureteroscope.
Background: A minority of urologists performing percutaneous nephrolithotomy (PCNL) achieve their own nephrostomy access. In an effort to simplify the access part of PCNL, we herein describe our initial experience with endoscopic-guided retrograde percutaneous access in the prone split-leg position. Case Presentation(s): After informed consent, a confirmed negative urine culture, and 1 week pretreatment with tamsulosin, four carefully selected PCNL patients underwent endoscopic-guided retrograde access in a prone split-leg position using the Lawson catheter. In all the four patients, we achieved endoscopic-guided retrograde upper pole access in the prone split-leg position. A single Clavien 3B complication occurred. Total fluoroscopy time for the PCNL averaged 162 seconds (51–283). Complete stone-free rate at 1 week based on CT scan was 25%, and a stone-free rate defined as <4 mm was 100%. Conclusion: Endoscopic-guided retrograde percutaneous upper pole access can be established efficiently with a modified Lawson technique in the prone split-leg position.
CT-guided percutaneous renal access has been described as a safe and effective access technique in patients with complex anatomy, including ectopic kidney, retrorenal colon, spinal dysraphism, hepatomegaly, and splenomegaly. In comparison to conventional intraoperative fluoroscopic-guided access, CT imaging allows for delineation of surrounding structures that are at risk for injury during percutaneous access. However, previous reports indicate that pelvic kidneys might be inaccessible percutaneously without laparoscopic assistance. Herein, we present a novel transgluteal route to renal access for percutaneous nephrolithotomy (PCNL) in a patient with a pelvic horseshoe kidney and severe spinal deformity.
CT abdomen and pelvis sagittal section. High attenuation lesion in the urethra and bladder lumen (arrow). 
Representative images from intraoperative cystogram. A small wisp of contrast extravasation (arrow). 
Bladder necrosis is an unusual and potentially devastating complication of embolization of the hypogastric arterial branches. The rich collateral blood supply makes this an extremely rare event. We present the case of a patient with bladder necrosis following placenta accreta that was treated with total abdominal hysterectomy and uterine artery embolization and cystotomy repairs.
Background: Alkaline-encrusted pyelitis (AEP) is rare and most often stems from a triad of immunodeficiency, urogenital tract trauma, and alkaline urinary infection. Corynebacterium Group D2 is the most common organism. It results in encrusting calcifications that adhere to most of the urothelial lining of the pelvicaliceal system and ureter. Left unchecked, or unrecognized, the disease process can progress to renal compromise. Studies suggest that management is based on elimination of the bacterium, acidification of the urine, and elimination of calcified plaques and encrustations. Herein, we report a case of a 56-year-old woman who developed AEP in her second transplanted kidney, and detail the diagnosis and treatment of the uncommon, yet potentially devastating, disease. Case Presentation: A 56-year-old woman with a history of lupus, end-stage renal disease, who was on her second renal transplant presented with symptoms of urinary tract infection. Urine was consistently alkaline with cultures repeatedly growing urease-splitting Corynebacterium. Subsequent imaging showed large obstructing ureteral and renal stones concerning for AEP. She was treated with transplant kidney percutaneous nephrolithotomy, culture-specific antibiotics, and urinary acidification. Conclusion: Clinical presentation, urinalysis, culture, and renal imaging, often with CT, are the mainstays for diagnosing AEP. If not addressed, AEP can advance to renal failure. Management often includes a multimodal approach involving treatment and prevention of the underlying infection, urinary acidification, and percutaneous or endoscopic removal of obstructing and large burden stones and encrustation.
Background: Encrusted uropathy (EU) is a rare disease caused by urea-splitting bacteria, most commonly Corynebacterium urealyticum, whose incidence is increasing. Standard treatment is based on pathogen-directed antibiotic therapy, urinary diversion, bladder instillations, and surgical resection of urinary calcifications. Case Presentation: We present the case of a 60-year-old man with symptomatic bilateral encrusted pyelitis and cystitis with acute renal failure. We initially treated the patient with antibiotic therapy, urinary diversion, and oral acidification with acetohydroxamic acid, achieving negative urinary cultures. Because of the persistence of encrusted pyelitis, the patient was discharged on oral l-methionine 500 mg bid and 12 months later the encrustations had almost disappeared. Finally, we performed right retrograde intrarenal surgery to remove a persistent small calcification. Conclusion: Oral urinary acidification with l-methionine is a valid treatment for urinary encrustations in EU, with no complications reported. Complete resolution of the calcifications may be achieved without the need for invasive processes and unnecessary manipulation of the urinary system.
CT scan demonstrating 3 cm enhancing left renal mass.
Background: Acquired von Willebrand disease (AvWD) is a rare and often underdiagnosed disease that typically is associated with lymphoproliferative, cardiovascular disease, and myeloproliferative disease. It is challenging to diagnose as it requires a hemostatic challenge to present itself. Case Presentation: This is a 46-year-old male with a history of multiple sclerosis complicated by neurogenic bladder who presented with intermittent gross painless hematuria. He underwent a gross hematuria workup. Cystoscopy demonstrated active bleeding from the right ureteral orifice. CT Urogram showed a filling defect in the right renal pelvis and endophytic 3 cm solid, enhancing left kidney mass. The patient underwent diagnostic cystourethroscopy, bilateral retrograde pyelogram demonstrating no filling defects bilaterally. Right ureteropyeloscopy demonstrated diffuse patchy erythema of the infrarenal collecting system with biopsies obtained. His postoperative course was complicated by gross hematuria requiring cystoscopy which demonstrated no upper tract bleeding and small pulsatile bleeding vessel in the bladder requiring cauterization. Hematology was consulted to rule out bleeding diathesis with workup demonstrating a von Willebrand deficiency (vWD). He had no family history of vWD and an AvWD was suspected. Hematologic workup was consistent with AvWD, type 2B vWD also known as a platelet-type von Willebrand disease. Renal pelvis biopsies were negative for pathology. Further investigation of the left renal mass confirmed a biopsy-proven clear cell renal cell carcinoma (ccRCC). He underwent a laparoscopic left radical nephrectomy with final pathology demonstrating pT1 ccRCC with negative margins. Postoperatively his repeat laboratories demonstrated normal factor VIII activity, ristocetin cofactor, and vWF antigen with normalized activated partial thromboplastin time. Follow-up imaging demonstrated no further evidence of disease supporting the hypothesis of a paraneoplastic syndrome from his ccRCC that caused an AvWD. Conclusion: This is the first case report to our knowledge of a paraneoplastic AvWD secondary to ccRCC. This should be on your differential when there is abnormal bleeding in the setting of renal masses.
Background: Cystoscopy using white light is a standard procedure for diagnosing bladder cancer; however, white light can result in missed lesions that are present, but not visible, such as in cases of carcinoma in situ (CIS). In this case report, we describe observing the nuclei of urothelial carcinoma cells in situ that were not visible with cystoscopy under white light using probe-based confocal laser endomicroscopy (pCLE) with acrinol and fluorescein during transurethral resection of a bladder tumor (TURBT). Case Presentation: A 59-year-old male with a medical history of neurogenic bladder dysfunction with multiple bladder diverticula was referred to the urology department for gross hematuria. TURBT was performed with the assistance of pCLE, using acrinol as a novel dye. Standard cystoscopy under white light could not detect any bladder tumor; however, pCLE using acrinol could detect the abnormal nuclei of bladder CIS. Subsequent histopathologic analysis of the specimen confirmed a diagnosis of bladder CIS. To our knowledge, this is the first reported case of bladder CIS diagnosed with the assistance of pCLE using acrinol in a patient undergoing a TURBT. Conclusion: pCLE using acrinol as a novel dye can help observe the cancerous nuclei of bladder CIS that cannot be detected using conventional cystoscopy under white light. Therefore, pCLE using acrinol is one possible modality for performing an optical biopsy during TURBT.
Background: Actinomycosis is a condition in which Actinomyces, a normal component of the oral and gastrointenstial flora, becomes pathogenic in the setting of damaged tissue, leading to widespread tissue destruction across fascial planes. Prior literature describing this condition is rare, particularly cases involving the retroperitoneum. In this study, we report a case of retroperitoneal actinomycosis caused by an infected, obstructing ureteral stone. Case Presentation: A 48-year-old woman with a history of substance abuse, malnutrition, and gastric bypass presented to the emergency room with a 3-week history of abdominal pain and fevers. Workup revealed a 9 mm obstructing right ureteral stone with associated perinephric fluid collection that was concerning for forniceal rupture. There was left hydronephrosis and a 3 mm lower pole renal calculus as well. The patient underwent emergent decompression where bilateral duplicated collecting systems were identified, requiring stenting of all four moieties to ensure maximal decompression in the setting of obstructive pyelonephritis. Urine cultures grew Escherichia coli and Candida. The patient continued to deteriorate despite culture appropriate antibiotic therapy; repeat scan revealed progression of her perinephric fluid collection into a loculated retroperitoneal abscess. A percutaneous drain was placed, and nearly half a liter of pus was evacuated. Fluid cultures grew Actinomyces, and she ultimately recovered after a prolonged course of antibiotics, including 1 month of intravenous therapy and an additional 6 months of oral treatment. All stones were ultimately removed via ureteroscopy. Conclusion: Actinomycosis is a rare invasive infection that is caused when the Actinomyces bacteria colonizes damaged tissue. We present the first reported case of urolithiasis inciting this process via tissue damage caused by obstruction and infection. Although rare, heightened suspicion is warranted among immunocompromised hosts who do not improve after decompression in such scenarios.
Background: Acupuncture has been widely studied, and theories regarding its analgesic mechanism of action have been proposed. It has been used for procedural analgesia; however, no reports of its use in urologic surgery have been reported. In this case report, we demonstrate how acupuncture can be used as an alternative to general anesthesia for transurethral resection of bladder tumor (TURBT). This may serve as an attractive option for bladder cancer patients with medical comorbidities, which predispose them to high risk for general anesthesia. Case Presentation: A 65-year-old Caucasian female with toxicant-induced loss of tolerance (TILT) was found to have a bladder mass. TURBT was discussed, and in light of her TILT syndrome, she elected to undergo the procedure with acupuncture in lieu of general anesthesia for fear of an adverse reaction. Acupuncture was performed by a trained practitioner with therapeutic needles placed in the ears, hands, abdomen, and lower extremities bilaterally. She was subsequently taken to the operating room where we performed a TURBT of a bladder tumor overlying the left ureteral orifice. The procedure was generally well tolerated and the patient experienced mild pain. There were no perioperative complications. The tumor was estimated to be 3 cm in largest diameter, and a total of 8 g of aggregate tissue was sent to our pathologists. Pathology analysis demonstrated adequate resection with detrusor muscle present in the sample. The bladder tumor was low-grade papillary urothelial cell carcinoma (Stage Ta). She has had tumor recurrence and has undergone repeat TURBT, but to date, she is 22 months free of bladder cancer. Conclusion: In this case report, we demonstrate that acupuncture is a safe and effective alternative to general anesthesia for patients undergoing TURBT. Since tobacco use is prevalent among bladder cancer patients, many of these individuals have associated medical comorbidities, which predispose them to high risk with general anesthesia. Therefore, acupuncture may serve as an attractive alternative for certain patients in this population.
Background: Urinary obstruction as a result of a late complication of a gunshot wound is rarely reported. Bullet shell fragments may migrate from their initial location into an area causing obstruction. In this study, we present a case of a left renal calculus surrounding a 9 mm gun shell in a patient with a solitary functioning left kidney. Case Presentation: A 53-year-old man presented with left hydronephrosis found on an urgent CT scan following complaints of left flank pain and signs of acute renal failure 10 years after suffering a gunshot wound to the abdomen. Urgent cystoscopy and bilateral retrograde pyelograms revealed a left ureteropelvic junction calculus surrounding a 9 mm bullet fragment that was ultimately removed percutaneously. Conclusion: Abdominal gunshot shell fragments may migrate over time causing urinary obstruction. In this case the past medical history of the previous gunshot wounds provided insight into the etiology of the patient's actual clinical presentation. This led to the best endoscopic approach for the effective treatment of this unique case.
Background: Gonadal vein thrombosis (GVT) has been reported in association with malignancy and pelvic inflammatory conditions. Patients who develop GVT often require systemic anticoagulation to reduce the risk of pulmonary embolism and other local and distant thromboembolic effects. As the gonadal vein courses from the pelvis toward its outlet in the upper abdomen, its intimate relationship to the ureter in the setting of vascular pathology may pose a risk for urinary obstruction in the adult. We are reporting a rare case of GVT leading to ureteral obstruction and acute kidney injury (AKI) in a young otherwise healthy male and provide a review of similar literature. Case Presentation: We describe a case of an otherwise healthy 29-year-old African American adult male presenting with acute diverticulitis and associated left GVT with no evidence of hypercoagulability, leading to ureteral obstruction, hydronephrosis, and AKI. Treatment with ureteral stent placement, endovascular intervention, and systemic anticoagulation led to resolution of his condition. Conclusion: This report details a rare case of confirmed GVT in an adult male with resultant urinary obstruction. Decompression of the collecting system and treatment of the significant venous obstruction with surgical intervention, combined with medical systemic anticoagulation, were effective in reversing the underlying cause.
CT showing massive bilateral AMLs and hematoma formation on right upper pole. AML, angiomyolipoma.
Angiogram, prelipiodol injection. Coils from previous embolizations shown.
Angiogram, pre-gelfoam, and tornado coils. Bleeding in upper pole identified.
Postembolization. Note absence of contrast extravasation beyond the coils.
Background: Hemorrhage from an angiomyolipoma (AML) of the kidney can be life threatening and arterial embolization is the primary treatment. Embolization is less invasive than surgery, is well tolerated, and major complications are rare. We describe a case of disseminated intravascular coagulation (DIC) after embolization of a bleeding renal AML in a 44-year-old man with massive bilateral AMLs. This report aims to highlight the possibility that acute DIC could be a major complication of embolization itself and so should be considered and screened for because, if present, it requires early and aggressive management. Case Presentation: A 44-year-old man with a history of large bilateral renal AMLs associated with tuberous sclerosis complex presented with visible hematuria and abdominal pain. Renal CT revealed bleeding from the right kidney. Embolization with polyvinyl alcohol and lipiodol was urgently performed. The following day he required multiple blood transfusions and repeat embolization, this time with gelfoam and “tornado” coils. He suddenly developed DIC, cardiovascular collapse and acute renal failure requiring many days in the intensive care unit for inotropic support and renal replacement therapy. Conclusion: Arterial embolization may be associated with increased risk of DIC in the setting of treating large bleeding renal AMLs. DIC may be a direct or indirect complication of this. The clinician must act quickly to identify this and treat this complication aggressively.
A noncontrast CT KUB showing bilateral renal and a right pelviureteral calculus. KUB, kidney, ureter, and bladder radiograph. 
(A) Light microscopy showing typical brown 2,8-DHA crystals. (B) Polarized light microscopy with typical central Maltese cross pattern. With permission from V. Edvardsson, MD, The APRT Deficiency Program of the Rare Kidney Stone Consortium ( dha/), Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland. APRT, adenine phosphoribosyltransferase; DHA, dihydroxyadenine. 
Background: Recurrent urolithiasis is troublesome for both patient and clinician, and in most cases, an underlying cause is not found. An important and underdiagnosed cause is adenine phosphoribosyltransferase (APRT) deficiency that gives rise to 2,8-dihydroxyadenine (2,8-DHA) stones. If diagnosed early, patient morbidity as well as the financial cost of treating stone recurrence can be avoided with simple medical therapy. Case Presentation: A 36-year-old white, Caucasian male with recurrent urolithiasis was found to have 2,8-DHA stones. This was difficult to manage, as these stones were often large, bilateral, matrix in structure, and translucent on plain X-rays. He underwent a multitude of interventions including both retrograde and anterograde endoscopic approaches as well as extracorporeal shock wave lithotripsy. The specific stone type was eventually discovered through infrared spectroscopy and he was promptly commenced on allopurinol, which significantly improved his stone burden and frequency of presentation with renal colic. Conclusion: APRT deficiency is underdiagnosed given the estimated prevalence of 1/50,000–1/100,000, however, with less than 300 reported cases worldwide. This is likely because of both a lack of awareness of the disorder among clinicians and the challenges of identifying 2,8-DHA stones. Increasing awareness of 2,8-DHA urolithiasis among urologists as well as physicians is, therefore, key in tackling this condition.
Background: A giant vesical calculus is one weighing >100 g. A long-standing vesical calculus can be associated with squamous cell carcinoma of bladder. Case Presentation: In this study, we report an unusual association of giant vesical calculus (weight 570 g) with adenocarcinoma of urinary bladder in a young man. We could find only two such cases in the literature. Conclusion: Rarity of the association of giant vesical calculus and adenocarcinoma of the bladder and their management issues warrant this presentation.
Background: Irreversible electroporation (IRE) is a soft tissue ablation technique using electrical pulses without thermal energy to create pores in the cell membrane, resulting in death from apoptosis rather than necrosis. Advantages include protection of blood vessels, nerves, and surrounding structures. Documented complications include periprocedure nausea/vomiting, infection, and severe pain. Ureteral stents are frequently used in management of hydronephrosis caused by malignant obstruction. We describe what is to our knowledge the first documentation of stent fragmentation secondary to IRE and subsequent management. Case Presentation: This is a 61-year-old male with history of metastatic rectal adenocarcinoma treated initially with chemotherapy and surgery. Follow-up imaging revealed hydronephrosis and enlarged right iliac lymph node. Ureteral stent was placed for management of the hydronephrosis and the patient was referred to undergo IRE for management of metastatic disease. After treatment, the patient had imaging performed that showed fractured right ureteral stent with proximal portion in the ureter and distal portion floating freely in the bladder. This complication was managed with staged endoscopic procedure involving adjacent ureteral stent placement and subsequent ureteroscopy and stent removal using delta grasper. Conclusion: We describe to our knowledge the first incidence as well as subsequent management of ureteral stent fracture from an increasingly common treatment modality for metastatic disease. Given the frequency of malignant ureteral obstruction managed with ureteral stents, knowledge of potential complications pertaining to the urologist is imperative.
Axial view of CT scan with contrast showing delayed nephrogram and hydronephrosis of both collecting systems (see arrows) on the right kidney.
Sagittal view of CT scan with contrast showing a hydronephrotic bifid ureter (red line indicating boundary between two ureteral segments) with enhancement at bifurcation (see arrow).
Retrograde pyelogram showing bifurcation at the proximal ureter (yellow arrow) with reduced flow through the more proximal ureteral segments (lower pole-green arrow, upper pole-red arrow) indicating partial obstruction.
Background: Secondary malignancies of the ureter are uncommon. We report the diagnosis and management of metastatic colon cancer to the bifurcation of a bifid ureter. Case Presentation: A 59-year-old man presented with diffuse metastasis with right hydronephrosis in both renal moieties of a partially duplicated system and an enhancing lesion within the proximal common ureter. Ureteral biopsy was positive for colorectal adenocarcinoma. The patient was subsequently started on palliative chemoradiation. Conclusion: The ureter is a rare location for hematogenous/lymphatic metastases. When a ureteral mass is present on imaging, ureteroscopy should be performed to characterize the extent of tumor and to rule out secondary malignancy.
Top-cited authors
Philip Low
  • Purdue University
George Sandusky
  • Indiana University Bloomington
Jay Natarajan
  • Northeast Ohio Medical University
Cheuk Fan Shum
  • National Healthcare Group
Clinton D Bahler
  • Indiana University School of Medicine