Retroperitoneal Hygroma.

We present a 46-year-old white male with a retroperitoneal hygroma protruding from the right flank.

Secondary pelvic congestion syndrome: description and radiographic diagnosis.

INTRODUCTION: Pelvic congestion syndrome (PCS) is a complex condition of the pelvic venous system leading to nonspecific pelvic pain that was initially described in females alone. The underlying abnormalities, though diverse, all result in increased pressure in the left gonadal vein which is transmitted retrograde into the pelvic venous system. Our primary aim was to describe our findings of secondary PCS as a distinct entity from primary PCS in that it has an identifiable vascular etiology and is gender nonspecific. We also aimed to assess the adequacy of late-arterial phase CT urography (CTU) as the initial imaging modality in diagnosing and evaluating secondary PCS. MATERIALS AND METHODS: We retrospectively reviewed 59 patients with PCS, 36 males and 23 females ages 24 to 63, from 2000-2011. To maximize opacification, CTU images were taken in the late-arterial phase with a 35-50 second delay after contrast administration. RESULTS: Review of our cases revealed multiple etiologies for PCS, including: Nutcracker syndrome (19 cases), cirrhosis (17), retroaortic left renal vein (11), tumor thrombosis of the IVC (5), portal vein thrombosis (4), renal cell carcinoma with left renal vein thrombosis (2), and left kidney AVF (1). The most common symptom was unexplained chronic pelvic pain. The patients in our series had clearly identifiable vascular flow abnormalities leading to the development of PCS, and were therefore diagnosed as having secondary PCS. All cases were easily identified utilizing CTU to visualize and measure dilation of the left gonadal vein and pelvic varices. This modality also proved valuable in the identification and management of the various underlying causes of secondary PCS. CONCLUSION: Secondary PCS is distinct from primary PCS in that it arises from clearly identifiable vascular flow abnormalities and occurs in both males and females. The diverse set of underlying etiologies, as well as the resulting congested varices, can be reliably and adequately visualized using CTU as the initial imaging modality.

Percutaneous radiologic gastrostomy: results and analysis of factors contributing to complications.

UNLABELLED: INTENT: Assessment of feasibility of percutaneous radiologic gastrostomy (PRG) for long- or short-term nutritional support and analysis of attendant complications and their underlying causes. MATERIALS AND METHODS: A retrospective analysis of outcome, complications, and their underlying causes was carried out in 391 patients who had percutaneous gastrostomies performed in two different university medical centers from January 2005 to April 2010 by interventional radiology. Forty-three were performed under general anesthesia and 348 were under local anesthesia and conscious sedation; in 349, fluoroscopic guidance was used, in 17 ultrasound, and in 22 CT. RESULTS: Three hundred and seventy-six procedures were technically successful (96%). The procedure-related mortality was 2.5%. Fifty-seven gastrostomies were removed after clinical condition of the patients had improved. Only 36 gastrostomies remained functional for a year or longer. Major complications attributable to PRGs occurred in 6.1% (24 of 391) of our patients. On retrospective analysis, faulty technique may have been a major factor in many of these 24 patients. Injuries of abdominal organs and misplaced gastrostomies occasioned by improper localization of T fasteners were the major culprits. Minor complications occurred in 17.6% of patients. DISCUSSION AND CONCLUSION: Meticulous pre-procedural assessment of the topographic anatomy, preferably by CT, is mandatory to avoid or minimize by injury of colon, spleen, liver etc. Precise placement of T fasteners and confirmation of gastric access under cross-table lateral fluoroscopy is necessary for proper placement of the gastrostomy tube. Percutaneous radiologic gastrostomy has proven an excellent technique for short- and long-term nutritional support.

Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline.

PURPOSE: The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria. MATERIALS AND METHODS: A systematic literature review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements. RESULTS: Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up. CONCLUSIONS: AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic_microhematuria_guideline.pdf to view this guideline in its entirety.

The fate of small renal masses, less then 1 cm size: outcome study.

PURPOSE: We evaluated the outcome and etiologies of small renal masses (less than 1 cm in size) discovered incidentally on 2 consecutive CTs that investigated nonurologic abdominal complaints. MATERIALS AND METHODS: A retrospective search for incidentally discovered small renal masses, less then 1 cm in size, was carried out in the files of 6 major US medical centers. 4822 such lesions had been reported over a 12 year period. A search of these patients' records revealed 1082 subsequent new CTs for non urologic complaints, allowing the assessment of the fate of the masses. Lesions enlarging, of ambivalent contour or enhancement were examined by a third multiphasic MDCT. The findings were interpreted by 2 blinded radiologists. RESULTS: Six hundred and four masses could no longer be identified, 231 were significantly smaller, 113 unchanged in size and 134 larger. Of the disappearing lesions 448 were located in the medulla, 94 both in medulla and cortex and 62 in cortex. Multiphasic MDCTs obtained in 308 masses enlarging, unchanged in size or of ambivalent appearance, revealed 7 neoplasms, 45 inflammatory lesions, 8 abscesses and 62 renal medullary necrosis. Concurrent antibiotic therapy of GI conditions may have caused some of the 496 lesions to disappear. CONCLUSION: It is questionable whether the small number of malignant neoplasms (0.4%), inflammatory lesions (5%) and renal medullary necrosis (6%) justify routine follow-up CTs and exposure to radiation. The delay in intervention in neoplastic lesions probably didn't influence tumor-free survival potential and clinical symptoms would soon have revealed inflammatory conditions. With exception of ambivalent lesions, clinical surveillance appears adequate.

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.

Effectiveness of superselective chemoembolization and radiofrequency ablation of hepatocellular carcinoma assessed in 21 explanted livers.

The efficacy of superselective transcatheter chemoembolization (TACE) and chemoembolization taking advantage of pharmacologic (noradrenaline) flow manipulation was assessed on 21 explanted livers with hepatocellular carcinoma (HCC). There was a high concentration of chemoembolizate in the target area. Correlation of gross anatomical and immunohistochemical findings (gold standard) of tumor volume, necrosis and residual viable tumor to predicted results by multiphasic helical computed tomography (CT) was poor. Tumor markers in explanted livers found free of tumor were low or absent; in livers with residual or recurrent tumor high. However, there did not appear to be a correlation between the degree of tumor necrosis and level of tumor markers. The recurrence-free post-orthotopic liver transplant (OLT) survival in our 21 patients appears to be substantially lower than that reported in the literature. The goal of retaining patients on the liver transplant list by repeated TACE or multimodality therapy (MMT) was achieved (drop out rate of only 16%).

Aminocaproic-acid seal to reduce or prevent bleeding after liver biopsy.

This study investigates the efficacy of an aminocaproic-acid seal to prevent or reduce the risk of bleeding attendant to liver biopsies. The simple technique of occluding the biopsy tract by injecting 1-2 mL of aminocaproic acid, a fibrinolysis inhibitor, while withdrawing the biopsy sheath appears to reduce substantially the risk of delayed bleeding. The technique may be most useful if large core biopsy needles must be used to provide an adequate specimen.