[Renal cirsoid aneurysm (congenital arteriovenous fistula): a rare cause of severe hematuria]. / Aneurisma cirsoide renal: una rara causa de hematuria severa.

OBJECTIVE: Congenital arteriovenous fistulas are an exceptional clinical feature. Although they are frequently asymptomatic, their presentation as severe hematuria pose an excellent diagnostic exercise and often immediate therapeutic action. METHODS/RESULTS: We report the case of a 75-year-old female patient presenting with severe hematuria producing anaemia, high blood pressure and congestive heart failure. Image tests revealed right ureteral-hydronephrosis with bladder blockage by blood clots. The endoscopic study (cystoscopy and ureterorenoscopy) alerted about the origin of the hematuria from the right kidney, finally requiring nephrectomy as definitive treatment. Pathology revealed the presence of a round formation with multiple vascular channels, arterial and venous, in the pyelocalicial submucosa, with focal epithelial erosion, compatible with congenital arteriovenous fistula. We review the diagnostic and therapeutic features in the literature. CONCLUSIONS: Renal congenital arteriovenous fistulas represent a diagnostic dilemma. They may present asymptomatic or condition clinical features derived from the shunt and high cardiac output (hypertensive cardiopathy and congestive heart failure) or from the erosion and acute hemorrhage into the urinary tract (severe renal hematuria). Treatment should be conservative with embolization or supraselective sclerosis. Nevertheless, in cases of big fistulas, post embolization revascularization, or hemodynamic instability nephrectomy is an excellent option.

[Concurrent tumors in a patient with giant hydronephrosis]. / Colisión tumoral en hidronefrosis gigante.

OBJECTIVES: Giant hydronephrosis, defined as the presence of a liquid volume over 1000 ml within the urinary collector system, is a rare clinical entity, the diagnosis of which is an excellent exercise because it lacks of a defined clinical presentation. METHODS/RESULTS: We report the case of a 66-year-old male under study for a suspicious digestive tumor due to a long lasting clinical picture with severe cachexia, asthenia, anemia, constipation, and abdominal mass. Radiological tests showed a great right hydronephrosis secondary to a culculus in the ureteral-pelvic junction. Simple nephrectomy was performed, evacuating 7800 ml of serous-hematic liquid from the pyelocalicial system. A histological diagnosis revealed the presence of multiple foci of transitional cell carcinoma and renal cell carcinoma associated. We review the diagnostic and therapeutic features in the literature. CONCLUSIONS: Giant hydronephrosis represents a diagnostic dilemma. It may present as an asymptomatic process, with clinical features of abdominal organs compression (bowel or urinary obstruction) or simulate abdominal tumors, massive ascites, or cystic retroperitoneal lesions. Simple nephrectomy is the treatment of choice in most cases, due to the advanced deterioration of the renal unit. Nevertheless, in some cases, in compromised patients, percutaneous drainage may be necessary as previous or definitive treatment to avoid changes in the hemodynamic balance secondary to the sudden abdominal decompression.

[Penile incarceration by multiple metal rings]. / Incarceración peneana por múltiples anillos metálicos.

OBJECTIVE: Penile incarceration is an infrequent clinical reality. Diagnosis is evident in most cases, and the challenges are to find the best way to retrieve the constrictive ring and repair the damage. Nevertheless, this event being curious has motivated us to report it. METHODS AND RESULTS: We report the case of a 48 year old patient victim of a "joke" resulting in a 13 day penile incarceration produced by 7 double metallic rings, 24 mm in internal diameter and 4 mm wide, which required section and extraction of the rings as well as wide tissue debridement and posterior plastic reconstruction using partial thickness cutaneous grafts. We review diagnostic an therapeutic features from the literature. CONCLUSIONS: Penile incarceration should be considered an emergency, so that the earlier the constrictive object is retrieved the lower the risk for complications secondary to penile devascularization, urinary retention and urethral damage. We emphasise the need to perform retrograde urethrography and suprapubic cystostomy if urethral lesion is suspected, a cutaneous vascular evaluation with doppler ultrasound or fluorescein test and the opportunity of cutaneous grafts to solve tissue lesion.