Liver transplantation in hepatocellular carcinoma - should we perform downstaging?

AIM: To compare the long-term outcomes between liver transplant (LT) recipients with hepatocellular carcinoma (HCC) who were downstaged with transarterial-chemoembolization (TACE) to the Milan criteria (MC) and those initially meeting the MC. METHODS: This retrospective study enrolled 198 patients with HCC: 38 were downstaged and 160 patients initially met the MC. Post-LT survival and HCC recurrence-free survival were evaluated. We assessed the association of death and HCC recurrence with TACE, baseline (age, sex, disease etiology, Model of End-stage Liver Disease, tumor number and the sum of maximum tumor diameters, waiting time, alpha-fetoprotein level) and explant characteristics (tumor number and the sum of maximum tumor diameters, micro- and macrovascular invasion). RESULTS: The recipient survival rates one, three, and five years after LT were 88.2%, 80.1%, and 75.9%, respectively. HCC recurrence-free probabilities were 92.3%, 87.9%, and 85%, respectively. The outcomes were comparable between the groups. In multivariate analysis, the number of tumors on the explant, age, and tumor recurrence were independent risk factors for death. Only the sum of maximum tumor diameters on the explant was an independent risk factor for HCC recurrence. CONCLUSIONS: Patients successfully downstaged with TACE to the MC can achieve post-LT recipient and HCC recurrence-free survival comparable with patients initially within the MC. Good response to TACE as a criterion for LT may be a method of selecting patients with favorable biological characteristics.

EFFICIENCY OF BREAST SHIELDING DEVICE IN OUT-OF-PLANE COMPUTERIZED TOMOGRAPHY IMAGING OF THE ABDOMEN - PRELIMINARY RESULTS.

The dose absorbed by sensitive breast glandular tissue in abdominal computed tomography examinations, even when the breasts are outside the primary imaging beam, is still significant. Several studies have explored using breast shielding with a protective lead sheet or a bra. Since the source of radiation in computed tomography rotates by 360° around the patient, we made a custom-tailored shielding device that wraps around the entire thorax. The hypothesis is that such a custom-tailored breast shielding device provides significantly better dose reduction. Study participants were female patients with no anatomic anomalies. Entrance surface doses were measured using thermoluminescence dosimeters placed on the skin of the breast in the control group without shielding and on the surface and below the shielding device in the group with anterior shielding and the group with the new device. As expected, according to literature data, doses measured at breast level were above the threshold that epidemiological studies determine as an increased risk of breast cancer development although they were not in the primary imaging plane. Preliminary results of our study showed that average dose reduction was 42% with conventional anterior shielding and 57% with wrapped shielding compared to the doses measured with no shielding.

SUCCESSFUL RESOLUTION OF NUTCRACKER SYNDROME WITH 3D PRINTED PEEK EXTRAVASCULAR STENT IN AN ADOLESCENT BOY.

Three-dimensional printed polyetheretherketone (PEEK) extravascular stent was applied to treat a 14-year-old boy with nutcracker syndrome. Digital subtraction angiography revealed a segment of the left renal vein (LRV) with reduced contrast filling immediately before its inflow into the inferior vena cava, and high-pressure gradient. The three-dimensional reconstruction model demonstrated that the LRV and the duodenum were contracted at the aortomesenteric angle, resulting in LRV compression from the abnormal high-level duodenal compartment. When duodenum courses between the abdominal aorta and superior mesenteric artery (duodenal interposition), the LRV entrapment occurs even at <90 aortomesenteric degrees. Three-dimensional printed PEEK extravascular stent was chosen to elevate the superior mesenteric artery and lower the duodenum position, thus relieving LRV compression. This extravascular application has significant advantages over open surgery, endovascular stenting and artificial vessel procedures with expanded polytetrafluoroethylene. It provides better cellular vitality by ensuring soft tissue proliferation. By reducing external acceleration and centrifugal force, a three-dimensional printed PEEK extravascular stent reduces adverse side effects. Such a stent has a distinctive personalized design, good stiffness, and durability that allows blood vessel growth, preventing stent migration and thrombosis. Therefore, it is suitable for both adult and pediatric patients. According to the abdominal ultrasound and multi-slice computed tomography scan, the postoperative follow-up results were satisfactory one year after surgery. The patient felt well, the blood flow in the LRV was not obstructed, and the blood flow velocity was average. The external stent was in place.

The role of magnetic resonance imaging and the expression of MMP-9 protein in the analysis of carotid atherosclerotic plaques in patients undergoing carotid endarterectomy: a prospective pilot study.

Components of carotid atherosclerotic plaque can be analysed preoperatively by non-invasive advanced imaging modalities such as magnetic resonance imaging (MRI). The expression of matrix metalloproteinase-9 protein (MMP-9), which has a potential role in remodelling of atherosclerotic plaques, can be analysed immunohistochemically. The aim of the present prospective pilot study is to analyse histological characteristics and expression of MMP-9 in carotid plaques of patients undergoing carotid endarterectomy (CEA) and to investigate the correlation with preoperative clinical symptoms and MRI features. Preoperative clinical assessment, MRI imaging, postoperative histological and immunohistochemical analyses were performed. Fifteen patients with symptomatic (7/15; 47%) and asymptomatic carotid artery stenosis undergoing CEA were included. Among symptomatic patients, 5 (71%) had recent stroke and 2 (29%) had recent transient ischaemic attack with a median timing of 6 weeks (IQR: 1, 18) before the surgery. Both groups did not significantly differ in respect to preoperative characteristics. Prevalence of unstable plaque was higher in symptomatic than asymptomatic patients, although it was not significant (63% vs. 37%, p = 0.077). The expression of MMP-9 in CD68 cells within the plaque by semiquantitative analysis was found to be significantly higher in symptomatic as compared to asymptomatic patients (86% vs. 25% with the highest expression, p = 0.014). The average microvascular density was found to be higher and lipid core area larger among both symptomatic patients and unstable carotid plaque specimens, although this did not reach statistical significance (p = 0.064 and p = 0.132, p = 0.360 and p = 0.569, respectively). Our results demonstrate that MRI is reliable in classifying carotid lesions and differentiating unstable from stable plaques. We have also shown that the expression of MMP-9 is significantly higher among symptomatic patients undergoing CEA.

Provisional focal stenting of complex femoropopliteal lesions using the Multi-LOC multiple stent delivery system - 12-month results from the LOCOMOTIVE EXTENDED study.

Background: This study aimed to evaluate a Multiple Stent Delivery System for provisional focal stenting of the femoropopliteal artery. Patient and methods: The LOCOMOTIVE EXTENDED study (Multi-LOC for flOw liMiting Outcomes after plain old balloon angioplasty and/or drug-coated balloon Treatment in the infrainguinal position with the objectIVE to implant multiple stent segments) is a prospective, single-arm, multicentre observational study. The Multi-LOC Multiple Stent Delivery System (B.Braun, Melsungen, Germany) was used for provisional focal stenting of the femoropopliteal artery. We enrolled 357 patients with 449 femoropopliteal lesions; all had flow-limiting dissections or recoil following angioplasty. Eligibility included Rutherford classification 2 to 5 with a de novo or non-stented restenotic femoropopliteal lesion undergoing plain balloon or drug-coated balloon angioplasty. The 6- and 12-month efficacy endpoints encompassed target lesion revascularisation and primary patency rates. Results: The mean patient age was 71 ± 10 years. The mean lesion length was 16.0 ± 9.7 cm; 44.5% were TASC II C/D lesions and 31.4% were chronic total occlusions. By operator choice, 45% of the patients underwent drug-coated balloon angioplasty. On average, 4.0 stents (each 13 mm long) were placed in each lesion, resulting in a scaffolding proportion of 56% of the total lesion length with a technical success rate of 98.3%. At 6 and 12 months, the freedom from clinically driven target lesion revascularisation was 95.5% and 88.7% and the primary patency rates were 88.7% and 82.3%, respectively. At 12 months, significant improvements were noted in Rutherford categories and ankle-brachial indices. In multiple regression analyses, both diabetes mellitus and no distal run-off vessel showed a trend toward worse TLR, while other factors such as DCB predilation or the lesion length were not predictive. Conclusions: The LOCOMOTIVE EXTENDED study demonstrated the safety and efficacy of the Multi-LOC stent system for focal provisional stenting of complex femoropopliteal lesions.

Cerebral Neuromonitoring during Carotid Endarterectomy and Impact of Contralateral Internal Carotid Occlusion.

BACKGROUND: The aim of this study was to identify the reliability of carotid artery stump pressure (SP) in predicting the neurologic changes and correlation with contralateral internal carotid artery (ICA) occlusion in patients undergoing eversion carotid endarterectomy (CEA). The optimal method for monitoring cerebral perfusion during CEA, performed under either local or general anesthesia, is still controversial. METHODS: We prospectively analyzed 118 consecutive patients undergoing eversion CEA under local anesthesia. We had 78 symptomatic (66%) and 40 asymptomatic patients (33.9%). Selective shunting was performed in patients who developed neurologic changes after carotid clamping regardless of SP. Correlation of preoperative symptom status, a degree of stenosis, status of contralateral ICA, arterial blood pressure, SP value, and the intraoperative need for shunting due to neurologic changes was evaluated for both groups: shunted and nonshunted. RESULTS: Selective shunting was performed in 12 patients (10%). There was no significant difference among the groups regarding the demographic characteristics. Mean carotid clamping time was 14.57 minutes. We had no perioperative mortality, stroke, or myocardial infarction. None of the patients required conversion to general anesthesia. We found a mean SP of 31 mm Hg as a reliable threshold for shunting (P < .001; sensitivity 92.3%; specificity 91.3%). Contralateral carotid occlusion was correlated with the significantly lower SP (27 ± 13 mm Hg; P = .001) and the higher need for shunt (50%). CONCLUSIONS: SP measurement is a reliable and simple method for monitoring the collateral cerebral perfusion and can predict the need for shunting during CEA. Patients with the contralateral ICA occlusion showed significantly lower SP, although it did not have impact on the outcome.

Embolisation of pulmonary arteriovenous malformations - case series.

PURPOSE: Pulmonary arteriovenous malformations (PAVM) are the direct communications between the pulmonary arteries and veins. These malformations can cause serious complications, and most of these patients should be treated. Herein we present our experience in the treatment of 18 cases of PAVM, treated with endovascular embolisation. MATERIAL AND METHODS: Eighteen patients with PAVMs underwent endovascular embolisation during a five-year period. Eight were male and 10 were female, with ages ranging from 16 to 65 years. Standard steel coils and vascular plug were used for embolisation. RESULTS: Embolisation was successful in 17 of 18 patients. Coiling was used in 10 patients, vascular plug in five, and both materials in two patients. All symptomatic patients with successful embolisation lost all their symptoms after treatment. Control angiography after embolisation showed a closure of AV shunt without migration of embolic material in all patients. Post-embolisation syndrome developed in four patients and late onset of pleural pain in three patients. There was no connection between pleural reaction and type of PAVM and embolic material. CONCLUSIONS: Endovascular PAVM treatment is a minimally invasive, highly successful method with a low rate of only transitory complications.

Low-dose Computed Tomography in a Pregnant Woman with a Ruptured Pseudoaneurysm of the Abdominal Aorta.

Imaging the pregnant patient presents a unique challenge to radiologist due to the risk of radiation to the conceptus (embryo/fetus). A rare case of a successfully recognized and treated pseudoaneurysm (PA) of the abdominal aorta is to be presented. The pseudoaneurysm occurred in the third trimester and had a favorable outcome for the mother and the baby. Emergent abdominal ultrasound (US) is the first modality in diagnostic algorithm for the rupture of aortic aneurysm in a pregnant woman. It provides the most rapid diagnostic information, although intestinal gas and abdominal tenderness may limit its accuracy. To confirm the findings, magnetic resonance angiography (MRA) or CT angiography (CTA) can be used. In our case, the diagnosis was established using a color Doppler ultrasonography of the abdomen and was later confirmed by a low dose CT scan of the abdominal aorta. MRA in such cases have some disadvantages. At many health centers, the monitoring of patients with acute ruptures is more difficult in the MR suite than at the CT scanner. MRA angiographic images are also subject to degradation by multiple artifacts and the visualization of the distal vasculature is suboptimal and inferior to the one done by CTA. Due to fetal movements, a small quantity of fresh blood can be overlooked by MR. MRA is often not available on a 24-hours basis, and the time required for making a diagnosis can preclude the use of MRA in an unstable patient. For this reason, we used a low dose CTA protocol to confirm the diagnosis. Low dose scanning protocols in CT can obtain sufficient diagnostic information while reducing the risk of radiation. A particular focus is put on the outline of new concepts for dose management and optimization. We used new approaches based on tube current modulation. The birth was induced by an urgent Caesarean section followed by a resection of a pseudoaneurysm and a reconstruction of the aorta with an end-to-end vascular prosthesis.

[ULTRASOUND GUIDED PERCUTANEOUS SCLEROTHERAPY OF SIMPLE RENAL CYSTS: PRIMARY SUCCESS AND PROCEDURE SAFETY]. / PERKUTANA SKLEROTERAPIJA JEDNOSTAVNIH CISTA BUBREGA VODENA ULTRAZVUKOM: PRIMARNI USPJEH I SIGURNOST PROCEDURE.

OBJECTIVE: To evaluate primary (technical) success and procedure safety in ultrasound (US)-guided percutaneous sclerotherapy of simple renal cysts, using 96% ethanol. PATIENTS: 17 patients with symptomatic simple renal cysts referred by nephrologists or urologists. METHODS: US-guided percutaneous puncture of the cyst with an 18G (gauge) needle and a "pigtail" 5F (French) catheter, drainage and inspection of the cyst content, and injection of ethanol. RESULTS: Puncture was rejected in two referred patients because of Bosniak II cyst and renal hilum proximity. 15 patients underwent puncture and drainage of the cyst content. In 4 patients ethanol was not injected because: thick or bloody cyst, proximity of renal hilum and severe pain during injection of ethanol. 11 patients underwent sclerotherapy of the cyst. The average size of sclerosed cyst was 8 cm (range 6-12 cm). There were no significant complications. CONCLUSION: US-guided percutaneous sclerotherapy of simple renal cysts is easy to perform and safe procedure, with the previous good selection of cysts that are suitable for the sclerotherapy.

Percutaneous Endovascular Treatment for Hepatic Artery Stenosis after Liver Transplantation: The Role of Percutaneous Endovascular Treatment.

BACKGROUND: To retrospectively analyze the outcomes of interventional radiology treatment of patients with hepatic artery stenosis (HAS) after liver transplantation at our Institution. MATERIAL/METHODS: Hepatic artery stenosis was diagnosed and treated by endovascular technique in 8 (2.8%) patients, who underwent liver transplantation between July 2007 and July 2011. Patients entered the follow-up period, during which we analyzed hepatic artery patency with Doppler ultrasound at 1, 3, 6, and 12 months after percutaneous endovascular treatment (PTA), and every six months thereafter. RESULTS: During the 12-month follow-up period, 6 out of 8 patients (75%) were asymptomatic with patent hepatic artery, which was confirmed by multislice computed tomography (MSCT) angiography, or color Doppler (CD) ultrasound. One patient had a fatal outcome of unknown cause, and one patient underwent orthotopic liver retransplantation (re-OLT) procedure due to graft failure. CONCLUSIONS: Our results suggest that HAS angioplasty and stenting are minimally invasive and safe endovascular procedures that represent a good alternative to open surgery, with good 12-month follow-up patency results comparable to surgery.

[Resistant hypertension and reasons for excluding patients from treatment with renal denervation]. / Rezistentna hipertenzija i razlozi iskljucivanja za postupak renalne denervacije.

Increased activation of the sympathetic nervous system is identified as an important factor in the development and progression of hypertension. In this context, a catheter-based approach has been developed to disrupt the renal sympathetic nerves, i.e. renal denervation. Among patients with resistant hypertension, it is very important to select patients using standardized stepwise screening. The potential success of renal denervation depends on the ability to select patients most likely to benefit. A multidisciplinary meeting in necessary. In this work, we describe the potential reasons for excluding patients from treatment with renal denervation.

Pseudokidney Sign in Gastric Cancer.

Pseudokidney sign (PKS) is a characteristic sonographic finding of an abnormal mass with a reniform appearance, and a hyperechoic central region surrounded by a hypoechoic area. It has been seldom documented in gastric cancer. A 75-year-old male patient presented with a palpable abdominal resistance in the left upper abdominal quadrant and ultrasound evaluation revealed a well-vascularized mass presenting with PKS. Regional lymphadenopathy was also found, and the working diagnosis of gastric cancer was established. The suspected diagnosis was later verified endoscopically and on pathohistological examinations as gastric adenocarcinoma. Computed tomography staging also revealed distant metastases to the lungs, liver, and adrenal glands and abdominal lymphadenopathy. The PKS often indicates gastrointestinal pathology, and it may be seen in benign and malignant conditions due to gastrointestinal wall thickening. Therefore, additional diagnostic examinations are advised for a more definite diagnosis.

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review.

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

Fragility spinal fractures among cirrhotic liver transplant candidates in Croatia.

INTRODUCTION: Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD). OBJECTIVES: The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results. MATERIAL AND METHODS: This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis. RESULTS: A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found. CONCLUSION: Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.

Effects of age on minimum effective volume of local anesthetic for ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND: Involutional changes of peripheral nervous system occur with aging. The aim of the study was to determine the minimum effective volume of local anesthetic required to offer an effective ultrasound-guided supraclavicular brachial plexus block in 50% of middle-aged (< 50 years) and elderly (> 65 years) patients. We hypothesized reduced minimum effective volume of local anesthetic in elderly patients. METHODS: Middle-aged (n = 22) and elderly (n = 22) patients undergoing upper limb surgery received an ultrasound-guided supraclavicular brachial plexus block. Structural analysis of the brachial plexus in supraclavicular region was obtained by measuring the cross-sectional area. The prospective, observer-blinded study method is a previously validated step-up/step-down sequence model where the local anesthetic volume for the next patient is determined by the outcome of the previous block. The starting volume was 30 ml (50 : 50 mixture, 0.5%wt/vol levobupivacaine, 2%wt/vol lidocaine). The minimum effective volume of local anesthetic was determined using Dixon and Masey method. RESULTS: The minimum effective local anesthetic volume significantly differed between middle-aged and elderly [23.0 ml, 95% confidence interval (CI) 13.7-32.3 vs. 11.9 ml, 95% CI 9.3-14.6; 95% CI of the difference 1.6-20.6, P = 0.027]. The cross-sectional area of brachial plexus was 0.95 ± 0.15 in middle-aged and 0.51 ± 0.06 cm(2) in elderly patients (P < 0.001). CONCLUSIONS: Within the present study, we report a reduced minimum effective anesthetic volume for ultrasound-guided supraclavicular block in elderly patients. Additionally, smaller cross-sectional surface area of brachial plexus in the supraclavicular region was observed.

Coil embolization and surgical removal of carotid body paraganglioma.

Carotid body paraganglioma has considerable malignant potential and locally aggressive behavior, so it should be treated as soon as it is discovered.We report the case of 60-year-old male patient with a carotid body paraganglioma (Shamblin group II) that was causing the carotid arteries to spread. Angiography showed 1 dominant feeding artery arising from the right external carotid artery. Selective angiography was performed 2 days before surgical removal of the tumor, and the feeding artery was successfully embolized with coils.Literature review reveals previous reports where preoperative embolization of the feeding arteries was done using ethanol, polymers, or other liquid agents. In our case, angiography (via femoral artery) was performed 2 days before surgical removal of the tumor, and the main feeding artery (a single branch arising from external carotid artery) was successfully embolized with coils rather than liquids.Performing coil embolization before operating reduced subsequent blood loss and made it easier to identify the feeding artery during surgery. Supraselective coiling, although as difficult as embolization with liquids, may reduce the incidence of postoperative stroke. At 1 year after surgery, the patient had no signs of tumor recurrence.

Section for Interventional Radiology--sIRcro 10 years of existence and organised activities (2000-2010).

Shortly after the Roentgen's discovery (1895), X-rays were applied for depicting vascular system (Lindenthal and Haschek 1896). But it took rather long time before another brilliant idea (Seldinger 1953) for percutaneous puncture and catheterization of superficial artery was developed instead of these previously performed and the surgical arteriotomy. The percutaneous puncture enabled another idea to emerge, i.e. percutaneous transluminal angioplasty--PTA (Dotter/Judkins 1964). Thus it was proved that catheter could be used not only in diagnostics but also in therapy, and the method was applied to other organs and organic systems. The application of interventional radiology in Croatia started in late 1970s and early 1980s. The number and type of procedures increased rapidly in the four largest hospitals and educational centres (Zagreb, Split, Rijeka, Osijek), so that the need was felt to establish a Section for Interventional Radiology of the Croatian Society of Radiology (2000).

Infrarenal inferior vena cava agenesis presenting as acute abdomen and hydronephrosis - case report.

The inferior vena cava agenesis (IVCA) is a rare and often asymptomatic malformation due to the abundant development of the collateral circulation. However, it is frequently found in young people and carries a significant risk of deep venous thrombosis (DVT). It is estimated that about 5% of patients under 30 years of age presenting with DVT have this condition. We report a case of a previously healthy 23-year-old patient presenting with signs of acute abdomen and hydronephrosis due to the thrombophlebitis of an unusual iliocaval venous collateral, which developed secondary to IVCA. After treatment, the iliocaval collateral and hydronephrosis completely regressed on a 1-year follow-up. To our knowledge, this is the first such case reported in the literature.

Urothelial carcinoma in a urinary bladder diverticulum: A case report and review of the literature.

Bladder diverticula are defined as an outpouching of the mucosa into the muscle layer of the bladder wall. There is a well-known link between urinary bladder diverticula and tumors arising within the diverticula. They are rare with an incidence rate of 0.8%-10%. We report an intradiverticular urothelial carcinoma in a 72-year-old man with a known history of multiple episodes of acute urinary retention and urinary tract infections, followed by transurethral resection of the benign prostatic hyperplasia.

Retroperitoneal Paraganglioma Treated With Tumor Resection and Replacement of the Inferior Vena Cava.

Retroperitoneal paragangliomas are tumors of neuroectodermal origin rarely appearing in the pediatric population. We report a case of a large paraganglioma infiltrating the right kidney and inferior vena cava in a 16-year-old boy who initially presented with a right-sided varicocele. Right retroperitoneal paraganglioma was embolized preoperatively, followed by total tumor excision, right nephrectomy, inferior vena cava resection, and reconstruction using a prosthetic vascular graft. Retroperitoneal tumors requiring surgery can successfully be treated by radical resection and replacement of the inferior vena cava in experienced centers.