Non-Contrast-Enhanced MR Arteriography of Potential Living-Related Liver Donor: Using Contrast Enhanced CT Arteriography as Standard Reference.

BACKGROUND: Contrast-enhanced computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the primary modalities to assess donors' vessels before transplant surgery. Radiation and contrast medium are potentially harmful to donors. PURPOSE: To compare the image quality and visualization scores of hepatic arteries on CTA and balanced steady-state free-precession (bSSFP) non-contrast-enhanced MRA (NC-MRA), and to evaluate if bSSFP NC-MRA can potentially be a substitute for CTA. STUDY TYPE: Prospective. POPULATION: Fifty-six consecutive potential living-related liver donors (30.9 ± 8.4 years; 31 men). FIELD STRENGTH/SEQUENCE: 1.5T; four bSSFP NC-MRA sequences: respiratory-triggered (Inhance inflow inversion recovery [IFIR]) and three breath-hold (BH); and CTA. ASSESSMENT: The artery-to-liver contrast (Ca-l) was quantified. Three radiologists independently assigned visualization scores using a four-point scale to potential origins, segments, and branches of the hepatic arteries, determined the anatomical variants based on Hiatt's classification, and assessed the image quality of NC-MRA sequences. STATISTICAL TESTS: Fleiss' kappa to evaluate the readers' agreement. Repeat measured ANOVA or Friedman test to compare Ca-l of each NC-MRA. Friedman test to compare overall image quality and visualization scores; post hoc analysis using Wilcoxon signed-rank test. P-value <0.05 was considered statistically significant. RESULTS: Inhance IFIR Ca-l was significantly higher than all BH bSSFP Ca-l (0.56 [0.45-0.64] vs. 0.37 [0.29-0.47] to 0.41 [0.23-0.51]). Overall image quality score of BH bSSFP TI1200 was significantly higher than other NC-MRA (4 [4-4] vs. 4 [3 to 4-4]). The median visualization scores of almost all arteries on CTA were significantly higher than on NC-MRA (4 [3 to 4-4] vs. 1 [1-2] to 4 [4-4]). The median visualization scores were all 4 [4-4 ] on Inhance IFIR with >92.3% observed scores ≥3, except the segment 4 branch (3 [1-4], 53.6%). The identification rates of arterial variants were 92.9%-97% on Inhance IFIR. DATA CONCLUSIONS: Although CTA is superior to the NC-MRA, all NC-MRA depict the donor arterial anatomy well. Inhance IFIR can potentially be an alternative image modality for CTA to evaluate the arterial variants of living donors. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

A comparative study of transperineal software-assisted magnetic resonance/ultrasound fusion biopsy and transrectal cognitive fusion biopsy of the prostate.

BACKGROUND: The advantages and disadvantages of transperineal and transrectal biopsies remain controversial in the era of prostate targeted biopsy. In this study, we compared the cancer detection and complication rates of transperineal magnetic resonance/ultrasound (MR/US) fusion biopsy and transrectal cognitive fusion biopsy of the prostate. METHODS: This was a comparative study of two prospectively collected cohorts. Men with clinically suspected prostate cancer and prostate imaging reporting and data system (PI-RADS) score ≥ 3 lesions on multi-parametric magnetic resonance imaging (mpMRI) were enrolled. They underwent either transperineal software fusion biopsy or transrectal cognitive fusion biopsy and systematic biopsy. The detection rates of any prostate cancer and clinically significant prostate cancer (csPC, defined as Gleason score ≥ 3 + 4) and the complication rates between both groups were analysed. RESULTS: Ninety-two and 85 patients underwent transperineal software fusion and transrectal cognitive fusion biopsies, respectively. The detection rate for any prostate cancer was similar between both groups (60.8% vs. 56.4%, p = 0.659). In terms of csPC detection, transperineal fusion biopsy outperformed transrectal fusion biopsy (52.2% vs. 36.5%, p = 0.036). In multivariate regression analysis, age, PI-RADS score > 3, and transperineal route were significant predictors of csPC. Meanwhile, transperineal biopsy resulted in a higher rate of urinary retention than transrectal biopsy (18.5% vs. 4.7%, p = 0.009). No serious infectious complications were noted, although a patient developed sepsis after transrectal biopsy. CONCLUSIONS: Transperineal software fusion biopsy provided a higher csPC detection rate than transrectal cognitive fusion biopsy and carried minimal risk for infectious complications in patients with MRI-visible prostate lesions.

Combining prostate health index and multiparametric magnetic resonance imaging in estimating the histological diameter of prostate cancer.

BACKGROUND: Although multiparametric magnetic resonance imaging (mpMRI) is widely used to assess the volume of prostate cancer, it often underestimates the histological tumor boundary. The aim of this study was to evaluate the feasibility of combining prostate health index (PHI) and mpMRI to estimate the histological tumor diameter and determine the safety margin during treatment of prostate cancer. METHODS: We retrospectively enrolled 72 prostate cancer patients who underwent radical prostatectomy and had received PHI tests and mpMRI before surgery. We compared the discrepancy between histological and radiological tumor diameter stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score, and then assessed the influence of PHI on the discrepancy between low PI-RADS (2 or 3) and high PI-RADS (4 or 5) groups. RESULTS: The mean radiological and histological tumor diameters were 1.60 cm and 2.13 cm, respectively. The median discrepancy between radiological and histological tumor diameter of PI-RADS 4 or 5 lesions was significantly greater than that of PI-RADS 2 or 3 lesions (0.50 cm, IQR (0.00-0.90) vs. 0.00 cm, IQR (-0.10-0.20), p = 0.02). In the low PI-RADS group, the upper limit of the discrepancy was 0.2 cm; so the safety margin could be set at 0.1 cm. In the high PI-RADS group, the upper limits of the discrepancy were 1.2, 1.6, and 2.2 cm in men with PHI < 30, 30-60, and > 60; so the safety margin could be set at 0.6, 0.8, and 1.1 cm, respectively. CONCLUSIONS: Radiological tumor diameter on mpMRI often underestimated the histological tumor diameter, especially for PI-RADS 4 or 5 lesions. Combining mpMRI and PHI may help to better estimate the histological tumor diameter.

Development of U-Net Breast Density Segmentation Method for Fat-Sat MR Images Using Transfer Learning Based on Non-Fat-Sat Model.

To develop a U-net deep learning method for breast tissue segmentation on fat-sat T1-weighted (T1W) MRI using transfer learning (TL) from a model developed for non-fat-sat images. The training dataset (N = 126) was imaged on a 1.5 T MR scanner, and the independent testing dataset (N = 40) was imaged on a 3 T scanner, both using fat-sat T1W pulse sequence. Pre-contrast images acquired in the dynamic-contrast-enhanced (DCE) MRI sequence were used for analysis. All patients had unilateral cancer, and the segmentation was performed using the contralateral normal breast. The ground truth of breast and fibroglandular tissue (FGT) segmentation was generated using a template-based segmentation method with a clustering algorithm. The deep learning segmentation was performed using U-net models trained with and without TL, by using initial values of trainable parameters taken from the previous model for non-fat-sat images. The ground truth of each case was used to evaluate the segmentation performance of the U-net models by calculating the dice similarity coefficient (DSC) and the overall accuracy based on all pixels. Pearson's correlation was used to evaluate the correlation of breast volume and FGT volume between the U-net prediction output and the ground truth. In the training dataset, the evaluation was performed using tenfold cross-validation, and the mean DSC with and without TL was 0.97 vs. 0.95 for breast and 0.86 vs. 0.80 for FGT. When the final model developed with and without TL from the training dataset was applied to the testing dataset, the mean DSC was 0.89 vs. 0.83 for breast and 0.81 vs. 0.81 for FGT, respectively. Application of TL not only improved the DSC, but also decreased the required training case number. Lastly, there was a high correlation (R2 > 0.90) for both the training and testing datasets between the U-net prediction output and ground truth for breast volume and FGT volume. U-net can be applied to perform breast tissue segmentation on fat-sat images, and TL is an efficient strategy to develop a specific model for each different dataset.

Combining prostate health index and multiparametric magnetic resonance imaging in the diagnosis of clinically significant prostate cancer in an Asian population.

OBJECTIVE: To evaluate the practicability of combining prostate health index (PHI) and multiparametric magnetic resonance imaging (mpMRI) for the detection of clinically significant prostate cancer (csPC) in an Asian population. PATIENTS AND METHODS: We prospectively enrolled patients who underwent prostate biopsy due to elevated serum prostate-specific antigen (PSA > 4 ng/mL) and/or abnormal digital rectal examination in a tertiary referral center. Before prostate biopsy, the serum samples were tested for PSA, free PSA, and p2PSA to calculate PHI. Besides, mpMRI was performed using a 3-T scanner and reported in the Prostate Imaging Reporting and Data System version 2 (PI-RADS v2). The diagnostic performance of PHI, mpMRI, and combination of both was assessed. RESULT: Among 102 subjects, 39 (38.2%) were diagnosed with PC, including 24 (23.5%) with csPC (Gleason ≥ 7). By the threshold of PI-RADS ≥ 3, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to predict csPC were 100%, 44.9%, 35.8%, and 100%, respectively. By the threshold of PHI ≥ 30, the sensitivity, specificity, PPV, and NPV to predict csPC were 91.7%, 43.6%, 33.3%, and 94.4%, respectively. The area under the receiver operator characteristic curve of combining PHI and mpMRI was greater than that of PHI alone (0.873 vs. 0.735, p = 0.002) and mpMRI alone (0.873 vs. 0.830, p = 0.035). If biopsy was restricted to patients with PI-RADS 5 as well as PI-RADS 3 or 4 and PHI ≥ 30, 50% of biopsy could be avoided with one csPC patient being missed. CONCLUSION: The combination of PHI and mpMRI had higher accuracy for detection of csPC compared with PHI or mpMRI alone in an Asian population.

Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.

OBJECTIVE. The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT. MATERIALS AND METHODS. Abdominopelvic CT examinations with three different oral contrast agents (each contrast agent: n = 300 patients) of 900 patients were retrospectively evaluated by two independent readers. For four segments of the gastrointestinal tract (i.e., the stomach, jejunum, ileum, and colon), readers recorded qualitative data (grade of nonuniform lumen opacification, types of inhomogeneous opacifications, presence of artifacts, and distribution of contrast agent) and quantitative data (CT attenuation of lumen [in Hounsfield units]). The results were compared among the three contrast agents using the Mann-Whitney U test and repeated-measures ANOVA with a post hoc Bonferroni correction. RESULTS. Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05). CONCLUSION. The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.

Analyses of sizable ZFS and magnetic tensors of high spin metallocomplexes.

The fictitious spin-1/2 Hamiltonian approach is the putative method to analyze the fine-structure/hyperfine ESR spectra of high spin metallocomplexes having sizable zerofield splitting (ZFS), thus giving salient principal g-values far from around g = 2 without explicitly providing their ZFS parameters in most cases. Indeed, the significant departure of the g-values from g = 2 is indicative of the occurrence of their high spin states, but naturally they never agree with true g-values acquired by quantum chemical calculations such as sophisticated DFT or ab initio MO calculations. In this work, we propose facile approaches to determine the magnetic tensors of high spin metallocomplexes having sizable ZFS, instead of performing advanced high-field/high-frequency ESR spectroscopy. We have revisited analytical expressions for the relationship between effective g-values and true principal g-values for high spins. The useful analytical formulas for the geff-gtrue relationships are given for S's up to 7/2. The genuine Zeeman perturbation formalism gives the exact solutions for S = 3/2, and for higher S's it is much more accurate than the pseudo-Zeeman perturbation approach documented so far (A. Abragam and B. Bleaney, Electron Paramagnetic Resonance of Transition Metal Ions, 1970; J. R. Pilbrow, J. Magn. Reson., 1978, 31, 479; F. Trandafir et al., Appl. Magn. Reson., 2007, 31, 553; M. Fittipaldi et al., J. Phys. Chem. B, 2008, 112, 3859), in which the E(Sx2 - Sy2) term is putatively treated to the second order. To show the usefulness of the present approach, we exploit FeIII(Cl)OEP (S = 5/2) (OEP: 2,3,7,8,12,13,17,18-octaethylporphyrin) and CoIIOEP (S = 3/2) well magnetically diluted in the diamagnetic host crystal lattice of NiIIOEP. The advantage of single-crystal ESR spectroscopy lies in the fact that the molecular information on the principal axes of the magnetic tensors is crucial in comparing with reliable theoretical results. In high spin states of metallocomplexes with sizable ZFS in pseudo-octahedral symmetry, their fine-structure ESR transitions for the principal z-axis orientation appear in the lower field far from g = 2 at the X-band, disagreeing with the putative intuitive picture obtained using relevant ESR spectroscopy. A ReIII,IV dinuclear complex in a mixed valence state exemplifies the cases, whose fine-structure/hyperfine ESR spectra of the neat crystals have been analyzed in their principal-axis system. The DFT-based/ab initio MO calculations of the magnetic tensors for all the high spin entities in this work were carried out.

Safety and oncological outcome of early intraoperative intravesicle mitomycin C vs. deferred instillation in patients receiving robot-assisted radical nephroureterectomy.

Introduction: Radical nephroureterectomy with concurrent bladder cuff excision (RNUBCE) is the gold standard surgical approach for high-risk primary upper tract urothelial carcinoma (UTUC). Given the notably high incidence of bladder tumor recurrence following this procedure, this study aimed to evaluate the effect and safety of intraoperative mitomycin-C (MMC) instillation vs. deferred instillation on overall oncological outcomes following robot-assisted RNUBCE. Methods: This is a retrospective chart review study. Patients with non-invasive (N0, not T3/T4) UTUC who underwent robotic RNUBCE combined an intraoperative MMC instillation or a deferred MMC instillation after surgery at a medical center in Taiwan between November 2013 and June 2020 were eligible for inclusion. Patients with prior bladder UC, carcinomas of other origins, received neoadjuvant chemotherapy, and had undergone kidney transplantation were excluded. All surgeries were executed by a single surgical team under the guidance of the same surgeon. The primary outcomes was the risk of bladder tumor recurrence between patients received intraoperative (IO) vs. deferred MMC instillation postoperatively (PO) during one-year follow-up. The secondary outcome was postoperative adverse events assessed by the Clavien-Dindo classification. Univariate and multivariable Cox regression analyses were performed to determine the associations between study variables and the outcomes. Results: A total of 54 patients were included in the analysis. 12 (22.2%) patients experienced a bladder tumor recurrence during follow-up (IO: 7.7%, PO: 35.7%, p < 0.021). After adjustment in the multivariable, intraoperative MMC instillation was significantly associated with lower risk of bladder recurrence [adjusted hazard ratio (aHR) = 0.15, 95% CI: 0.03-0.81, p = 0.028]. No MMC-related Clavien-Dindo Grade III-IV adverse events were found in either group. Conclusion: IIntraoperative MMC instillation is safe and associated with a lower bladder tumor recurrence risk in patients undergoing robotic RNUBCE for UTUC than deferred instillation. Future large, prospective studies are still warranted to confirm the findings.

Asymmetric vibrations in the organ of Corti by outer hair cells measured from excised gerbil cochlea.

Pending questions regarding cochlear amplification and tuning are hinged upon the organ of Corti (OoC) active mechanics: how outer hair cells modulate OoC vibrations. Our knowledge regarding OoC mechanics has advanced over the past decade thanks to the application of tomographic vibrometry. However, recent data from live cochlea experiments often led to diverging interpretations due to complicated interaction between passive and active responses, lack of image resolution in vibrometry, and ambiguous measurement angles. We present motion measurements and analyses of the OoC sub-components at the close-to-true cross-section, measured from acutely excised gerbil cochleae. Specifically, we focused on the vibrating patterns of the reticular lamina, the outer pillar cell, and the basilar membrane because they form a structural frame encasing active outer hair cells. For passive transmission, the OoC frame serves as a rigid truss. In contrast, motile outer hair cells exploit their frame structures to deflect the upper compartment of the OoC while minimally disturbing its bottom side (basilar membrane). Such asymmetric OoC vibrations due to outer hair cell motility explain how recent observations deviate from the classical cochlear amplification theory.

Growth Patterns of Prostate Cancers Undetected by Prostate 3T Multiparametric MRI.

BACKGROUND/AIM: The multiparametric magnetic resonance imaging (mpMRI)-ultrasound (US) fusion targeted biopsy (TB) is a useful diagnostic device for men with suspected prostate cancer (PC) and can increase the detection rate for clinically significant PCs (csPC). However, few studies have shown pathological findings of undetectable csPCs on the prostate mpMRI. PATIENTS AND METHODS: This study investigated the growth patterns of csPC undetected in prostate mpMRI. The study enrolled 248 patients with suspected PCs and ≥PI-RADS 2 lesions, who then underwent mpMRI-US fusion TB and nearly prostate-mapping systematic biopsies (SB). A total 248 biopsies included 404 regions of interest in TB and 2976 mapping-regions in SB. RESULTS: The detection rates of csPC, defined as PC grade group (GG) ≥2, were 42% in TB and 44% in SB, and the highest detection rate was 50%, using both TB and SB. Approximately 79% of PI-RADS 3/4/5 with any PC showed csPC. A total 201 PI-RADS 3/4/5 lesions showed benign prostatic hyperplasia, lymphocytic prostatitis, or fibromuscular stroma only in the core tissues. Notably, 22 csPCs detected in SB but undetected in prostate mpMRI preferentially showed a pattern of mixed well-formed and fused PC glands. The other patterns including cribriform glands and poorly formed glands with intracytoplasmic vacuoles were also seen. Approximately 85% of the 22 csPCs showed tumor volume less than 50% of core tissues. CONCLUSION: Changes in prostatic stroma amounts, inflammation severity, tumor volume and growth patterns of PC glands affected the detectability of prostate mpMRI.

Simultaneous pulmonary and inferior vena cava thromboembolism secondary to pelvic osteosarcoma.

Thromboembolism presenting with malignancy is common in adults but rare in children. We describe the case of a 17-year-old boy admitted to our hospital with syncope. Computed tomography revealed thromboembolism in both the lungs. Magnetic resonance imaging found thromboembolism in the inferior vena cava and a large heterogeneous mass in the pelvis. Pelvic osteosarcoma was confirmed by computed tomography-guided biopsy. Despite intensive chemotherapy and local radiation, only transient response was noted, the tumor remaining unresectable. To our knowledge, this is the first reported case of simultaneous pulmonary and inferior vena cava thromboembolism secondary to pelvic osteosarcoma in children. We also emphasize syncope as a unique feature of pulmonary thromboembolism. Accordingly, thromboembolism should be kept in mind as the first manifestation of occult malignancy, even in children.

Combined Immunotherapy and Tyrosine Kinase Inhibitor Treatment for Metastatic Renal Cell Carcinoma With Unknown Primary Origin: A Report of Two Cases and Literature Review.

BACKGROUND/AIM: Renal cell carcinoma (RCC) of unknown primary origin is rarely identified and accounts for only 5% of cancers of unknown primary origin (CUP). The disease prognosis is typically poor because of no standard and effective therapy. Our review indicated that 23 cases have been reported and treated with conventional chemotherapy or tyrosine-kinase inhibitors alone; accordingly, most patients showed partial response or progression diseases with short survival time. CASE REPORT: Herein, we present two cases of metastatic RCC of unknown primary origin. One case was papillary type and the other was clear cell type. According to the recent clinical trials in patients with metastatic RCC, a combination of immunotherapy and tyrosine-kinase inhibitors exhibited better response than conventional therapy or tyrosine-kinase inhibitors alone. Both present cases accepted a combination treatment with immunotherapy and tyrosine-kinase inhibitor and showed stable diseases. The radiological progression-free time for the case with metastatic papillary RCC was 5 months, and that with clear cell RCC was 6 months until now. CONCLUSION: The combination of immunotherapy and tyrosine-kinase inhibitors is at least as effective as a tyrosine-kinase inhibitor alone, and superior to conventional chemotherapy for treating metastatic RCC of unknown primary origin.

A Case Report of Intratesticular Hematoma in a Patient with Reiter's Syndrome.

We present a case of a 28-year-old male patient with a spontaneous intratesticular hematoma. He had no history of trauma but experienced sudden onset of painful swelling in his right testis. Initially, testicular malignancy was suspected. The tumor marker of testis, including alfa-fetoprotein, lactic dehydrogenase, and ß-human chorionic gonadotropin, was within normal range. The patient had been diagnosed with Reiter's syndrome at the age of 20 and had been treated with sulfasalazine, non-steroidal anti-inflammatory drugs, and acetaminophen for eight years. Various imaging techniques before operation planning, including ultrasonography and computed tomography, revealed a hematoma that accounted for 32% of the testicular volume. During the waiting period before the operation, the patient was diagnosed with a hematoma and avoided a possible diagnosis of malignancy. Follow-up imaging with computed tomography and magnetic resonance imaging confirmed the presence of an intratesticular hematoma that had decreased in size. Since no other related factor contributed to this hematoma, and considering the possible hematological side effects of sulfasalazine, we suggest that this may be a rare side effect of sulfasalazine. Although the patient's testis was preserved, further fertility should be observed because animal studies have reported that testicular hematoma may cause fertility changes if the initial volume occupied is over 30% of the testis.

Learning Curve of Transperineal MRI/US Fusion Prostate Biopsy: 4-Year Experience.

This study aimed to evaluate the learning curve of transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy in a team composed of a single surgeon, a single radiologist, and a single pathologist. We prospectively enrolled 206 patients undergoing MRI/US fusion prostate biopsy and divided them into four cohorts by the year of biopsy. We analyzed temporal changes in clinically significant prostate cancer (csPC) detection rate, percentage of positive cores on biopsy, and Gleason upgrading rate after radical prostatectomy. The csPC detection rate by MRI/US fusion targeted biopsy (TB) increased significantly (from 35.3% to 60.0%, p = 0.01). With increased experience, the csPC detection rates for small (≤1 cm) and anterior target lesions gradually increased (from 41.2% to 51.6%, p = 0.5; from 54.5% to 88.2%, p = 0.8, respectively). The percentage of positive cores on TB increased significantly (from 18.4% to 44.2%, p = 0.001). The Gleason upgrading rate gradually decreased (from 22.2% to 11.1%, p = 0.4). In conclusion, with accumulated experience and teamwork, the csPC detection rate by TB significantly increased. Multidisciplinary team meetings and a free-hand biopsy technique were the key factors for overcoming the learning curve.

Salvage surgeries for splanchnic artery aneurysms after failed endovascular therapy: case series.

INTRODUCTION: Splanchnic arterial aneurysms are a rare but potentially lethal disease with a mortality rate of more than 10% after rupture. Endovascular therapy is the first-line treatment for splanchnic aneurysms. However, appropriate management for splanchnic aneurysms after failed endovascular therapy remained inconclusive. MATERIALS AND METHODS: A retrospective review was performed for consecutive patients (from 2019 to 2022) who underwent salvage surgeries for splanchnic artery aneurysms following failed endovascular therapy. The authors defined failed endovascular therapy as the technical infeasibility to apply endovascular therapy, the incomplete exclusion of the aneurysm, or the incomplete resolution of preoperative aneurysm-associated complications. Salvage operations included aneurysmectomy with vascular reconstruction and partial aneurysmectomy with directly closing of bleeders from the intraluminal space of the aneurysms. RESULTS: Seventy-three patients received endovascular therapies for splanchnic aneurysms, and 13 failed endovascular trials. The authors performed salvage surgeries for five patients and enrolled them in this study, including four false aneurysms of the celiac or superior mesenteric arteries and a true aneurysm of the common hepatic artery. The causes of failed endovascular therapy included coil migration, insufficient space for safely deploying the covered stent, a persistent mass effect from the postembolized aneurysm, or infeasibility for catheter cannulation. The mean hospital stay was nine days (mean±SD, 8.8±1.6 days), with no one suffering 90-day surgical morbidity and mortality, and all patients getting symptoms improvement. During the follow-up period (mean±SD, 24±10 months), one patient suffered a small residual asymptomatic celiac artery aneurysm (8 mm in diameter) and was treated conservatively due to underlying liver cirrhosis. CONCLUSION: Surgical management is a feasible, effective, and safe alternative for splanchnic aneurysms after failed endovascular therapy.

Intramesosigmoid hernia: preoperative diagnostic MDCT findings.

Internal hernias, protrusion of abdominal viscera into an intraperitoneal fossa, are uncommon causes of bowel obstruction, and preoperative diagnoses are difficult. We report a rare case of a 47-year-old female with strangulated small bowel obstruction secondary to an intramesosigmoid hernia preoperative diagnosis by multi-detector row computed tomography. We highlight the preoperatively diagnosed value and findings of MDCT in intramesosigmoid hernia.

Right paraduodenal hernia: characteristic MDCT findings.

Right paraduodenal hernia is a very rare cause of abdominal pain. It can lead to bowel obstruction, ischemia, and perforation with a high mortality. A timely and correct diagnosis with a rapid diagnostic tool is mandatory. However, clinical diagnosis of right paraduodenal hernia is difficult for its nonspecific symptoms. Traditionally, paraduodenal hernia was diagnosed by small bowel series that was a time-consuming image study. We report a case of right paraduodenal hernia with pre-operative fast diagnosis by multidetector row computed tomography. Fortunately, the ischemic bowel loops were timely alleviated by reduction and resection was prevented.

Renal Ewing Sarcoma: A Challenging Diagnosis.

No. Abstract. DOI: 10.52547/ijkd.6601.

Laparoscopic ureterolithotomy and retrograde flexible ureteroscopy-assisted transperitoneal laparoscopic ureteroureterostomy for a huge ureteropelvic junction stone and multiple small renal stones: A CARE-compliant case report.

RATIONALE: Concurrent kidney and ureteral stones are always complicated and a clinical challenge. Improvements in endoscopic equipment have led to the widespread adoption of retrograde intrarenal surgery, which has a good stone clearance rate. On the other hand, laparoscopic ureterolithotomy (LUL) has been reported to be non-inferior to retrograde flexible ureteroscopy in stone-free rate and the need for axillary procedures, and to have a significantly lower rate of post-operative sepsis compared to retrograde flexible ureteroscopy. We describe a case managed with LUL followed by laparoscope-assisted retrograde intrarenal surgery (LA-RIRS) in a single operation for a large upper ureteral stone and small renal stones, which is usually challenging and requires axillary procedures. PATIENT CONCERNS: The patient was a 66-year-old male with underlying hypertension and diabetes mellitus. He reported severe flank pain after receiving endoscopic management of concurrent right ureteropelvic junction stone and multiple renal stones about 1 month previously. DIAGNOSIS: The residual stones were reassessed using non-contrast computed tomography before surgery. A 2.8-cm residual ureteropelvic junction stone and multiple renal stones with a maximum length of 1 cm were found. A second operation was considered to be necessary due to the deterioration of his renal function and refractory flank pain. INTERVENTIONS: We performed LUL followed by LA-RIRS. Two surgeries were completed in a single operation. The Jackson-Pratt drain was removed 3 days after the operation. OUTCOMES: After the surgery, no high-grade complications were recorded according to the Clavien Dindo classification. A follow-up kidney, ureter, and bladder radiograph performed 2 months after the operation revealed no residual stones. Renal echo revealed no obstructive nephropathy 1 month after double-J catheter removal. CONCLUSION: LUL with LA-RIRS with a stone basket for renal stone extraction is a safe and feasible technique, and no step surgery or axillary procedures were needed in our case. If clinical cases with a huge stone burden over the ureter are indicated for LUL with concurrent small renal stones, LUL with LA-RIRS can be an alternative option.

Graft kidney hydronephrosis caused by transplant ureter inguinal hernia: A case report.

RATIONALE: Ureteral obstruction of the graft kidney is a common complication of kidney transplantation. However, ureteral obstruction caused by inguinal hernia has rarely been reported. We present a rare case of ureteral obstruction with allograft dysfunction caused by an inguinal hernia. PATIENT CONCERNS: A 76-year-old man, who was a renal transplant recipient, presented with bilateral pitting oedema, reduced urine output, and right inguinal hernia. DIAGNOSES: Abdominal computed tomography revealed severe hydroureteronephrosis of the kidney allograft. A right inguinal hernia with ureteral incarceration was observed. INTERVENTIONS: The patient underwent graft percutaneous nephrostomy, followed by antegrade insertion of a double-J tube (DJ). Gradual improvement was observed in his renal function. Right inguinal herniorrhaphy was performed 5 days later. OUTCOMES: The renal function returned to normal after percutaneous nephrostomy and insertion of the DJ. A right inguinal direct-type hernia with ureter adhesion to the hernial sac was observed during the surgery. The posterior wall defect was repaired by the McVay technique. The DJ was removed after 1 month. The patient's renal function remained stable at 6-month follow-up. LESSONS: The orientation of the graft kidney has a significant influence on the location of the ureter. Upward orientation of the hilum will result in superficial location of the ureter, rendering it close to the hernial sac and susceptible to incarceration. The transplant surgeon should be aware of such a presentation of graft dysfunction with inguinal hernia to prevent a delay in the diagnosis and graft loss.