A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein.

PURPOSE: Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations. METHODS: Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV). RESULTS: The average length of the LAV was 21 mm its mean width was 5 mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8 mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found. CONCLUSIONS: The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks.

Cadaveric study of arterial renal anatomy and its surgical implications in partial nephrectomy.

PURPOSE: Partial nephrectomy is gaining, nowadays, more interest in oncologic kidney surgery. This type of surgery requires the good knowledge of vascular renal anatomy to make it safe and to guarantee good functional and oncological outcomes. This paper exposes the clinical implication of the arterial renal anatomy in nephron-sparing surgery. METHODS: This is a cadaveric study of 71 human kidneys performed at Charles Nicolle mortuary. The right and left kidneys with surrounding tissues were removed en bloc with the adjacent part of the aorta and inferior vena cava, cleared and studied. Colored resin was injected in each artery, vein, and urinary ducts, with a specific color code for each structure. Corrosion technique was used to eliminate the surrounding tissue, leaving only the colored resin matrix. The Ternon anatomic classification of the inferior polar artery, based on its emergence point was used. RESULTS: Multiple renal arteries were noted in 9.85% of casts. Anterior and posterior division of main renal artery was found in 95.7% of cases. Posterior segmental artery crossed posteriorly the upper caliceal infundibulum and the renal pelvis in 93% of cases. The upper renal pole was vascularized by an apical segmental artery in 16.9% of cases and a superior polar artery in one case (1.4%). The mid pole of the kidney was supplied by a unique anterior branch and a single posterior branch in 40% of cases. Inferior polar artery was found in 52 casts (73.23%). Type I of Ternon was found in 6 casts (11.53%), Type II in 25 cases (48.07%), Type III in 19 cases (36.53%), Type IV in 2 cases (3.84%), and type V in 13 casts (25%). CONCLUSION: Renal vascular anatomy presents large variations. Good knowledge of the segmental arterial anatomy of the kidney is a primordial to a safe partial nephrectomy. Good preoperative vascular mapping can be of great help for the surgeon.

Xanthogranulomatous pyelonephritis in adults: clinical, biological, radiological and therapeutic main findings in diffuse and focal forms. About 42 cases.

INTRODUCTION: Xanthogranulomatous pyelonephritis (XGPN) is a particular form of chronic renal suppuration characterized by the destruction of renal parenchyma and its replacement by a granulomatous tissue containing xanthomatous cells. OBJECTIVE: To report and describe the main clinical, biological, radiological and therapeutic aspects of xanthogranulomatous pyelonephritis in adults in focal and diffuse forms. METHODS: This was a monocentric retrospective study involving 42 cases of XGPN operated and histologically confirmed between 2005 and 2015. We included in our study the patients belonging to any age, of both sexes, with a preoperative CT and whose XGPN diagnosis was confirmed histologically. Clinical, biological, bacteriological, radiological data and surgical procedures were collected and analyzed. RESULTS: The mean age was 50 years (34-79) with a sex ratio of 0.61. The XGPN was diffuse in 88% and focal in 12% of cases. Clinical symptoms were dominated by low back pain (95%), fever (64%) and recurrent urinary tract infections (41%). Urine culture was positive in 67% of cases and Escherichia Coli was the most isolated germ (36%). 64% of patients had inflammatory anemia and 57% of patients had an inflammatory biological syndrome. Ultrasound and CT revealed obstruction of the urinary tract in all cases: a lithiasic cause in 90% of cases and the rest were isolated cases of retroperitoneal fibrosis, abnormal pyelo-ureteral junction, ureteral stenosis and pyelo-ureteric duplicity. A peri-renal abscess and / or psoas was associated in 6 cases (14%). The preoperative diagnosis was often pyonephrosis (50%). Neoplasia was suspected in 4 cases. The treatment consisted in a radical nephrectomy for all patients preceded by drainage of the excretory pathways in 41% of the cases and drainage of a collection in 21% of the cases. CONCLUSION: The XGPN is a rare entity whose diagnosis is difficult. This is suspected on a cluster of clinical and biological arguments and can be evoked on the preoperative CT. The kidney cancer is the main differential diagnosis.

Anatomical variations of renal venous vascularisation. A study of 71 three-dimensional kidney endocasts.

BACKGROUND: A better understanding of the anatomy of the renal vein and its relationship with the arterial and excretory systems can prevent intra operative complications. METHODS: Three-dimensional endocasts of intrarenal vessels and renal collecting systems were obtained from fresh cadavers, by injecting a polyester resin coloured with different pigments. A total of 71 endocasts were studied: 37 right kidneys and 34 left kidneys. RESULTS: Renal vein was unique in 88% of cases and double in 11% of cases. It was formed in 52% of cases by 3 trunks. Intrarenal veins anastomosed together to form 2 levels of arcades in 28% of cases and 3 levels in 71% of cases. The venous drainage of the upper pole was provided by two anterior and posterior plexus in 38% of cases, and by a single anterior plexus in 61% of cases. In 22% of cases, the venous drainage of the lower pole was provided by both an anterior and a posterior plexus, and in 77% of cases, there was only an anterior plexus. Renal artery was posterior to the vein in 66% of cases. It was anterior to the vein in 29% of cases, and located directly above it in 4% of cases. In 60% of cases, we noted a close relationship between the anterior surface of the ureteropelvic junction and the lower branch of the renal vein. CONCLUSION: Venous vascularisation of the kidney appears to be variable and its relationship with the arterial and the excretory systems may be complex.

Primary testicular non-Hodgkin lymphoma. a 10-year Tunisian single-institute experience.

BACKGROUND: Primary testicular non-Hodgkin lymphoma (NHL) is an uncommon extra nodal presentation, accounting for 1% of all NHL and 1 to 9% of testicular neoplasms. Median age at time of presentation is 60 years old. Anthracycline based chemotherapies are most frequently used. AIM: To analyze baseline characteristics, treatment modalities and survival of six cases of primary testicular non-Hodgkin lymphoma. METHODS: We screened 46 testicular neoplasm cases registered from January 1999 to January 2009 and found six primary testicular lymphoma patients. These six cases were analyzed for baseline clinical features, investigations, treatment and outcome variables. RESULTS: Median age was 50 years old and median duration of symptoms was 4 months. All patients had testicular swelling. Four patients had abdominal lymphadenopathy. Most patients had diffuse large B-cell histology. All patients underwent high inguinal orchidectomy and five were treated with anthracycline based chemotherapy. Four patients completed therapy and one of them relapsed two years later. CONCLUSION: Primary testicular NHL is an uncommon entity and with current combined modality treatment, the outcome may be as good as nodal NHL.

Retrovesical hydatid cyst: an unusual location of hydatid disease about a case series.

Hydatid disease is an endemic zoonosis in regions with temperate climates where pastoral farming is common. Retrovesical localization is rare. Given the rarity of this entity, the lack of personal clinical experience, and the difficulty with detecting early symptoms, the diagnosis remains elusive for years. Methods: This is a 30-year retrospective, descriptive and analytic study of seven patients who were hospitalized and operated on in the Department of Urology during 30 years (1990-2019). Outcomes: The average patient age was 54 years (range: 28-76). Signs of bladder irritation were the predominant presenting complaint. No cases of hydaturia were noted. Preoperative diagnosis was based on ultrasonography and serology tests. Hydatid serology was positive for three patients. In three cases, a hydatid cyst of the liver was associated. A partial cystopericystectomy was performed for five patients, it was total for one patient. The resection of the prominent dome was realized once. No cystovesical fistula was found. The mean postoperative stay was 16 days. The postoperative course was uneventful for five patients. Urinary fistula occurred in one patient. One case of infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation. Conclusion: The preoperative diagnosis of retrovesical hydatid cysts is based mainly on ultrasonography. Open surgery is the treatment of choice. Different approaches are possible. Given the rarity of this entity, management should be guided by experienced experts.

Management of blunt renal trauma on pre-existing diseased kidneys: a cross-sectional study.

Pathological kidney trauma is a special entity. Congenital or acquired lesions may interfere with clinical presentation, radiological imaging, and the therapeutic approach. Objective: Our objective was to determine the clinical, radiological, and therapeutic features of this entity. Materials and methods: The medical records of 37 observations were retrospectively collected from January 1992 to February 2022. All cases were explored by a kidney ultrasound and/or a computed tomography scan, and classified according to the American Association of Surgery of Trauma. Pre-existing renal abnormalities were found in 37 patients among 203 (18.2%). The most common underlying lesion were urolithiasis (37.8%) followed by pyelo-ureteral junction syndrome (32.4%). Surgical abstention was decided in 11 cases, four nephrectomies were performed as a matter of urgency, and seven nephrectomies were performed remotely. The cure of uropathy was performed after an average delay of 3 months. Conclusion: Kidneys with underlying pathology are habitually more susceptible to trauma. Contusions are often benign contrasting with a high nephrectomy rate.

[Emphysematous pyelonephritis. Epidemiological, clinical, biological, bacteriological, radiological, therapeutic and prognostic features. Retrospective study of 30 cases]. / La pyélonéphrite emphysémateuse. Particularités épidémiologiques, clinico-biologiques, bactériologiques, radiologiques, thérapeutiques et évolutives. Etude rétrospective de 30 cas.

BACKGROUND: Emphysematous pyelonephritis is an uncommon, necrotizing bacterial infection of the kidney. It is a severe, life threatening affection. AIMS: To study the epidemiological, clinical, biological, bacteriological and radiological features of this affection, and to describe its therapeutic management and prognostic characteristics. METHODS: We conducted a retrospective study including 30 patients who were treated for an emphysematous pyelonephritis, in Charles Nicolle hospital department of urology, from 1987 to 2009. RESULTS: Emphysematous pyelonephritis generally affects adults. It is especially favored by diabetes and urinary tract obstruction. Escherichia coli is the main causative agent. Uroscan is the key of diagnosis. It is both medical and surgical emergency; the treatment combines intensive care with appropriate antibiotics and often drainage. Nephrectomy may be necessary from the outset, or after drainage failure. Prognosis is poor, with a high mortality rate (23 %), in our series. CONCLUSION: Management of emphysematous pyelonephritis poses real problems. This affection is still threatening, despite of advances in intensive care.

Bladder exstrophy in adulthood: About a case report.

Bladder exstrophy is a severe malformation characterized by the lack of the anterior sub-umbilical abdominal wall, and the front wall of the bladder. We present a rare case of a 26-year-old woman without any previous medical or surgical history, that we treated for bladder exstrophy. We performed an iliac osteotomy, bladder enlargement using the ileum and a Monti-type continent urinary derivation and a Promentofixation. A vesico-cutaneous fistula was diagnosed after surgery and we failed to manage it after two surgical revision. Therefore, we performed a cystectomy and a non-continent Bricker external urinary derivation.

Comparison of the prognosis of primary vs. progressive muscle invasive bladder cancer after radical cystectomy: Results from a large multicenter study.

PURPOSE: To assess whether progressive and primary muscle invasive bladder cancer (MIBC) have different prognosis after radical cystectomy or not. To date only a few data are available on this topic with conflicting results. Further studies on large cohort are needed to clarify these outcomes that may influence bladder cancer management for these patients. MATERIAL AND METHODS: A multicentre retrospective study was conducted on patient treated for MIBC at 5 centres between 2005 and 2015 by radical cystectomy. Patients' outcomes were compared between patients with primary MIBC vs. progressive MIBC subsequent to a history of non-muscle invasive bladder cancer (NMIBC). RESULTS: A total of 1197 patients were included. Median (IQ) age was 65 (58-72) years and median follow-up was 65 months. Baseline characteristics were similar between the groups as well as the Tumour pT stage, N status and positive surgical margins. Patients with progressive MIBC had worse overall survival (OS) (hazard ratio [HR] 1.36, [95%CI 1.10-1.76]; P = 0.004), cancer specific survival (CSS) (HR 1.41 [1.13-1.78]; P = 0.002), and recurrence-free survival (RFS) (HR 1.21 [1.01-1.49]; P = 0.05). Pathological stage ≥pT3, positive surgical margins, and positive lymph nodes status (pN+) were also found as predictors of OS, CSS, and RFS. CONCLUSIONS: Our results suggest that patient having a progressive BC have a worse prognosis in terms of OS, PFS, and CSS than patient with primary disease. These 2 groups may require different management and patients with high risk NMIBC should be assessed properly to avoid progression and be offered early cystectomy.

[Place of percutaneous nephrolithotomy in the treatment of staghorn stones, 83 cases]. / Place de la néphrolithotomie percutanée dans le traitement des lithiases rénales coralliformes. A propos de 83 cas.

BACKGROUND: Staghorn stone is considered as a dreadful type of renal stones. The choice of the best treatment is always difficult. AIM: To evaluate the results of percutaneous nephrolithotomy in the treatment of staghorn stones. METHODS: We report 83 cases of staghorn stones that were treated by percutaneous nephrolithotomy during a period of 10 years from 1994 to 2004. RESULTS: The mean age was 44 years and sex-ratio was 2,2. The right kidney was treated alone in 42% of cases, the left one in 56% of cases and both kidneys in only two cases. The mean area of stones was 6,6 cm2. One renal punction was necessary in 97% of cases. The rate of stone free after percutaneous nephrolithotomy only was about 54% and when combined with lithotripsy the rate was 64%. CONCLUSION: Combined treatment using percutaneous nephrolithotomy and lithotripsy is considered as the best procedure for staghorn stones treatment.

Endoscopic meatotomy in the treatment of ureterocele: results in adult patients.

To evaluate the efficacy of endoscopic meatotomy in the treatment of ureterocele in adults. A retrospective study of adult patients with ureterocele, treated between January 1987 and December 2014. In 47 patients, 55 intravesical ureteroceles were diagnosed and classified as 18 right, 21 left and eight bilateral (38%, 44% and 17% respectively). According to the Bruézière classification, 41 (75%) ureteroceles were type A and 14 (25%) others were type C. These ureteroceles were complicated by calculus formation in 22 cases, moderately dilated excretory pathways in 16 cases and both complications in a total of 9 cases. Four patients had a complicated ureterocele with pyelonephritis, one of which was emphysematous. The endoscopic treatment was performed in cases of complicated and/or symptomatic ureteroceles. Fifty one cases were treated by a "smiling mouth" meatotomy consisting in a transverse horizontal incision, with the treatment of any associated complication. The mean operative time was 35 minutes (10-90). The operative follow-up was uneventful in 42 patients and complications occurred in 5 patients (2 urinary retentions, 2 infectious complications and one hematuria). The mean duration of postoperative stay was 1-2 days. The mean follow-up was 15 months. Four patients developed vesicoureteral reflux and no stenosis was noted. The endoscopic incision of the ureteroceles seems today, after reviewing the results, to be a good treatment of adult ureterocele. It is a simple, minimally invasive and has a low morbidity rate.

Bellini duct carcinoma revealed by cutaneous metastasis: A case report.

INTRODUCTION: Cutaneous metastasis of renal cell carcinoma is rare and the majority of these metastases are asynchronous. The scalp and face are the major sites of metastases, followed by the chest and abdomen. However, the entire body surface can be affected. When diagnosed, patients are multi-metastatic in 50-80% of cases during follow-up post nephrectomy. CASE PRESENTATION: We report here a patient who consulted a dermatologist for multiple skin nodules that appeared 3 months prior. A skin biopsy of a nodule was performed and the pathological examination and immunohistochemistry profile confirmed a metastasis of Bellini Carcinoma, which is a renal cell carcinoma of the collecting duct. A thoraco-abdomino-pelvic scan showed a left renal tumor locally advanced with lung and liver metastases. Chemotherapy was indicated and the patient died four months after diagnosis. DISCUSSION: Bellini carcinoma is a very rare type of carcinoma of renal cell origin with a very poor prognosis as it is diagnosed already at a metastatic state in the vast majority of cases. After analysis of the data from the literature, our case is the second reported case of a Bellini carcinoma revealed by cutaneous metastases. The peculiarity of our observation is metastases occurred on all four limbs and at the trunk level, and the asymptomatic characteristic of Bellini's carcinoma, which is a rare situation. CONCLUSION: The originality of this observation is based on the mode of presentation of a rare renal tumor by an even rarer metastasis of the skin.

Unusual Bladder Metastasis from a Primary Gastric Carcinoma: Two Case Reports and Review of Literature.

Primary bladder cancer is a frequent malignancy in the urology field, whereas secondary bladder neoplasms from a distant organ are extremely rare. This paper aims to report two rare cases of a secondary tumor of the urinary bladder from a primary gastric tumor and to perform a literature review of similar reported cases in order to better characterize its clinicopathological features and diagnosis in effort to shed light on this rare condition. The final diagnosis of secondary adenocarcinoma was made histologically after transurethral biopsy or resection of the bladder lesion. In one case, the bladder metastasis was a synchronous metastasis, and in the second case, it occurred under chemotherapy five months after initial diagnosis with gastric adenocarcinoma. Secondary adenocarcinoma of the bladder is extremely rare but should be considered when evaluating a bladder lesion in a patient treated for gastric cancer or presenting with gastric symptoms.

Inguinal Solitary Fibrous Tumor: A Case Report.

INTRODUCTION: A solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that may occur in a wide range of sites, more commonly in the pleura. We report a well-documented case of an SFT with malignant histology arising in the inguinal region. CASE PRESENTATION: A 59-year-old man, with an unremarkable medical history, presented with a slow-growing painless mass in the left side of the inguinal region, which he had ignored for 3 years. On clinical examination, there was an indurated, irreducible, mobile, and painless mass in the left side of the inguinal area. Magnetic resonance imaging and computed tomography results revealed a 15-cm mass made up of soft tissue and with nonspecific radiologic aspect. The tumor was totally excised, and the results of the pathologic examination concluded it was an SFT. DISCUSSION: The aim of our case report is to present a rare extrapleural localization of an SFT. Although its radiologic features are not specific, SFT should be considered in the differential diagnosis of inguinal masses.

Severe penile injury due to condom catheter fixed by a rubber band: A case report.

INTRODUCTION: Condom catheters are considered as a safe tool in the management of male urinary incontinence, yet complications may occur, especially in debilitated patients, with psychiatric disorders. PRESENTATION OF CASE: A 58-year-old paraplegic man, suffering from schizophrenia, who had been using condom urinary catheters, was referred to our department for "penile injury". Interrogation revealed that he was placing a rubber band tightly around his penis to maintain the condom. Examination showed a 4 cm defect interesting the proximal portion of the penis including the corpus spongiosum and the urethra. A surgical repair was performed, consisting in covering the defect using the surrounding tissue. Unfortunately, the patient developed penile gangrene four weeks after surgery. A partial penectomy was performed. DISCUSSION: Condom catheters are known as a safe tool to manage urinary incontinence in male patients, providing an adequate care. Long-term use may result in complications including urinary tract infection (40%) and skin injuries ranging from inflammation to gangrene. Gangrene, secondary to strangulation of the penis, is however uncommon. These complications are more common in debilitated patients with poor medical care or psychiatric disorders. In case of necrosis, debridement should be performed, which may result in a partial or a total penectomy if necessary. CONCLUSION: Condom catheter is frequently used to manage male urinary incontinence but it should not be used carelessly or overlooked as it can cause severe complications such as penile strangulation and penile gangrene.

Bilateral duplex collecting system with bilateral vesicoureteral reflux: a case report.

BACKGROUND: A bilateral duplex collecting system is an unusual renal tract abnormality. Vesicoureteral reflux may be associated. We describe a rare case of bilateral duplex collecting system with bilateral vesicoureteral reflux in which the refluxing ureter on the left side drains the upper pole moiety contrary to what is often found. CASE PRESENTATION: A 24-year-old married Arab woman presented with ascending left-sided flank pain during micturition. She complained of recurrent urinary tract infections. A physical examination and laboratory tests were normal. Voiding cystourethrography and computed tomography scan detected bilateral duplex collecting system, grade IV vesicoureteral reflux on the left side, and grade I vesicoureteral reflux on the right. She underwent left heminephrectomy and dextranomer/hyaluronic acid injections on the right side. After a year of follow-up, a clinical examination and imaging findings were unremarkable. CONCLUSIONS: A bilateral duplex collecting system with refluxing upper pole moiety ureter is a very rare entity. The diagnosis should be suspected when exploring any flank pain with recurrent urinary tract infections to avoid subsequent renal impairment. Furthermore, this case shows how some common symptoms may lead to finding an unexpected urinary tract abnormality.

Solitary fibrous tumor of the kidney: A case report.

INTRODUCTION: Solitary fibrous tumor (SFT) is rare, representing 2% of all soft tissue tumors and is usually described in the thoracic cavity. Only 105 cases of renal SFT have been reported. CASE PRESENTATION: A 55-year-old men with lower urinary tract symptoms, had a routine renal ultrasound which showed a cortical mass of the left kidney measuring 36 × 23 × 39 mm, with peripheral enhancement, and a central fluid collection on CT. On MRI, it was iso-intense to the kidney in T1 and hyper-intense with restricted diffusion in T2 images. The diagnosis of renal cell cancer was likely and an open partial nephrectomy was performed. Microscopic examination showed a mesenchymal neoplasm with long spindle cell and Immunohistochemical staining positive for CD34 and Bcl-2 confirming the diagnosis of SFT. There was no evidence of tumor recurrence or metastasis nine months after discharge. DISCUSSION: Up to now, only 105 cases of occurring renal SFT have been reported. SFTs are usually asymptomatic when they have a small size, that's why the diagnosis is often delayed. Blood tests do not have any diagnostic value. Imaging features are not specific for the diagnosis of SFT which are diagnosed as renal cell carcinoma and treated as such. Typical immunohistochemical characteristic is a high positivity for CD34. As SFT has a malignant potential, careful follow-up is mandatory,searching for local recurrence or metastasis which was reported in few cases. CONLUSION: SFTs are indolent tumors and are usually diagnosed as renal cell carcinomas preoperatively and the final diagnosis is always based on immunohistochemical study.