Sperm retrieval rate and pregnancy rate in infertile couples undergoing in-vitro fertilisation and testicular sperm extraction for non-obstructive azoospermia in Hong Kong.

OBJECTIVE: There are currently no local data on the sperm retrieval and pregnancy rates in in-vitro fertilisation and testicular sperm extraction cycles, especially with regard to the presence of genetic abnormalities. This study aimed to determine the sperm retrieval and pregnancy rates in infertile couples who underwent in-vitro fertilisation and testicular sperm extraction for non-obstructive azoospermia. METHODS: This retrospective case series was conducted at a tertiary assisted reproduction unit in Hong Kong. Men with non-obstructive azoospermia who underwent in-vitro fertilisation and testicular sperm extraction between January 2001 and December 2013 were included. The main outcome measures were sperm retrieval and pregnancy rates. RESULTS: During the study period, 89 men with non-obstructive azoospermia underwent in-vitro fertilisation and testicular sperm extraction. Sperm was successfully retrieved in 40 (44.9%) men. There was no statistically significant difference in the sperm retrieval rate of those with karyotypic abnormalities (2/5, 40.0% vs 28/61, 45.9%; P=1.000) and AZFc microdeletion (3/6, 50.0% vs 28/61, 45.9%; P=1.000) compared with those without. Sperms were successfully retrieved in patients who had mosaic Klinefelter syndrome (2/3, 66.7%) but not in the patient with non-mosaic Klinefelter syndrome. No sperms were found in men with AZFa or AZFb microdeletions. Pregnancy test was positive in 15 (16.9%) patients and the clinical pregnancy rate was 13.5% (12/89) per cycle. The clinical pregnancy rate per transfer was 34.3% (12/35). CONCLUSIONS: The sperm retrieval rate and clinical pregnancy rate per initiated cycle in men undergoing in-vitro fertilisation and testicular sperm extraction in our unit were 44.9% and 13.5%, respectively. No sperms could be retrieved in the presence of AZFa and AZFb microdeletions, but karyotype and AZFc microdeletion abnormalities otherwise did not predict the success of sperm retrieval in couples undergoing in-vitro fertilisation and testicular sperm extraction. Genetic tests are important prior to testicular sperm extraction for patient selection and genetic counselling.

Disease spectrum and treatment patterns in a local male infertility clinic.

OBJECTIVE: To review disease spectrum and treatment patterns in a local male infertility clinic. DESIGN: Case series. SETTING: Male infertility clinic in a teaching hospital in Hong Kong. PATIENTS: Patients who were seen as new cases in a local male infertility clinic between January 2008 and December 2012. INTERVENTION: Infertility assessment and counselling on treatment options. MAIN OUTCOME MEASURES: Disease spectrum and treatment patterns. RESULTS: A total of 387 new patients were assessed in the male infertility clinic. The mean age of the patients and their female partners was 37.2 and 32.1 years, respectively. The median duration of infertility was 3 years. Among the patients, 36.2% had azoospermia, 8.0% had congenital absence of vas deferens, and 48.3% of patients had other abnormalities in semen parameters. The commonest causes of male infertility were unknown (idiopathic), clinically significant varicoceles, congenital absence of vas deferens, mumps after puberty, and erectile or ejaculatory dysfunction. Overall, 66.1% of patients chose assisted reproductive treatment and 12.4% of patients preferred surgical correction of reversible male infertility conditions. Altogether 36.7% of patients required either surgical sperm retrieval or correction of male infertility conditions. CONCLUSIONS: The present study provided important local data on the disease spectrum and treatment patterns in a male infertility clinic. The incidences of azoospermia and congenital absence of vas deferens were much higher than those reported in the contemporary literature. A significant proportion of patients required either surgical sperm retrieval or correction of reversible male infertility conditions.

Current status of robot-assisted surgery.

The introduction of robot-assisted surgery, and specifically the da Vinci Surgical System, is one of the biggest breakthroughs in surgery since the introduction of anaesthesia, and represents the most significant advancement in minimally invasive surgery of this decade. One of the first surgical uses of the robot was in orthopaedics, neurosurgery, and cardiac surgery. However, it was the use in urology, and particularly in prostate surgery, that led to its widespread popularity. Robotic surgery, is also widely used in other surgical specialties including general surgery, gynaecology, and head and neck surgery. In this article, we reviewed the current applications of robot-assisted surgery in different surgical specialties with an emphasis on urology. Clinical results as compared with traditional open and/or laparoscopic surgery and a glimpse into the future development of robotics were also discussed. A short introduction of the emerging areas of robotic surgery were also briefly reviewed. Despite the increasing popularity of robotic surgery, except in robot-assisted radical prostatectomy, there is no unequivocal evidence to show its superiority over traditional laparoscopic surgery in other surgical procedures. Further trials are eagerly awaited to ascertain the long-term results and potential benefits of robotic surgery.

Subinguinal microsurgical varicocelectomy for male factor subfertility: ten-year experience.

OBJECTIVE: To investigate the impact of subinguinal microsurgical varicocelectomy on semen parameters and pregnancy outcomes in couples with male factor subfertility. DESIGN: Case series. SETTING: Male Infertility Clinic in an academic institution in Hong Kong. PATIENTS: The clinical records of 42 consecutive subfertile male patients who had subinguinal microsurgical varicocelectomy (from January 2000 to December 2009) were retrospectively reviewed. All the patients had a known history of subfertility and abnormalities in one or more semen parameters. Female subfertility factors were not addressed. Only grade 2 or higher clinically palpable varicoceles were operated on. MAIN OUTCOME MEASURES: Preoperative and postoperative semen analyses based on the World Health Organization criteria; the outcome measures included changes in semen parameters and whether a pregnancy ensued. RESULTS: The mean age of patients and their spouses were 38 and 33 years, respectively. The mean duration of infertility was 4 years; 37 patients had primary infertility and five had secondary infertility. The mean (± standard deviation) sperm concentration improved from 12 ± 19 million/mL to 23 ± 29 million/mL following varicocelectomy (P<0.001), the mean sperm motility improved from 26% ± 16% to 32% ± 18% (P<0.001), and the mean normal morphology increased from 5% ± 7% to 6% ± 6% (P<0.001). Postoperatively, 23 (55%) of the patients achieved pregnancy, 11 (26%) being spontaneous, 1 (2%) by intrauterine insemination, and 11 (26%) by in-vitro fertilisation. Among 20 patients with severe preoperative oligospermia (<5 million/mL), statistically significant improvements occurred in postoperative mean sperm concentration, motility and morphology (all P<0.001), and five (25%) of them achieved a spontaneous pregnancy. There was one intra-operative injury to the testicular artery with immediate repair and no testicular atrophy. Five (12%) of the patients had recurrences. No preoperative factors appeared predictive of a pregnancy ensuing. CONCLUSIONS: In couples with male infertility due to varicoceles, subinguinal microsurgical varicocelectomy was shown to improve sperm concentrations, motility and morphology, and the likelihood of a pregnancy. Spontaneous pregnancy was achieved in 25% of the couples in which the man had severe oligospermia.

Robot-assisted versus standard laparoscopic partial nephrectomy: comparison of perioperative outcomes from a single institution.

OBJECTIVE: To evaluate the perioperative outcomes of robot-assisted laparoscopic partial nephrectomy and standard laparoscopic partial nephrectomy in a teaching hospital. DESIGN: Retrospective study. SETTING: Division of Urology, Department of Surgery, Queen Mary and Tung Wah hospitals, Hong Kong. PATIENTS: The first 10 consecutive patients who had robot-assisted laparoscopic partial nephrectomy for renal tumours between January 2008 and September 2009 with prospective data collection were evaluated. Their outcomes were compared with the last 10 consecutive patients in our database, who had standard laparoscopic partial nephrectomy between November 2004 and October 2007. MAIN OUTCOME MEASURES: Demographics, tumour characteristics, perioperative outcomes, renal function, and pathological outcomes. RESULTS: There were no differences between the groups with regard to age (63 vs 56 years; P=0.313) and tumour size (2.7 vs 2.8 cm; P=0.895). No significant difference was found between the two groups with respect to the operating room time (376 vs 361 min; P=0.722), estimated blood loss (329 vs 328 mL; P=0.994), and length of hospital stay (7 vs 14 days; P=0.213). A statistically significant shorter mean warm ischaemic time for the robot-assisted group was noted (31 vs 40 minutes; P=0.032). Respective renal functional outcomes as shown by the difference between day 0 and day 60 serum creatinine levels were comparable (+10 vs +7 mmol/L; P=0.605). In both groups, there were no intra-operative complications or instances of surgical margin tumour involvement. Three patients endured postoperative complications in the standard laparoscopic group (a perinephric haematoma, urine leakage, and lymph leakage) compared with one in the robot-assisted group (a perinephric haematoma). These complications all resolved with conservative treatment. CONCLUSIONS: Robot-assisted laparoscopic partial nephrectomy is a technically feasible alternative to standard laparoscopic partial nephrectomy, and provides comparable results. Robot-assisted laparoscopic partial nephrectomy appears to offer the advantage of decreased warm ischaemic time. Longer follow-up is required to assess renal function and oncological outcomes. Further experience and randomised trials are necessary to compare robot-assisted with standard laparoscopic partial nephrectomy.

Microsurgical vasoepididymostomy for obstructive azoospermia.

OBJECTIVES: To evaluate the efficacy of microsurgical vasoepididymostomy for patients with obstructive azoospermia attending our institutions. DESIGN: Retrospective study. SETTING: Division of Urology, Department of Surgery, Queen Mary and Tung Wah hospitals, Hong Kong. PATIENTS: All patients with obstructive azoospermia due to epididymal obstruction who had undergone microsurgical vasoepididymostomy in the study hospitals from July 2001 to November 2007. MAIN OUTCOME MEASURES: Causes of epididymal obstruction, operative techniques, patency rates, and pregnancy outcomes of their female partners. RESULTS. Twenty-two patients with obstructive azoospermia due to epididymal obstruction had undergone 23 microsurgical vasoepididymostomy procedures. The mean age of patients and their female partners was 36 and 30 years, respectively. Six procedures were performed by the Berger's triangulation intussusception technique and 17 by Marmar or Chan's two-suture intussusception techniques. The mean operating time of unilateral and bilateral procedures was 164 and 203 minutes, respectively. The median follow-up duration was 15 months. The overall patency rate was 57%; being 50% and 64% for unilateral and bilateral procedures, respectively. The patency rate of patients with epididymal fluid positive for sperm was 71%. The mean best sperm count was 23.1 million/mL, with forward motility of 19% and normal morphology of 7%. The overall paternity rate was 32%. Natural pregnancy was achieved in three cases and assisted reproduction was used in four. CONCLUSIONS: Microsurgical intussusception vasoepididymostomy is a viable option for couples with male factor infertility due to obstructive azoospermia. Reasonable patency outcomes were achieved in the present series of cases. Individualised counselling, with expectations based on anticipated surgical outcomes, should be offered to couples before resorting to assisted reproduction.

Chromosomal anomalies and Y-microdeletions among Chinese subfertile men in Hong Kong.

OBJECTIVE: To report the type and frequency of chromosomal anomalies and Y-microdeletions among Hong Kong Chinese subfertile men with sperm concentrations lower than 5 million/mL. DESIGN. Retrospective study. SETTING: A reproductive centre in Hong Kong. PARTICIPANTS: A total of 295 Chinese subfertile men who underwent both karyotyping and Y-microdeletion studies from 2000 to 2007 were categorised as having non-obstructive azoospermia (n=71), very severe oligospermia (sperm concentration>0 and 2 and <5 million/mL, n=66). MAIN OUTCOME MEASURES: Karyotyping and Y-microdeletion studies. RESULTS: The prevalence of chromosomal anomalies and Y-microdeletions in the study population were 8.5% (25/295; 95% confidence interval, 5.6-12.3%) and 6.4% (19/295; 3.9-9.9%), respectively. The total prevalence of chromosomal anomalies and Y-microdeletions was 13.2% (39/295; 95% confidence interval, 9.6-17.6%) as five cases of non-obstructive azoospermia showed both Y structural alterations and AZFbc deletion. The corresponding figures for chromosomal anomalies in the groups with non-obstructive azoospermia, very severe oligospermia, and severe oligospermia were 21.1% (15/71; 95% confidence interval, 12.3-32.4%), 5.7% (9/158; 2.6-10.5%), and 1.5% (1/66; 0.0-8.2%). While for Y-microdeletions they were 8.5% (6/71; 3.2-17.5%), 8.2% (13/158; 4.5-13.7%) and 0% (0/66; 0.0-4.4%), respectively. The respective overall prevalence rates for chromosomal anomalies and Y-microdeletions in these groups were: 22.5% (16/71; 13.5-34.0%), 13.9% (22/158; 8.9-20.3%), and 1.5% (1/66; 0.0-8.2%). CONCLUSIONS: Our findings strongly support the recommendation for both karyotyping and Y-microdeletion analyses in subfertile men with sperm concentrations of 2 million/mL or lower before they undergo assisted reproduction treatment.

Glycosylation profile of differently charged IgA1 and their binding characteristics to cultured mesangial cells in IgA nephropathy.

BACKGROUND: IgA nephropathy (IgAN) is characterized by mesangial deposition of polymeric IgA1 (pIgA1), yet the pathogeneic mechanism remains unresolved. In the present study, we examined the glycosylation profile of differently charged IgA1 from IgAN patients. The binding characteristics of these IgA1 fractions to cultured human mesangial cells (HMC) and hepatoma cell lines (HepG2) were studied. METHODS: Differently charged IgA1 were isolated by ion exchange chromatography. The glycosylation profile in the carbohydrate moieties of these differently charged IgA1 was analyzed by galactose (Gal)-, galactose-acetylgalactosamine (Gal-GalNAc)-, or sialic acid-specific enzyme-linked lectin binding assays (ELLA). The binding characteristic of these IgA1 to HMC was examined by flow cytometry and competitive binding assay. RESULTS: Anionic pIgA from IgAN patients showed less reactivity in (Gal)- and (Gal-GalNAc)-specific ELLA (p < 0.01). There was higher reactivity for anionic pIgA1 in alpha(2,6)-linked sialic acid-specific ELLA (p < 0.01). Anionic pIgA1 from IgAN patients exhibited increased binding to cultured HMC and the binding was significantly reduced after neuraminidase treatment (p < 0.05). In contrast, anionic pIgA1 from IgAN patients bound less to cultured HepG2 cells and the binding was enhanced following neuraminidase treatment (p < 0.05). CONCLUSIONS: We demonstrated an unusual glycosylation and sialylation pattern of anionic pIgA1 in IgAN which may have an important effect on its pathogenesis.

Carcinoid tumour of the kidney in a Chinese woman presenting with loin pain.

Renal carcinoid tumours are uncommon. The aetiology is not yet fully understood and there is still no useful diagnostic tool for detecting them. We report our experience managing a Chinese woman with a primary renal carcinoid tumour.

Intrarectal administration of lidocaine gel versus plain lubricant gel for pain control during transrectal ultrasound-guided extensive 10-core prostate biopsy in Hong Kong Chinese population: prospective double-blind randomised controlled trial.

OBJECTIVE: To compare the level of pain experienced by patients during transrectal ultrasound-guided prostatic biopsy using intrarectal 2% lidocaine gel versus plain lubricant gel. DESIGN: Prospective double-blind randomised controlled trial. SETTING: Regional hospital, Hong Kong. PATIENTS: From March 2002 to December 2003, patients who underwent ultrasound-guided prostate biopsy at a Geriatric Urology Centre. MAIN OUTCOME MEASURES: Pain and discomfort scores measured by horizontal visual analogue scales. RESULTS: A total of 338 consecutive patients were randomised to lidocaine gel or plain lubricant gel groups. The two groups were statistically similar in demographic and disease characteristics. There were no significant statistical differences in pain or discomfort score in the lidocaine gel and plain lubricant groups--pain score: 1.75 versus 1.79 (P=0.66) on day 0 and 0.21 versus 0.15 (P=0.97) on day 1; discomfort score: 0.79 versus 0.77 (P=0.86) on day 0 and 0.12 versus 0.12 (P=0.76) on day 1. No major complications were recorded in this cohort. CONCLUSIONS: Transrectal ultrasound-guided trucut biopsy of the prostate can be safely performed with no anaesthesia in Chinese patients. Pain and discomfort are minimal. It was found that 2% lidocaine gel has no statistical therapeutic or analgesic benefit over plain lubricant gel.

Laparoscopic nephrectomy: an early experience at Queen Mary Hospital.

OBJECTIVE: To report our early experience of laparoscopic nephrectomy. DESIGN: Prospective data collection. SETTING: Queen Mary Hospital, Hong Kong. PATIENTS: Transperitoneal laparoscopic nephrectomies were performed on 40 patients between July 1997 and December 2002. MAIN OUTCOME MEASURES: Demographic and perioperative data including operating time, blood loss, postoperative pain score, analgesic requirement, complications, time to resume oral intake, ambulatory state, and length of hospital stay. RESULTS: Laparoscopic nephrectomy was performed for 21 solid renal masses, five transitional cell carcinomas, and 14 non-functioning kidneys. Seven (17.5%) patients had previous abdominal surgery. The mean body mass index of the patients was 23.9 kg/m(2) and the mean operating time was 229 minutes. The mean estimated blood loss was 370 mL, and two patients required conversion to open surgery because of intra-operative bleeding. Other complications include diaphragmatic injury, port-site bleeding, chyle leakage, bleeding peptic ulcer, and myocardial ischaemia. The postoperative mean analgesic requirement was 26 mg of morphine sulphate equivalent. The mean time for patients to resume oral diet and full ambulation was 1.3 and 2.8 days, respectively, and the mean length of hospital stay was 6.7 days. The mean diameter of the solid renal tumour was 4.1 cm and the surgical margins of all resected specimen for malignant tumours were negative. CONCLUSION: Laparoscopic nephrectomy is a safe and efficacious approach for resection of benign non-functioning kidneys and malignant renal tumours.

2-[125I]iodomelatonin-binding sites in the human kidney and the effect of guanosine 5'-O-(3-thiotriphosphate).

Putative melatonin receptors in normal kidney cortical tissues of patients with transitional cell carcinoma or renal cell carcinoma were characterized using a melatonin agonist, 2-[125I]iodomelatonin, as the radioligand. 2-[125I]Iodomelatonin-binding sites in the human kidney were stable, saturable, reversible, and of high affinity. The binding affinity was 15.2 +/- 2.5 pmol/L, and the binding density was 1.79 +/- 0.19 fmol/mg protein. The unity of the Hill coefficients and linearity of the Scatchard plots suggested that 2-[125I]iodomelatonin was bound to a single class of binding sites. Pharmacological characterization showed that these binding sites were highly specific to 2-iodomelatonin, melatonin, 6-hydroxymelatonin, and 6-chloromelatonin. Guanosine 5'-O-(3-thiotriphosphate) decreased the binding affinity and density of 2-[125I]iodomelatonin-binding sites in the kidney, suggesting that these binding sites are coupled to a G-protein. The characterization of 2-[125I]iodomelatonin-binding sites in normal kidney tissues taken from patients with transitional cell carcinoma or renal cell carcinoma suggests the existence of 2-[125I]iodomelatonin-binding sites in the human kidney cortex, which is in line with the findings of 2-[125I]iodomelatonin-binding sites in kidneys of other mammals and birds. The implication of a direct melatonin action on renal function in the human is proposed.

Reexploration for complications after esophagectomy for cancer.

Among 316 patients who underwent resection for esophageal cancer, 23 required reexploration for complications and 10 died. The commonest reason for reexploration was leakage (eight patients). Development of leakage necessitating reexploration was associated with a hospital mortality rate of 75%. Other reasons for reexploration were postoperative bleeding (n = 7), chylothorax (n = 2), burst abdomen (n = 2), diaphragmatic herniation (n = 1), bile peritonitis (n = 1), bowel gangrene (n = 1), and tracheal perforation (n = 1). Definite or presumed technical error could be identified in 18 of the 23 patients requiring reexploration and indicated that the majority of reexplorations were for complications that appeared to be potentially avoidable. When reexploration became necessary, early intervention offered the best chance of survival.

The use of CHROMagar Orientation as a primary isolation medium with presumptive identification for the routine screening of urine specimens.

The aim of the study was to compare the use of a novel differential culture medium CHROMagar, for both primary isolation and presumptive identificaton, with the method currently used in our laboratory for screening mid-stream-urine samples (MSU). Routine methods (RM) included blotting paper imprinting of all specimens and additional quantitative culture on cysteine lactose electrolyte-deficient agar (CLED) for selected samples together with Microbact 12E for further identification. The CHROMagar method (CH) relied on the use of blotting paper imprints, colonial colour and morphology on CHROMagar only. With respect to the 3390 MSU specimens examined, both methods yielded similar results in 3240, including > or = 87% of Escherichia coli, Pseudomonas spp., Staphylococcus spp., Proteus mirabilis/Morganella morganii and Enterobacter/Serratia/Klebsiella/Citrobacter spp. Of the 52 discordant identifications, yeasts were reported as staphylococci on CHROMagar in 10. The overall cost of materials per specimen was US$ 0.30 by RM and $ 0.24 by CH. It took about 3 min to perform each Microbact test. Thus, CHROMagar plus Gram stain and other simple bench tests gave results similar to those using our current method, but had the advantage of saving time and materials.

Severe acute cholangitis: the role of emergency nasobiliary drainage.

The role of emergency endoscopic nasobiliary drainage (NBD) in the management of severe acute cholangitis was evaluated by comparing the outcome of 15 patients who underwent the procedure as an initial treatment with that of 20 patients who underwent emergency surgery. Biliary sepsis was successfully controlled without complication in all 15 patients by the insertion of a 7F nasobiliary catheter through a limited papillotomy. Subsequent definitive elective treatment included endoscopic stone clearance (n = 6), common duct exploration (n = 8), and bili-enteric reconstruction (n = 1). Among the 20 patients who had surgical treatment, cholecystectomy (n = 11), cholecystostomy (n = 1), and transhepatic intubation (n = 1) were done in addition to common duct exploration. Although patients undergoing endoscopic NBD were significantly older (75.3 years vs 60.1 years; p less than 0.05) and more jaundiced (total bilirubin, 120.3 mmol/L vs 70.4 mmol/L; p less than 0.05), comparable morbidity (40% vs 65%) and mortality (6.7% vs 20%) was observed. Initial endoscopic NBD provides a safe and effective therapeutic option for the management of fulminant biliary sepsis. Among patients with complicated ductal anatomy, endoscopic NBD should first be attempted because, when successful, definitive reconstruction may be performed on an elective basis. The value of its routine application for all patients, however, remains to be validated by further clinical studies.

Day case hematuria diagnostic service: use of ultrasonography and flexible cystoscopy.

OBJECTIVES: To assess the efficacy of a day case diagnostic service employing ultrasonography and flexible cystoscopy in the evaluation of patients presenting with painless gross hematuria. METHODS: From July 1994 to June 1997 a prospective study was conducted for 312 consecutive patients presenting with painless gross hematuria. They were evaluated in a day case diagnostic service setting, where ultrasonography and flexible cystoscopy were performed together with other laboratory investigations. Intravenous urography was subsequently performed for possible additional diagnostic information. RESULTS: Eighty-one urinary malignancies were detected in 78 patients; 51 were carcinoma of the bladder, and the next most common was renal cell carcinoma (n = 15). Definitive diagnoses were made in 68 patients and an abnormality was noted in 9 other patients after the day case workup. The day case diagnostic workup has led to highly selective use of computed tomography scans with high diagnostic yield; intravenous urography only added important diagnostic information, not available from the earlier workup, in 9 patients. CONCLUSIONS: Day case diagnostic service is a feasible arrangement. By combining ultrasonography and flexible cystoscopy, most carcinomas were diagnosed and abnormalities detected. Such a service enhances rapid completion of diagnostic workup, and operations for surgical conditions can be scheduled more promptly.

Case report: perinephric angiomyolipomas in tuberous sclerosis.

Bilateral large perinephric angiomyolipomas in a young Chinese woman with tuberous sclerosis are reported. Computed tomography (CT) demonstrated large fatty masses, containing abnormally dilated blood vessels and muscle strands, within the Gerota's fascia bilaterally. There were multiple foci of involvement in both kidneys. The diagnosis was confirmed on histological examination of the excised left perinephric angiomyolipoma and nephrectomy specimens. The patient subsequently developed bilateral pneumothoraces which were surgically treated. High resolution CT showed extensive thin-walled cysts in both lungs.

Spontaneous rupture of renal tumours: the role of imaging in diagnosis and management.

This study aimed to evaluate whether patients presenting with spontaneous haemorrhage from renal tumours could be accurately diagnosed and initially managed conservatively, and evaluate the role of imaging in guiding the timing and type of subsequent operation. The clinical features, imaging findings and management of seven patients presenting with spontaneous rupture of renal tumour over a 5-year period were reviewed. The information from various imaging studies was evaluated in relation to the subsequent course of intervention. The tumours consisted of six angiomyolipomas and one renal cell carcinoma. In all cases, imaging studies were diagnostic, with computed tomography being the most useful single modality. Emergency surgery was required in one patient for evacuation of suspected infected haematoma and wedge excision of angiomyolipoma. Three elective nephrectomies were performed, while three other patients with ruptured angiomyolipoma were treated conservatively and remained well, without any intervention. In conclusion, patients presenting with spontaneous rupture of renal tumour can be managed conservatively initially. Imaging facilitates accurate pre-operative diagnosis, which was angiomyolipoma in all but one patient in this series. The subsequent intervention can be tailored according to the lesion type and the anticipated risk of re-haemorrhage.

Spontaneous renal pseudoaneurysm rupture presenting as acute intraabdominal haemorrhage.

A 39-year-old man with a known history of end-stage renal disease presented with hypovolaemic shock and acute abdominal pain. Blood-stained peritoneal fluid was present. Right perirenal and extensive mesenteric haematomas were seen at laparotomy and CT. Right renal arteriography demonstrated a small renal artery pseudoaneurysm, and embolization was performed. The patient later developed intractable sepsis and died despite nephrectomy and drainage of the infected haematomas. Although there is an increasing trend towards conservative management of spontaneously ruptured kidneys from benign causes, embolization followed by early surgery should be considered in cases of extensive intraabdominal haemorrhage.