Using MR angiography for surgical planning in pelvic kidney renal cell carcinoma

Pyelonephritis of an ectopic right kidney pretending as acute appendicitis: An unusual case

Introduction

Acute appendicitis is a common condition presenting in emergency department. A patient presenting with pain associated with fever, and tenderness in the right iliac fossa will be suspected to have Acute Appendicitis. However a variety of other clinical conditions may have similar features and may be required to be excluded. Acute pyelonephritis in an ectopic right kidney is a rare clinical condition which may mimic Acute Appendicitis.

Case presentation

We present a middle-age male with complaints of pain in the right lower quadrant of the abdomen with high grade fever for one week. Clinical suspicion and initial ultrasonography (USG) of abdomen supported the diagnosis of acute appendicitis. The patient was initially managed conservatively and later non-contrast computed tomography (NCCT) scan was done that revealed right ectopic kidney with acute pyelonephritis. The appendix was within normal limits on NCCT scan.

Discussion

Ectopic kidneys result from anomalies of ascend which can result in several complications depending upon its position. Acute appendicitis can also cause pyuria and may mimic urosepsis amounting to its close anatomical proximity to urinary bladder. An un-ascended ectopic kidney with pyelonephritis mimicking acute appendicitis is a rare occurrence. USG and CT scan are important tools in the differential diagnosis but however, USG is greatly operator dependent; CT scan provides excellent diagnostic accuracy.

Conclusion

This case report signifies importance of NCCT abdomen in accurate diagnosis of conditions featuring as right lower abdominal pain and fever. Also emphasizing significance of NCCT prior to any surgical intervention, if any conflict of diagnosis occurs.

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Right lower abdomen pain and fever are most commonly attributed to acute appendicitis.

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Cases are reported in past with co-existing pyelonephritis and appendicitis as well as pyelonephritis mimicking appendicitis.

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Pyelonephritis in ectopic kidney and appendicitis are very hard to differentiate on basis of history and lab parameters.

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NCCT abdomen can serve as augmented imaging modality in such cases with diagnostic dilemmas.

Anterior column reconstruction of the lumbar spine in the lateral decubitus position: anatomical and patient-related considerations for ALIF, anterior-to-psoas, and transpsoas LLIF approaches

PURPOSE

Circumferential (AP) lumbar fusion surgery is an effective treatment for degenerative and deformity conditions of the spine. The lateral decubitus position allows for simultaneous access to the anterior and posterior aspects of the spine, enabling instrumentation of both columns without the need for patient repositioning. This paper seeks to outline the anatomical and patient-related considerations in anterior column reconstruction of the lumbar spine from L1-S1 in the lateral decubitus position.

METHODS

We detail the anatomic considerations of the lateral ALIF, transpsoas, and anterior-to-psoas surgical approaches from surgeon experience and comprehensive literature review.

RESULTS

Single-position AP surgery allows simultaneous access to the anterior and posterior column and may combine ALIF, LLIF, and minimally invasive posterior instrumentation techniques from L1-S1 without patient repositioning. Careful history, physical examination, and imaging review optimize safety and efficacy of lateral ALIF or LLIF surgery. An excellent understanding of patient spinal and abdominal anatomy is necessary. Each approach has relative advantages and disadvantages according to the disc level, skeletal, vascular, and psoas anatomy.

CONCLUSIONS

A development of a framework to analyze these factors will result in improved patient outcomes and a reduction in complications for lateral ALIF, transpsoas, and anterior-to-psoas surgeries.

Case Report on Crossed Fused Renal Ectopia With a Large Calculus and Its Management

Among congenital renal anomalies, the ectopic kidney is a rare occurrence. Crossed fused renal ectopia (CFRE) - an even rarer subtype of ectopic kidney - is characterized by both kidneys being fused together on one side of the spine. CFRE is usually asymptomatic but can present with vague symptoms if the anomalous kidney becomes infected, is obstructed by calculus, or has a neoplastic change. There is no indication for surgical intervention if the kidney functions normally. This report presents a case of CFRE in a 31-year-old male with recurrent right flank pain resulting from a large calculus in the upper moiety of the fused kidney. The calculus was surgically removed by percutaneous nephrolithotomy (PCNL). The patient was discharged on analgesics, antibiotics, and potassium citrate tablets, with an order to follow up after one month. On follow-up, the patient’s double-J (DJ) stent was removed and an X-ray was performed to rule out any complications. No signs of stones, strictures, or other complications were noticed.

Wilms tumor in a left pelvic kidney: A case report

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Nephroblastoma is the most common pediatric renal tumor.

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Genitourinary anomalies and syndromes frequently co-exist.

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The existence of Wilms tumor in association with unilateral pelvic renal ectopia is very rare.

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Nephroblastoma in a left pelvic kidney presenting as lower abdominal mass in a 10 year old is presented.

Introduction

Wilms tumor(nephroblastoma) is the most common renal tumor in childhood.The most frequent anomalies and syndromes associated with this tumor involve the genitourinary tract. The occurrence of Wilms tumor with renal ectopia is rare.When present,Wilms tumor is usually found in association with other forms of renal ectopia like horseshoe kidneys or crossed fused renal ectopia. However, reports of the occurrence of Wilms tumor in unilateral pelvic renal ectopia is uncommon. We report a case of Wilms tumor in a pelvic left kidney.

Presentation of case

A 10 year old girl presented to the out-patient department with a one year history of lower abdominal mass, pain and hematuria. Examination revealed a mass in the suprapubic region. Radiological investigations showed a tumor in a left pelvic kidney. She was managed with preoperative chemotherapy, surgery and adjuvant chemotherapy. Histopathologic examination of the nephrectomy specimen confirmed the diagnosis of nephroblastoma.

Discussion

The occurrence of Wilms tumor in association with renal ectopia is rare. There are few reports of tumors arising in unilateral pelvic ectopic kidneys. A multi-modal treatment approach involving the use of chemotherapy, surgery and radiotherapy (for high-risk tumors) in the management of Wilms tumor gives good outcome.

Conclusion

Tumors arising from a pelvic kidney should be considered as part of the differential diagnosis of lower abdominal masses in children.

Renal cell carcinoma in a lumbar ectopic kidney

Introduction

Lumbar ectopic kidney is a rare developmental renal anomaly. We report a case of renal cell carcinoma in lumbar ectopic kidney with an abnormality of the main renal artery piercing the renal parenchyma.

Case presentation

A 70‐year‐old female was referred to our division with an incidentally diagnosed ectopic kidney. Computed tomography angiography detected the right kidney at the lumbar (L3‐L4) level with an early‐enhanced 44‐mm‐diameter mass. The kidney had a laterally facing renal hilum and renal arteries piercing the renal parenchyma from the medial side. An open radical nephrectomy was performed using a peritoneal approach, and no perioperative complications were observed. The pathological diagnosis was clear cell carcinoma (pT1).

Conclusion

This is the first case report of renal cell carcinoma in a lumbar ectopic kidney. It highlights the importance of preoperational imaging for aberrant artery and careful surgical management.

Preoperative evaluation of pelvic kidney renal cell carcinoma with 64-slice CT and 3D-CT angiography

We report a case of a 55-year-old woman, who presented with a vague pelvic pain and was found to have an ectopic pelvic kidney involved by a mass. Preoperative assessment was done by multi-slice CT and 3D-CT angiography. According to our knowledge only eight cases of pelvic kidney tumor have been reported in the literature and our case is the first report of using multi-slice CT and 3D-CT angiography in the preoperative evaluation of these cases.

Gerota's fascia over a pelvic ectopic kidney: Myth or reality?

OBJECTIVE

To prospectively evaluate for the presence or absence of Gerota's fascia in a pelvic ectopic kidney, as this is not well documented.

MATERIALS AND METHODS

Between January 2007 and July 2011, all patients with normal renal functions presenting to the Urology Clinic with pelvic ectopic kidney were evaluated for the presence of fascia similar to Gerota's fascia. Specific evaluation included a contrast-enhanced computed tomography (CT) scan and open surgery where indicated. A literature search using PubMed was also done for the period between 1990 and May 2011 using the terms 'Gerota's fascia', 'perirenal fascia,' and 'pelvic kidney'.

RESULTS

Eleven patients were evaluated. The mean age was 28.6 years (range 7 to 50). The presentation included stone disease in six, pelvi-ureteric obstruction in three, and as part of the evaluation for other causes of lower abdominal pain, it was found in two. A CT scan performed on eight patients did not show any evidence of fascia, while surgical exploration done on seven showed a well-defined fascial layer, at least on the ventral aspect of the kidney. A literature search also did not show any information about Gerota's fascia in the pelvic kidney.

CONCLUSION

Further anatomical / radiological studies are needed to definitively document the presence of Gerota's fascia around a pelvic kidney. Our data is more in favor of the presence of such a perirenal fascia similar to Gerota's fascia.

Renal cell carcinoma in an ectopic pelvic kidney in a patient presenting with acute urinary retention

The incidence of renal cell carcinoma in a pelvic kidney is rare, and has only been described in a very small number of cases. We describe a case where an incidental ectopic kidney with invasive renal cell carcinoma was diagnosed during a separate emergency admission for acute urinary retention.

Ectopic kidney with varied vasculature: demonstrated by CT angiography

An ectopic kidney was found incidentally in a 20-year-old male patient during the abdominopelvic CT angiography. It was situated on the right side at the abdominopelvic junction, partly in the abdomen at the level of the intervertebral disc between L3 and L4 superiorly and partly in the greater pelvis at the level of the promontorium and close to the inferior border of the sacroiliac joints. It was supplied by two arteries which were nearly in the same caliber, and each of which branched from the common iliac arteries both close to the aortic bifurcation. There were two renal veins. The larger one which was emerging from the lateral part of the ectopic kidney was draining into the inferior vena cava. The smaller one which was the only hilar vessel of the ectopic kidney was draining into the left common iliac vein. The orthotopic left kidney was also supplied by two arteries from the abdominal aorta. Ectopic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Ectopic position and varied vasculature can predispose to iatrogenic trauma during interventional radiological and laparoscopic procedures, and emergency operations.

Dynamic contrast-enhanced magnetic resonance imaging for assessing tumor vascularity and vascular effects of targeted therapies in renal cell carcinoma

Traditional cross-sectional tumor imaging focuses solely on tumor morphology. With the introduction of targeted biological therapies in human trials, morphologic change may lag behind other physiologic measures of response on clinical images. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a new imaging method for assessing the physiologic state of tumor vascularity in vivo. DCE-MRI, which uses available imaging techniques and contrast agents, assays the kinetics of tumor enhancement during bolus i.v. contrast administration. Modeling of the temporal enhancement pattern yields physiologic variables related to tumor blood flow and microvessel permeability. Changes in these variables after vascular-targeted therapy can then be quantified to evaluate the tumor vascular response. As these responses may precede morphologic tumor shrinkage, DCE-MRI might serve as a noninvasive means of monitoring early tumor response to vascular-targeted therapy. Renal cell carcinoma provides an excellent model for assessing the effect on DCE-MRI in clinical trials. The vascular richness of renal tumors provides a large dynamic scale of DCE-MRI measures. Patients with disseminated renal cell carcinoma frequently present with one or several large tumors, creating an easy imaging target for DCE-MRI evaluation. Finally, renal cell carcinoma is clearly susceptible to therapies that target tumor angiogenesis. DCE-MRI can be used to monitor the vascular changes induced by such therapies. Future efforts must be directed to standardizing image acquisition and analysis techniques to quantify tumor vascular responses.

Absence of Gerota’s fascia in pelvic ectopic kidney: Implications in laparoscopic radical nephrectomy

We report the anatomic alterations in pelvic ectopic kidney and its bearing on the performance of laparoscopic radical nephrectomy (LRN) and its likely effect on the ultimate oncologic outcome. A patient with Stage T2N0M0 renal tumor in a pelvic kidney underwent transperitoneal LRN. LRN was performed by mobilizing the specimen with an adequate amount of perirenal fat, because no distinct Gerota's fascia can be found in the pelvic kidney. At 1 year of follow-up, the patient was free of disease. LRN is a good option for managing localized renal tumor even in the pelvic kidney. The impact of the absence of Gerota's fascia in the pelvic kidney needs further evaluation.

Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy

BACKGROUND

Ectopic (pelvic) kidney is the most common congenital renal anomaly with an incidence of 1 in 500 to 1 in 2000. A pelvic kidney can be encountered at pelvic or paraaortic lymphadenectomy.

CASE REPORTS

In two patients undergoing pelvic lymphadenectomy, lobulated tumors near the pelvic brim were initially interpreted as bulky lymph node conglomerates. Further dissection showed the ureter to originate from the masses, leading to a diagnosis of pelvic kidney.

CONCLUSION

Pelvic kidneys mistaken for bulky lymph nodes are a potential intraoperative pitfall in patients with gynecologic malignancies. Keys to recognition include an index of suspicion, identifying the course of the ureter and origin of the renal vessels, and confirming absence of a kidney at the normal location.