971 A Rare Case of a Reno-colic Fistula Presenting as a Retroperitoneal and Psoas Abscess

Background Fistulous connections arising between the kidney and colon are rare and develop due to multiple aetiologies. We present a rare case of a reno-colic fistula presenting unusually as a retroperitoneal and psoas abscess managed surgically with a good outcome. Case Report A 49-year-old lady presented with 5-day history of left flank pain and swelling with no significant surgical or medical history. Physical examination revealed a tender left renal angle with raised inflammatory markers (CRP and WCC). Computed tomography (CT) revealed an extensive collection extending from an atrophic left kidney through the retroperitoneum and psoas into the subcutaneous tissues with possible fistulation into the descending colon. This was initially treated with antibiotics and percutaneous drainage of the collection. A reno-colic fistula was confirmed via left retrograde pyelogram. Under the multidisciplinary care of the urology and colorectal general surgical teams she underwent a left nephrectomy, large bowel resection and defunctioning colostomy successfully and was discharged eight days later. Histology later confirmed an extensively scarred atrophic left kidney with multiple renal stones with no preserved glomeruli, focal inflammatory infiltrate and stromal calcification consistent with end stage nephropathy. With the resected 5 cm descending colon showing mucosal and serosal inflammation consistent with site of fistula. Conclusions Reno-colic fistula is rare and presentation with a retroperitoneal and psoas abscess uncommon. We report a rare case of a reno-colic fistula secondary to a chronically infected and obstructed left kidney managed surgically with a good outcome.

Primary leiomyoma of the ureter: a case report

Background Only 14 cases of leiomyoma with ureteral origin have been reported previously. Such primary leiomyomas often present as hydronephrosis, making the diagnosis difficult. Radical nephroureterectomy is often performed because of the possible diagnosis of a malignant tumor. We report the 15th case of primary leiomyoma with a ureteral origin. Case presentation A 51-year-old Japanese man presented with a chief complaint of asymptomatic gross hematuria with a history of hypertension. Enhanced computed tomography showed a tumor at the upper part of the right ureter that appeared to be the cause of hydronephrosis and contracted kidney; no retroperitoneal lymphadenopathy and distal metastasis were observed. A well-defined 20-mm (diameter) defect was identified at the upper of the right ureter on retrograde pyelogram with no bladder cancer on cystoscopy. Urine cytology and right divided renal urine cytology findings were negative. Laparoscopic nephroureterectomy was performed, and the extracted tumor measured 20 × 13 mm. Histopathological examination revealed primary leiomyoma with no recurrence 16 months after the operation. Conclusions Preoperative examination with the latest available ureteroscopic technology can help preserve renal function in the case of benign tumors by enabling preoperative ureteroscopic biopsy or intraoperative rapid resection. Moreover, nephroureterectomy is recommended in the case of preoperative suspicion of ureteral malignant tumors.

Malpositioned Right Ureteral Stent into the Duodenum: A Rare Case Report

Double J (DJ) stenting is a routine procedure in our urological practice to treat ureteral obstruction. We report a rare case where the proximal coil of a DJ stent was found in the second part of duodenum diagnosed on imaging and confirmed by upper gastrointestinal endoscopy, in a patient with chronic right flank pain who underwent emergency right DJ stenting elsewhere. He presented to our institution 3-months later for further management. It is important to be aware of all possible complications before placing DJ stents and be aware that if any such complication arise, they need to be dealt with early. It is important to avoid blind DJ stent insertion especially in acute or inflammatory conditions. One can avoid such situations by stenting under image guidance and preferably with a retrograde pyelogram (RGP) or by deploying a guidewire under direct vision using a ureteroscope. If stent malposition is suspected then early detection and replacement of the malpositioned DJ stent under fluoroscopic guidance is an essential step in management.

Renal calyceal diverticulum mimicking a large renal cyst-A case report

Renal calyceal diverticulum are outpouching from renal calyx or pelvis into the renal cortex lined by transitional cell epithelium. We report a case of 35 years old male with history of accidental fall from bike, who presented with persistent right loin pain and hematuria. CT Urogram showed multiple large right renal cysts (BOSNIAK II). Patient was planned laparoscopic renal cyst deroofing. Due to suspicion of calyceal diverticulum, an intraoperative Retrograde Pyelogram (RGP) was done which showed calyceal diverticulum. Laparoscopic calyceal diverticulotomy with closure of communication was done. If only a cyst deroofing was done considering the CT finding alone, it would have ended up in post-operative complication of urinoma which may require a re-surgery. This case report emphasizes the importance of anticipating calyceal diverticulum and intraoperative attempts in the form of doing RGP to identify calyceal diverticulum which mimic renal cyst regardless of CT finding in suspected cases. Keywords: Calyceal diverticulum; large renal cyst; retrograde pyelogram; laparoscopic calyceal; Diverticulotomy.

Uretero-Iliac artery fistula: a rare cause of haematuria

A woman in her mid-forties with a history of cervical cancer requiring chemoradiation presented with bilateral ureteral strictures secondary to radiation therapy. The ureteral obstruction was initially relieved with bilateral percutaneous nephrostomy tubes, and subsequently, bilateral ureteral stents. Over the course of 8 months, she presented with multiple episodes of severe gross haematuria. This persisted even after stent removal and conversion back to percutaneous nephrostomy tubes. The initial evaluation, done with concern for an uretero-iliac artery fistula, which included bilateral retrograde pyelograms and CT angiography was non-diagnostic. Given continued haematuria, repeat endoscopic evaluation was undertaken; on retrograde pyelogram, brisk contrast was seen to pass into the arterial system, consistent with a left ureteroarterial fistula. The patient underwent endovascular iliac artery stent placement. Subsequently, the patient underwent resection of the iliac artery with endovascular graft in situ, left distal ureterectomy with proximal ureteral ligation following femoral-to-femoral bypass. This allowed for complete resolution of the patient’s gross haematuria episodes.

Massive retroperitoneal haemorrhage after retrograde pyelogram in end-stage kidneys: A case report

Severe retroperitoneal haemorrhage after retrograde pyelogram (RPG) is rare and has not been reported in the literature. One of the few indications for performing RPG in end-stage kidneys is evaluation of the upper urinary tract for malignancy. We present a rare case of massive retroperitoneal haemorrhage in a 58-year-old man, with a history of deceased donor kidney transplantation for end-stage kidney disease (ESKD), following bilateral RPG for the evaluation of urothelial cancer. The bleeding was successfully stopped with renal artery angioembolisation. This case demonstrates the importance of exercising extra caution when performing endoscopic procedures in patients with ESKD and keeping the intrarenal pressure as low as possible.

Retrograde Pyelogram during intended Cystogram: A Rare complication of a common procedure

Inadvertent placement of the urinary catheter into the ureter can cause several complications. We describe a rare complication during cystogram due to unrecognized inadvertently placed urinary catheter in ureter, resulting in a life-threatening situation. A 47-year-old multiparous female underwent total laparoscopic hysterectomy for adenomyosis. During early postoperative period, she developed vesicovaginal fistula and transvaginal repair of fistula was done. During filling cystography done at 2 weeks, she developed right loin pain and urosepsis. Contrast extravasation was seen in the right renal subcapsular space with Foley's catheter inside the right ureter. Subsequently, she recovered well.