Laparoscopic Resection of Renal Capsular Endometriosis in a Woman with Menstrual-Related Flank Pain: Case Report

Background Although involvement of the urinary system is not uncommon, endometriosis in the kidneys is rare. To date, laparoscopic partial nephrectomy has been the preferred approach for managing renal endometriosis. Here, we report for the first time the results of laparoscopic removal of a renal capsular endometriosis in a malrotated kidney in an attempt to save the whole kidney parenchyma, in terms of feasibility and safety. Case presentation A 37-year-old female presented with periodic right flank pain associated with her menstrual cycle. On imaging, a malrotated right kidney and a hypodense irregular-shaped lesion measuring 30 * 20 * 15 mm were seen in the superior portion of the right perinephric space. Histologic evaluation of the ultrasound-guided biopsy was consistent with renal capsular endometriosis. The patient underwent laparoscopic surgery to remove the capsular mass while preserving the normal renal parenchyma. Pathological examination of the biopsy obtained during surgery was in favor of renal endometriosis. At 6-month follow-up, the patient’s pain had completely disappeared and no complications had occurred. In addition, imaging did not show any remarkable recurrence. Conclusion Renal endometriosis should be strongly considered as a differential diagnosis in female patients with a renal capsular mass and exacerbation of flank pain during menstruation. Based on our experience, with preoperative needle biopsy and clearing the pathology, laparoscopic removal of the mass in spite of renal anatomic abnormality is feasible and safe and thus could be considered as a possible treatment option.

What happened to the preserved renal parenchyma after partial nephrectomy?

e16581 Background: Partial nephrectomy (PN) is the standard therapy for small renal mass, despite various degree of ischemia reperfusion injury (IRI) is always inevitable as the renal artery is usually clamped during PN. In mouse IRI model, unilateral renal artery clamped for 21 minutes results to sever kidney fibrosis in one year. However, what happened to the preserved renal parenchyma after several years since PN is still a mystery. The aim of the study is to compare the pathological chronic kidney disease (CKD) score of normal renal parenchyma before and several years after PN, as well as to explore the factors that associated with CKD score increase and GFR decline. Methods: We retrospectively collected the clinicopathologic data of 114 renal cell carcinoma (RCC) patients who underwent PN and subsequent radical nephrectomy (RN) due to tumor recurrence in 19 Chinese centers and Cleveland clinic. Macroscopic normal renal parenchyma was sampled at least 5 mm away from the tumor border in PN specimen and at distal portion of the kidney in RN specimen. Pathological CKD score is a summary of glomerular, tubular, interstitial, and vascular score. MDRD2 equation was used to estimate the glomerular filtration rate (GFR). Predictive factors for CKD score increase were evaluated by logistic regression. Results: A total of 64 patients that have all the required data were included in the analysis. The median duration warm ischemia (n = 41) and hypothermia (n = 23) were both 23 min. In a median interval of 2.44 years, the CKD score arose in 73.4% (47/64) patients, with 45.3% (29/64) cases increased by ≥3. Even so, no kidney fibrosis was observed in this cohort including in those with extend warm ischemia (≥45min). There was no significant difference in the change of CKD score during patients with different ischemia time and type. However, patients with comorbidities such as hypertension, diabetes mellitus or CKD (HTN/DM/CKD) showed higher rate and extent of CKD score increase. In multivariate analysis, HTN/DM/CKD was found to be an independent predictor for the CKD score increase [OR:4.24 (1.23-14.64)]. However, the decline of GFR was mild and analogous between patients with or without CKD score increase (23.03±22.53ml/min/1.73m2 vs. 24.27±21.79ml/min/1.73m2, p = 0.856). Conclusions: In majority, preserved renal parenchyma after PN suffered pathological deterioration. Ischemia time and type seem to have limited impact on the change of CKD score of preserved renal parenchyma during PN. Patients with HTN/DM/CKD have higher risk of CKD score increase in despite of similar mild GFR deterioration.

A Hybrid Approach for Treating Recurrent Renal Cell Carcinoma (RCC) in a Single Kidney with a Tethered Ureter

This case highlights a hybrid treatment model used successfully in a patient with complicated recurrent renal cell carcinoma (RCC), following partial nephrectomy, in the context of a single kidney. Scar tissue from previous surgery tethered the ureter to the margin of the lesion and combined with obesity, rendered simple percutaneous intervention challenging. The patient was ultimately successfully treated using a hybrid approach of open surgical access, ureterolysis, and intraoperative ultrasound-guided radiofrequency ablation. This approach optimized the volume of conserved normal renal parenchyma and eliminated the need for postoperative dialysis treatment, with no recurrence at 13 months follow-up.

Pediatric renal pseudotumour

We present a case of 6-year-old female with history of respiratory distress who went into respiratory failure requiring intubation. Patient was subsequently found to be in hypertensive crisis with hyponatremic hypochloremic metabolic acidosis and acute kidney injury. Renal ultrasound was performed to find the cause of hypertension. The ultrasound study demonstrated lobulated isoechoic to hyper echoic mass-like lesion in the middle and lower pole of the right kidney with increased vascularity on Color Doppler examination. The renal mass was finally diagnosed as a pseudotumour, representing hypertrophied portion of the spared normal renal parenchyma in otherwise atrophic right kidney. Diagnosis was made using a combination of US, MRI, DMSA and CT angiography thus avoiding unnecessary surgical intervention.

Analysis of the miRNA-29 family expression in patients with clear cell renal cancer

Почечно-клеточная карцинома (ПКК) является распространенной почечной неоплазией различных морфологических типов, среди которых светлоклеточная ПКК встречается наиболее часто. Считается, что семейство микроРНК-29, включающее микроРНК-29a, микроРНК-29b и микроРНК-29c, связано с агрессивностью и прогнозом течения злокачественных новообразований и может быть перспективным биомаркером для прогнозирования инициации, прогрессирования и патогенеза рака. Уровни экспрессии микроРНК-29a, -29b и -29c были определены в 30 парах образцов нормальной и опухолевой ткани почки пациентов с скПКК с использованием количественной ПЦР в реальном времени. Было обнаружено статистически значимое снижение экспрессии микроРНК-29a (Fold change=0,213; р-value=0,0016) в опухолевой ткани по сравнению с нормальной почечной паренхимой. Renal cell carcinoma (RCC) is a common renal neoplasia of various morphological types, among which clear cell RCC is most common. It is believed that the miRNA-29 family, including miRNA-29a, miRNA-29b and miRNA-29c, is associated with aggressiveness and prognosis of malignant neoplasms and can be a promising biomarker for predicting the initiation, progression and pathogenesis of cancer. Expression levels of miRNA-29a, -29b, and -29c were determined in 30 pairs of normal and tumor tissue samples from the kidneys of patients with RCC using real-time quantitative PCR. A statistically significant decrease in miRNA-29a expression was found (Fold change = 0.213; p-value = 0.0016) in tumor tissue compared with normal renal parenchyma.

Management of a Donor Supernumerary Kidney During Renal Transplantation: A Case Report

Introduction: A fused hilar supernumerary kidney was discovered in a donor organ upon reperfusion during renal transplantation. There is a paucity of literature regarding this anomaly and its management in renal transplant recipients. Case Presentation: Back table preparation of a right deceased donor kidney revealed a duplicated renal artery and ureter. Complex reconstruction of the vasculature was performed avoiding extensive hilar dissection. Following anastomosis of the renal vasculature to the recipient’s iliac vessels, reperfusion revealed a suspicious lower pole renal mass. Frozen section biopsies of the mass were consistent with normal renal parenchyma. Urology was consulted intraoperatively and confirmed the mass to be a small accessory kidney with a separate collecting system, thin parenchyma and hydroureteronephrosis. A nephrectomy of the supernumerary kidney was performed. Discussion: Supernumerary kidneys are extremely rare and infrequently encountered by transplant surgeons. They are usually asymptomatic and incidentally discovered on imaging. If discovered intraoperatively careful inspection must be performed to evaluate for stigmata of potential complications. Conclusion: Knowledge of this entity is important to provide crucial intraoperative decision making and management if encountered in a donor organ. Careful evaluation of these anomalies must be performed when considering resection in order to avoid later complications, with caution that resection may compromise renal function.

Validation of Region of Interest Measurements for the Objective Assessment of Post-Contrast Enhancement of Renal Lesions on MRI

Objective: The aim of this study was to validate the use of region of interest (ROI) measurements in MRI to objectively assess for enhancement in suspected solid renal masses and to determine a minimum threshold value for true enhancement. Methods: Contrast-enhanced renal MRI studies performed between January 2015 and December 2017 for patients with a known renal mass who had subsequent biopsy, or partial/radical nephrectomy were included. Two body imaging fellows independently measured the mean ROI values of renal masses, normal renal parenchyma, the ipsilateral psoas muscle and external air on the pre- and post-contrast sequences. The absolute and percentage changes in the mean ROI values were calculated. The readers were blinded to the pathology results. Results: 104 patients were included in this study (mean age of 65 years; 58 males and 46 females). 74 patients (71%) had a diagnosis of renal cell carcinoma (RCC). Pathology showed clear-cell RCC in 55%, papillary RCC in 22%, and other RCC subtypes in 23%. There were 30 non-RCC renal lesions (29%), including oncocytoma, renal papillary adenoma, and renal metastasis. The minimum percentage change in ROI values in the pre- versus post-contrast images for all pathology-proven RCCs was 23% (range: 23–437%, mean: 143%); this represents relative enhancement and was referred to as the Signal Intensity Index (SII). The percentage change for normal renal parenchyma ranged from 32–317%. The maximum percentage change in ROI values for pathology proven renal cysts was 13% (range: −5–13%, mean: 3.5%). There was excellent inter observer agreement between the two readers [Intra-class correlation coefficient (r) 0.81]. Conclusion: The percentage change in ROI values (SII) can be a helpful tool in the objective assessment of true enhancement of renal masses and can supplement subtraction images. The minimum threshold for enhancement in our study was 23%. Advances in knowledge: Enhancement of a renal lesion can be determined using the objective tool of ROI measurements in the pre- and post-contrast MR images with a percentage change of 20% or above indicating enhancement. This is an additional objective tool, which in conjunction with the subtraction images may improve detection and appropriate diagnosis of renal lesions. It could also be helpful in cases where the subtraction images are degraded by motion artefact.

Xanthogranulomatous Pyelonephritis Associated with Hepatic Dysfunction in Pregnancy

Xanthogranulomatous pyelonephritis is a rare disease characterised by the replacement of normal renal parenchyma by foamy macrophages. The only treatment for this type of pyelonephritis is of a surgical nature with partial or total nephrectomy. The occurrence of xanthogranulomatous pyelonephritis during pregnancy is a rare event (with only 6 cases described in the literature). We report a case of xanthogranulomatous pyelonephritis in a 32-week pregnant woman associated with hepatic dysfunction.