U-Net Modelling-Based Imaging MAP Score for Tl Stage Nephrectomy: An Exploratory Study

We evaluate the stability of the clinical application of the MAP scoring system based on anatomical features of renal tumour images, explore the relevance of this scoring system to the choice of surgical procedure for patients with limited renal tumours, and investigate the effectiveness of automated segmentation and reconstruction 3D models of renal tumour images based on U-net for interpretative cognitive navigation during laparoscopy Tl stage radical renal tumour cancer surgery. A total of 5 000 kidney tumour images containing manual annotations were applied to the training set, and a stable and efficient full CNN algorithm model oriented to clinical needs was constructed to regionalism and multistructure and to finely automate segmentation of kidney tumour images, output modelling information in STL format, and apply a tablet computer to intraoperatively display the Tl stage kidney tumour model for cognitive navigation. Based on a training sample of MR images from 201 patients with stage Tl renal tumour cancer, an adaptation of the classical U-net allows individual segmentation of important structures such as renal tumours and 3D visualisation to visualise the structural relationships and the extent of tumour invasion at key surgical sites. The preoperative CT and clinical data of 225 patients with limited renal tumours treated surgically at our hospital from August 2011 to August 2012 were retrospectively analysed by three imaging physicians using the MAP scoring system for the total score and the variables R (maximum diameter), E (exogenous/endogenous), N (distance from the renal sinus), A (ventral/dorsal), L (relationship along the longitudinal axis of the kidney), and h (whether in contact with the renal hilum). The score for each variable (contact with the renal hilum) was statistically compared with each other for the three observers. Patients were divided into three groups according to the total score—low, medium, and high—and according to the surgical procedure—radical and partial resection. The correlation between the total score and the score of each variable and the choice of surgical procedure was analysed. The agreement rate of the total score and the score of each variable for all three observers was over 90% ( P ≤ 0.001). The map scoring system based on the anatomical features of renal tumour imaging was well stabilized, and the scores were significantly correlated with the surgical approach.

Total laparoscopic resection by medial-retroperitoneal approach using virtual navigation: two case reports of primary retroperitoneal schwannoma

Background We report two rare cases of retroperitoneal schwannoma completely resected by a laparoscopic medial-retroperitoneal approach aided by virtual navigation. Three-dimensional images have been used in liver and lung surgery, but there are few prior reports on retroperitoneal surgery. Case presentation These two case reports are of a 60-year-old man and a 40-year-old man with asymptomatic retroperitoneal schwannoma. In both cases, the tumors were located in the right renal hilum and were close to the duodenum, right ureter, and inferior vena cava. Simulation using three-dimensional images was performed before surgery, and a medial-retroperitoneal approach was performed to secure a wide surgical field. During the operation, we confirmed the location of the main feeder and the relationship between the tumor and organs with those shown on the three-dimensional images and performed total laparoscopic resection. Conclusion The medial-retroperitoneal approach provides operative safety. Preoperative simulation and intraoperative navigation with three-dimensional images, which can be freely rotated and interactively visualized from any angle, are useful methods to enhance the surgeon’s understanding of a patient’s specific anatomy and are especially effective when resecting a retroperitoneal tumor that is located in an anatomically deep and complex location.

Total Laparoscopic Resection by Retroperitoneal Approach Using Virtual Navigation: Two Case Reports of Primary Retroperitoneal Schwannoma

Background: We report two rare cases of retroperitoneal schwannoma completely resected by laparoscopic retroperitoneal approach aided by virtual navigation.Case presentation: These two case reports are of a 60‐year‐old man and a 40‐year‐old man with asymptomatic retroperitoneal schwannoma. In both cases, the tumors were located in the right renal hilum and were close to the duodenum, right ureter, and inferior vena cava. Simulation using three-dimensional images was performed before surgery, and a retroperitoneal approach was performed to secure a wide surgical field. During the operation, we confirmed the location of the main feeder and the relationship between the tumor and organs with those shown on the three-dimensional images and performed total laparoscopic resection.Conclusion: The retroperitoneal approach provides operative safety. Preoperative simulation and intraoperative navigation with three-dimensional images are useful methods to enhance the surgeon’s understanding of a patient’s specific anatomy and are especially effective when resecting a retroperitoneal tumor that is located in an anatomically deep and complex location.

Endoscopic ultrasound-guided trans-duodenal fine-needle biopsy of a small renal mass: case report and review of the literature

Background The incidental detection of small renal masses (SRMs) is increasing and biopsy to obtain pathological diagnosis is increasingly proposed as a diagnostic tool to guide further management. Renal mass biopsies are traditionally performed via a percutaneous approach. However, this is not always feasible due to anatomical limitations. A rarely reported alternative biopsy approach for SRMs is endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB). Herein, we describe a case of EUS-guided trans-duodenal FNB for a SRM that was not amenable to standard percutaneous biopsy. Case presentation A 48-year-old man was incidentally found to have a right-sided SRM measuring 2.9 × 2.2 × 2.4 cm during evaluation for a hernia. It was anterior, interpolar, completely endophytic and near the renal hilum. The tumor was not amenable to traditional percutaneous biopsy due to its anterior location. However, the renal mass was in close proximity to the descending duodenum and so it was felt that an EUS-guided trans-duodenal FNB would be feasible. The procedure was successful without any complications. The specimen adequacy was satisfactory for evaluation and consistent with renal papillary carcinoma with WHO/ISUP grade 3 nuclear changes. Conclusion Our case report demonstrated that EUS-guided trans-duodenal FNB was a safe and feasible approach to obtaining biopsy tissue diagnosis of a SRM that was not amenable to percutaneous biopsy.

Postpartum ovarian vein thrombosis manifesting as acute appendicitis: a case report

Background Postpartum ovarian thrombosis is an uncommon condition. It appears with the nonspecific, predominantly right-sided abdominal symptoms and must be differentiated from other acute visceral conditions. If left untreated, postpartum ovarian thrombosis can have severe consequences, including sepsis, pulmonary embolism, and even death. Momentarily, there are no specific guidelines for postpartum ovarian thrombosis management. We present a case of postpartum ovarian thrombosis admitted to our hospital with symptoms of acute appendicitis. Case presentation A 39-year-old Omani obese multiparous woman of Afro-Arab origin was admitted with acute symptoms, mainly abdominal pain, fever, and vomiting 1 week postpartum. Clinical picture and biochemical profile did not exhibit a recognizable pattern. Ultrasonography excluded retained products of conception. Computerized scan for abdomen and pelvis with oral and intravenous contrast reported a dilated tubular structure in the right adnexa extending up to the right renal hilum level with surrounding inflammation. Those findings were consistent with the thrombophlebitis of the right ovarian vein. Blood cultures and sensitivity showed group A β-hemolytic streptococci sensitive to penicillin G and clindamycin. The patient was treated successfully with antibiotics and therapeutic anticoagulants and discharged home 3 days later; follow-up was arranged. Conclusion This pathology is an exceptional entity in Oman. Therefore, awareness of this unique condition is required so that clinicians will be vigilant, exploring similar cases with imaging and avoiding unnecessary surgical interventions.

Anatomical study on variable disposition of structures in the renal hilum

Background: The hilum is a deep vertical fissure present anteromedially in the kidney, and contains renal vessels and pelvis. Due to advancements in imaging techniques; nephron sparing surgeries like laparoscopic partial nephrectomy have become more common. In these procedures, only specific branch of renal artery, and tributary of renal vein are ligated in the renal hilum. This requires adequate skill of the surgeon as the structures are crowded in the renal hilum. The knowledge of arrangement of renal hilar structures is also important for radiologists to correctly interpret renal angiograms and other radiological scans.Methods: The present study was conducted in the department of anatomy, Vardhman Mahavir medical college, New Delhi on 64 kidneys derived from embalmed human cadavers. The renal hilum was dissected and the sequence of structures from anterior to posterior direction was noted.Results: The kidneys were classified in 6 patterns, with the classical pattern (renal vein, artery and pelvis from anterior to posterior) observed in 37.5% cases only. Remaining 62.5% cases exhibited variations, of which the pattern 2 (V-A1-P-A2) was seen in maximum cases (26.5%).Conclusions: The classical pattern described in anatomical textbooks is not the only pattern of arrangement of renal hilar structures. Instead, variant patterns are commonly encountered. The present study attempts to elucidate the variant anatomy of the renal hilar region to help radiologists and surgeons in proper diagnosis and treatment.

Renal Perivascular Epithelioid Cell Tumor with Lymph Nodes Metastasis: A Case Report and Literature Review

Background: Perivascular epithelioid cell tumor (PEComa) is mesenchymal tumor that originated from perivascular epithelioid cells. Angiomyolipoma (AML) is a common benign PEComa, composed of blood vessels, smooth muscle and mature adipose tissue. Epithelioid angiomyolipoma (EAML) is a rare subtype of AML that has the potential to be malignant.Case presentation: The patient was a 42-year-old woman admitted to the hospital for her left low back swelling. The computed tomography angiography (CTA) revealed a 6.3*5.5*6.7cm cystic-solid tumor in the intermediate kidney. Then we performed a left nephrectomy. Postoperative pathology showed that the tumor was angiomyolipoma (PEComa) with necrotic formation and was 6cm*6cm*5.5cm in size. Additionally, lymph nodes involved (4/17) were observed in the left renal hilum. Immunohistochemistry staining indicated that tumor cells focally expressed MelanA and HMB45. No evidence of disease progression at the six-month follow-up after surgery.Conclusions: Lymph nodes involvement in renal PEComa was rare and was regarded as a type of metastasis. Lymph nodes metastasis might indicate a poor prognosis.

“Non-Parasitic” and “Non-Iatrogenic” Chyluria: Its Diagnosis and Treatment

Chyluria occurs in all its forms with milky urine, recurrent episodes of acute urinary retention, left renal colic and proteinuria. In non-parasitic or iatrogenic diseases, it is secondary to communicate between the cisterna system of the chyli and the lymphatics of the calyx system of the left urinary tract with a retrograde passage of a kilo and its appearance in the urine which therefore take on a milky appearance [1, 2]. Sometimes, episodically, especially after the ingestion of a high-fat meal, the quantity of kilo is so abundant that it can cause obstruction of the upper urinary tract and of the bladder, resulting in renal colic or acute urinary retention that may require their unblocking with double J stent or bladder catheter [3, 4]. After conservative attempts with a fat-free diet or with the parenteral diet, in case of their failure, surgery must be performed by performing a para-aortic and renal hilum lymphadenectomy and, in severe cases, with intraperitonealization of the kidney and left ureter. This is the case of the patient reported below and successfully treated recently with an innovative “open” surgical technique.

Efficacy and safety of prophylactic superselective embolization for angiomyolipoma at the renal hilum

Objective This study investigated the efficacy and safety of superselective transcatheter arterial embolization for angiomyolipoma at the renal hilum. Methods Between August 2012 and January 2015, 13 patients with 16 angiomyolipomas at the renal hilum underwent initial, prophylactic, superselective transcatheter arterial embolization. The patients were followed by computed tomography or magnetic resonance imaging, and volume-reduction ratios after embolization were measured. Results The mean or median post-embolization volume reduction ratios were 23% (follow-up duration, 1–2 months), 55% (3–6 months), 55% (7–12 months), 66% (1–2 years), 67% (2–3 years), and 54% (>3 years). After initial embolization, none of the 16 tumors bled or required surgery; two (13%) tumors recurred; and three (19%) tumors received repeat embolization. Estimated glomerular filtration rates were not decreased at medians of 7 days (near the time of discharge) and 39 days (first clinical follow-up) post-procedure, compared with baseline. Except for post-embolization syndrome, no procedure-related complications occurred. Conclusions Superselective embolization for renal hilar angiomyolipoma is safe and kidney-preserving, with good tumor volume reduction and bleeding prevention.