435 Renal denervation in a patient with uncontrolled arterial hypertension secondary to polycystic kidney disease

Aims Autosomal dominant polycystic kidney disease (ADPKD) represents the most common inherited cause of chronic kidney disease. Typical manifestations of this condition include secondary hypertension, abdominal pain, haematuria and urinary tract infections. Despite the progressive increase in the use of antihypertensive therapy in patients with ADPKD in the last decades, reaching blood pressure target is often difficult in this setting due to the complex physiopathology of arterial hypertension in ADPKD. Catheter-based renal sympathetic denervation (RDN) represents nowadays a therapeutic strategy to approach resistant hypertension. Based on consistent results of several sham-controlled clinical trials, the evidence of safety and efficacy of this procedure is increasing, also in patients with multiple comorbidities including chronic kidney disease. Patients with ADPKD often develop chronic severe kidney-related pain, caused by distension of the renal capsule due to the expansion of the cysts. RDN was proposed to be an effective therapeutic option able to relieve loin pain. Methods A 49-year-old man affected by ADPKD was referred to our centre for resistant uncontrolled arterial hypertension, despite combined therapy with five antihypertensive drugs. He also complained about intense loin pain and 3 years earlier underwent two surgical interventions to remove voluminous renal cysts, that did not relieve chronic pain. His kidney function was moderately decreased at presentation, with progressive decline in the previous years. After a multi-disciplinary discussion with a nephrologist and algologist, the patient was proposed for RDN with the aim of lowering blood pressure and reducing pain. He was treated in July 2018, and after the procedure, was observed a better control of blood pressure but no benefits on pain. Because of the persistence of intractable loin pain, the patient was submitted to a second RDN in December 2018. Also, after this procedure, blood pressure declined remarkably, decreasing his need for antihypertensive medications without a significant worsening of kidney function. Unfortunately, no benefit on chronic pain was observed. Results ADPKD is characterized by the progressive bilateral development of focal renal cysts. Cardiovascular complications, mainly related to hypertension, are a major cause of morbidity and mortality for these patients. RDN could be a valid and safe therapeutic option for the treatment of secondary hypertension in this setting.

Coexistence of Pelviureteric Junction Obstruction and Vesicoureteral Reflux

Introduction: The most common upper urinary tract problem in children is obstruction at the pelviureteric junction. It happens with varying degrees of seriousness. Ultrasonography and DTPA (Diethylene Triamine Penta-acitic Acid) renography are commonly used to detect it. Objective: To find out the coexistence of ipsilateralpelviureteric junction obstruction with vesicourenteral reflux. Materials and Methods: This prospective study was conducted in the Department of Paediatric Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2006 to May 2007 over a period of 1 year 5 months. Thirty-five patients with unilateral hydronephrosis due to PUJ obstruction were included in this study (age: 1 month-15 years). Results were analyzed using Statistical Package for Social Science (SPSS). Results: Incidence of Vesicoureteral reflux (VUR) among pelviureteric junction (PUJ) obstruction patients was 8.6%. Of them Grade-I VUR was 33.3% and grade-II VUR was 66.7%. Mean age of the patients was 4.71 ± 1.97 years and with VUR was 9.33 ± 4.93 years. Male to female ratio was 4:1. Only 5.7% mothers had regular antenatal checkup and 28.5% had irregular. Majority of the patients 28 (80%) were presented with painless loin mass, 6 (17.1%) with fever, 8 (22.9%) with loin pain and 8 (22.9%) with failure to thrive. Three patients (8.6%) showed abnormal R/M/E and all of the abnormal R/M/E samples showed positive culture. Conclusions: Incidence of Vesicoureteral reflux (VUR) among pelviureteric junction (PUJ) obstruction patients was 8.6%. Medicine Today 2021 Vol.33(2): 94-97

Giant leiomyoma of the urinary bladder: A case report

Urinary bladder leiomyoma is a rare tumour accounting for less than 0.5% of all urinary bladder tumours. Till now, less than 250 cases were documented with variable sizes, most of them were less than 10 cm in maximum diameter. Here we present a 68- year-old female patient with urinary bladder giant leiomyoma measuring about 13 cm. She presented with right loin pain. Postcontrast computed tomography of the abdomen and pelvis revealed a large posterolateral right-sided urinary bladder mass with moderate right hydroureteronephrosis. It was managed by partial cystectomy. The patient had an uneventful postoperative course. Postoperative pathological examination of the specimen confirmed giant leiomyoma of the urinary bladder.

A rare case report on double J stenting in a rare case antepartum patient with right sided hydronephrosis and hydroureter

Gestational hydronephrosis (GH) is caused due to dilatation effect of the progesterone as well as physical pressure of the gravid uterus. In pregnancy, its management is challenging as routine radiological investigations and surgical treatments cannot be performed due to the potential harm to the foetus. Women who fail to respond to conservative methods require intervention. Acute hydronephrosis and renal colic are common aetiologies for loin pain, and can lead to severe form of urinary tract infection affecting perinatal outcome. Double J (DJ) stenting during pregnancy is safe, requiring no intra-operative imaging, and inserted under local anaesthesia. It provides good symptom relief, low complication rate, efficient and safe modality for women with refractory symptoms. Multidisciplinary approach to this procedure is advised.

Urinothorax, another complication of bladder tumor: case report

Background Rupture of the fornix is a rare and serious urological complication of obstructive pathologies. The main cause is ureteral stone, but rarely a bladder tumor. Described complications of fornix rupture are superinfection, perirenal abscesses and even sepsis, but not urinothorax. Case presentation Patient of 56 years old, active and chronic smoker, was hospitalized for anemia and obstructive renal failure on a non-documented bladder tumor; clinically, he was presented with hematuria and an intense right loin pain associated with homolateral basithoracic pain and dyspnea. The CT scan without injection showed a right perirenal collection with bilateral renal dilatation on endo-vesical tumor and a right pleural effusion of less abundance. The ratio of pleural fluid creatinine to blood creatinine was greater than 1, confirming urinothorax. As an emergency, a percutaneous nephrostomy was performed. After clinical stabilization, the patient underwent a trans-urethral resection of the bladder and derivation by a double j stent. The ultimate evolution was favorable. Conclusions Beyond the metabolic complications secondary to obstructions, mechanical complications, which can also be fatal, must be included.

Spontaneous rupture of pyonephrosis presenting as anterior abdominal wall abscess: a rare case report

Background A pyonephrosis caused by an obstructing calculus is typically accompanied by fever, loin pain, and other signs of urinary tract infection. Occasionally, severe thinning of the renal parenchyma in pyonephrosis allows direct forniceal rupture into the retroperitoneum and very rarely into the anterior abdominal wall, misconstruing it as an isolated abdominal wall abscess. Case presentation Diabetes-related 55-year-old diabetic male presented with abscess in his periumbilical region extending into right lumbar region. He did not exhibit any urinary symptoms, and contrast enhanced computed tomography [CECT] abdominal and pelvic examinations revealed right pelvic calculus with pyonephrosis. There is a 7.5 mm defect in the lower pole of the right kidney with 171 cc of collection adjacent to the kidney communicating with 150 cc of superficial abdominal wall collection through a 15 mm defect. Incision and drainage of abdominal and retroperitoneal abscesses were done at first. Right DJ stenting was performed. Right lateral decubitus was placed for dependent drainage. Resolution of residual collections was confirmed by subsequent ultrasonography KUB, and drain was then removed. Right DJ stenting done, and patient was discharged. Two months later, DTPA scan done and revealed GFR of 30 ml/min of right kidney. Patient underwent right percutaneous nephrolithotomy. Conclusion The sudden rupture of pyonephrosis is a rare event. Even rarer is the presentation of pyonephrosis as an abscess on the anterior abdominal wall. The correct diagnosis and search for the source of the abscess must be undertaken before intervention. An aggressive and prompt management is needed to prevent further complications from occurring. This case is being presented to add to the literature with regard to abnormal presentations of ruptured pyonephrosis and its management.

Biochemically silent phaeochromocytoma presenting with non-specific loin pain

A 55-year-old woman presented with a 4-month history of right-sided non-specific loin pain and 6 kg weight loss. A CT scan of the abdomen and pelvis showed an incidental 4.5 cm right-sided adrenal lesion which was not typical of an adrenal adenoma. This was further confirmed on MRI of the adrenals. Biochemical investigations to investigate for a functional adrenal lesion included serum catecholamines and metanephrines, an aldosterone to renin ratio and an overnight dexamethasone suppression test. These were all negative. A laparoscopic adrenalectomy was performed in view of the large size of the lesion. Histology was consistent with a phaeochromocytoma, which confirmed the diagnosis of a non-secreting phaeochromocytoma. Non-secreting phaeochromocytomas are rare and usually found in patients with known genetic mutations. Adrenal lesions not related to any mutations similar to our case are even rarer and reported even less in the literature.

Cardiac tamponade secondary to Dressler’s syndrome

A 56-year-old woman presented to hospital with chest pain. Following review and investigations in the medical assessment unit, she was diagnosed with costochondritis and discharged home. She represented 10 days later and was mottled and hypotensive with a high lactate, raised inflammatory markers, an acute kidney injury and bilateral loin pain. A CT of the thorax, abdomen and pelvis showed pleural effusions and a large pericardial effusion with features of cardiac tamponade on subsequent echocardiography. A pericardiocentesis was performed and she was admitted to intensive care for haemofiltration. Once the patient was stable, an inpatient cardiac MRI was requested to further investigate an enhancing pericardium and echo-bright areas in the inferior, inferoseptal and inferolateral walls of the left ventricle demonstrated on echocardiography. The cardiac MRI showed evidence of a recent infarction in the right coronary artery (RCA) territory with pericardial inflammation and a resolved pericardial effusion. Overall, the findings were in keeping with Dressler’s syndrome.

Recurrent Acute Kidney Injury with Severe Loin Pain and Patchy Renal Ischaemia after Anaerobic Exercise without Renal Hypouricaemia in a New Zealand European Male

Acute kidney injury with severe loin pain and patchy renal ischaemia after anaerobic exercise (ALPE) is a rare clinical syndrome. ALPE has predominantly been described in Japanese and Korean populations to date. Many cases and most recurrent examples are associated with renal hypouricaemia. We describe a 28-year-old New Zealand European male without renal hypouricaemia who developed recurrent ALPE whilst performing elite-level sport. Avoiding elite-level anaerobic exercise was successful at preventing further episodes. This report confirms the first known case of ALPE in a New Zealand European male and raises the possibility that ALPE is an under-recognized condition. Long-term outcomes of recurrent ALPE remain unclear, and preventative strategies should be implemented to preserve renal function. Avoiding intense anaerobic exercise is an effective preventative strategy.