A renal artery pseudoaneurysm (RAP) is created by high-pressure blood passing from a lacerated artery into the renal parenchyma. It has been reported to occur after trauma, renal biopsy, percutaneous nephrostomy, percutaneous nephrolithotomy (PCNL), and open or laparoscopic partial nephrectomy. The incidence of this rare, potentially life-threatening complication is likely to increase with the increasing popularity of endoscopic renal procedures. We present a case of a 60-year-old male who received PCNL for a calculus in the lower calyx of the left kidney. Twenty days after the PCNL, the patient was readmitted due to severe gross hematuria and clot retention. Angiography revealed a pseudoaneurysm arising from the interlobar artery of the lower pole. RAP is often difficult to diagnose and requires a high index of suspicion. We successfully performed coil angiographic embolization, which is considered the most appropriate treatment. Other treatment options are discussed.

Siavash Falahatkar, Hossein Hemmati, Gholamreza Mokhtari, Ahmad Assadollahzadeh, Aliakbar Allahkhah

Submitted January 16, 2011 - Accepted for Publication March 6, 2011

KEYWORDS: Intrarenal; Pseudoaneurysm; Percutaneous nephrolithotomy; Complication; Minimally invasive surgery

CORRESPONDENCE: Dr. Hossein Hemmati, Urology Research Center, Guilan University of Medical Sciences, Sardare Jangal Street, Rasht, Guilan 41448, Islamic Republic of Iran ().

CITATION: UroToday Int J. 2011 Jun;4(3):art36. doi:10.3834/uij.1944-5784.2011.06.07

An appendicular mass was discovered in a 44-year-old female recipient of a living donor kidney at the beginning of the transplant surgery. The donor nephrectomy was put on hold while the mass was explored. A perforated appendix was found and an appendectomy was completed with suture ligation of its stump. Because all infected tissue was eliminated, we proceeded with the kidney transplant. Immunosuppression treatment was tailored to the special circumstances. Only antithymocyte globulin was used until the patient had return of bowel function. She was discharged home on regular triple immunosuppression and doing well at the 6-month follow-up examination. The incidental discovery of an appendicular mass at the time of transplant surgery may not be an absolute contraindication to immediate kidney transplantation, if the patient meets specific selection criteria.

Toufeeq Khan, Mirza Anzar Baig, Abdul Haleem

Submitted January 1, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Live donor kidney transplantation; Immunosuppression; Appendicular mass; Appendectomy

CORRESPONDENCE: Dr. Taqi F Toufeeq Khan MD FRCS, Riyadh Military Hospital, P.O. Box 7897/624, Riyadh, 11159, Kingdom of Saudi Arabia ().

CITATION: Urotoday Int J. 2011 Jun;4(3):art39. doi:1944-5784.2011.06.09

ABBREVIATIONS AND ACRONYMS: ATG, antithymocyte globulin; DSA, donor-specific antibodies; IG, immune globulin; IV, intravenous; MMF, mycophenolate mofetil; MP, methylprednisone; PE, plasma exchange; WBC, white blood cell.

INTRODUCTION: Some studies of primary realignment of urethral stricture show higher long-term complication rates than those observed in patients treated with delayed repair, but the results are not thoroughly documented. The purpose of this study was to evaluate the results of early endoscopic management of posttraumatic posterior urethral stricture by visual internal urethrotomy (VIU).

METHODS: Participants were 14 males with posterior urethral strictures following a car accident. All patients had partial injuries to the urethra. The strictures were 1-2 cm long. Participant mean age was 21 years (range, 18-26 years). Patients were evaluated by medical history, clinical examination, laboratory investigations, and radiological imaging. VIU was done within 2 weeks of trauma. Follow-up examinations were done at 1, 3, 6, 12, and 24 months after surgery. Outcome measures were flow rates and postoperative complications.

RESULTS: All patients were continent with satisfactory flow rates. One patient had impotence, but his condition was improved at the 6-month follow-up. Other complications included dysuria (n = 5), urinary tract infection (UTI) (n = 2), and urge incontinence associated with UTI (n = 1). After 12 months, 1 patient required surgical intervention due to a decrease in flow rate and recurrence of stricture.

CONCLUSION: Based on this report of 14 patients, early endoscopic urethral realignment surgery is a safe procedure with few complications. Endoscopic restoration of urethral continuity may be considered for early treatment of posttraumatic posterior urethral stricture.

Ahmed Shelbaia

Submitted March 15, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Stricture posterior urethra; Early management; Visual internal urethrotomy

CORRESPONDENCE: Dr.Ahmed Shelbaia, MD, Borg Elatbaa, Faisal Street, 5th Floor, Flat 5, Giza, Egypt ().

CITATION: UroToday Int J. 2011 Jun;4(3):art43. doi:10.3834/uij.1944-5784.2011.06.13.

ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection; VIU, visual internal urethrotomy.

INTRODUCTION: The effect of a transurethral catheter on urodynamic pressure-flow studies has been questioned, especially for patients with bladder outlet obstruction (BOO). The purpose of this retrospective study was to compare urodynamic outcomes measured during free uroflowmetry with pressure-flow studies using a transurethral catheter.

METHODS: We retrospectively reviewed the records of 22 adult patients who had voided volume that did not differ by more than 20% during 2 assessments: free uroflow and pressure-flow with a transurethral 5 Fr catheter in situ. The outcome measures were maximum flow (Qmax), average flow rate, voiding time, time to Qmax, and flow acceleration. Free uroflow and pressure-flow outcomes were compared using paired t tests. A Bonferroni adjustment was applied; probability < .01 was considered statistically significant.

RESULTS: There were 17 males and 5 females. The mean age was 39.9 years (range, 18-80 years). The urodynamic findings were reported as: normal (n = 6), hypocontractile detrusor (n = 5), BOO (n = 5), overactive bladder symptom complex (n = 4), and low pressure-low flow system (n = 2). Qmax was significantly higher during free uroflow than during pressure-flow recordings (P = .001). Average flow rate was also significantly higher during free uroflow (P < .001). Voiding time was significantly slower and acceleration was significantly faster during free uroflow (both with P = .001). There was no significant difference between recording conditions in the time to Qmax.

CONCLUSION: There appears to be a significant decrease in some uroflow measurements with a 5 Fr urethral catheter in situ during pressure-flow studies, which is contrary to the previous claim that any catheter smaller than 6 Fr does not alter the results. This measurement artifact needs to be considered when interpreting urodynamic studies, particularly if the patient has BOO. To compensate for differences between the free uroflow rate and uroflow rate with a catheter, the free uroflow rate and detrusor pressure may need to be considered when evaluating the degree of BOO.

Gajanan S Bhat, Girish G Nelivigi, Chandrashekhar S Ratkal, Venkatesh G K

Submitted February 19, 2011 - Accepted for Publication March 10, 2011

KEYWORDS: Bladder outlet obstruction; Urodynamics

CORRESPONDENCE: Dr. Gajanan S. Bhat, Resident in Urology, Institute of Nephrourology, Victoria Hospital Campus, Fort Bangalore- 560 002, Karnataka, India ().

CITATION: UroToday Int J. 2011 Jun;4(3):art37. doi:10.3834/uij.1944-5784.2011.06.08

ABBREVIATIONS AND ACRONYMS: BOO, bladder outlet obstruction; Pdet, detrusor pressure; Qmax, maximum flow.

Giant hydronephrosis caused by congenital ureteropelvic junction obstruction is very rare, particularly now that imaging techniques are more widely available. We introduce a 16-year-old boy who presented with abdominal pain and distention. He had a cystic mass in the central and right side of the retroperitoneum that filled the space from the right subdiaphragmatic area superiorly to the pelvis inferiorly. It measured 35 cm x 23 cm x 20 cm. His pelvic capacity was 8050 mL. The parenchyma of the right kidney was not observed; the left parenchyma was normal. We performed a right thoracoabdominal nephrectomy. Early diagnosis is essential to the prevention of this disorder.

Volkan Bulut, Gökhan Koç, Ali Feyzullah Sahin, Yavuz Balaban, Isık Hasan Özgü

Submitted February 2, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Giant hydronephrosis; Ureteropelvic junction

CORRESPONDENCE: Dr. Volkan Bulut, Urology Department, Tepecik Training and Research Hospital, gaziler cad., Izmir, 35010, Turkey ().

CITATION: UroToday Int J. 2011 Jun;4(3):art41. doi:10.3834/uij.1944-5784.2011.06.11

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; UPJ, ureteropelvic junction; VUCA 19-9, voided urine carbohydrate antigen 19-9.

INTRODUCTION: The effect of hemodialysis on acquired cystic renal disease (ARCD) in patients with end-stage renal disease (ESRD) is not fully understood. The purpose of the study was to determine the prevalence of ARCD in patients with ESRD from our institution and to investigate the relationship between ARCD and the duration of hemodialysis.

METHODS: This prospective cross-sectional study was conducted between August 2008 and August 2009. We evaluated a total of 410 patients with ESRD; 182 patients were still undergoing hemodialysis at the end of the study period and 228 patients had hemodialysis followed by renal transplantation. Patients with autosomal dominant polycystic kidney disease were excluded. Patients had renal sonography evaluations before and during hemodialysis. Chi-square was used to compare the categorical distribution of the total number of patients with ESRD with the subset of patients with ARCD for the outcome measures of age, sex, duration of hemodialysis, and causes of ESRD.

RESULTS: A total of 34 cases were excluded due to lack of cooperation. From the remaining 376 patients, 31 (8.2%) had ARCD, 80 (21.3%) had a simple renal cyst, and the remaining 265 (70.5%) had noncystic ESRD. The mean age was 45 years (SD = 17; range, 10-85 years). The largest percentage of the total population of patients with ESRD was 20-39 years old; the largest percentage of patients with ARCD was > 60 years old (P < .001). There was no significant difference in the sex distribution of the total group and the subset of patients with ARCD. The mean duration of hemodialysis for all patients in the study was 27 months (SD = 14; range, 1 month to 17 years). Most of the total population of patients with ESRD were on dialysis for < 1 year; most patients with ARCD were on dialysis for > 5 years (P < .001). The majority of both the total number of patients and the patients with ARCD had hypertension or hypertension plus diabetes mellitus.

CONCLUSION: Patients who are on long-term hemodialysis should be monitored for the development of ARCD.

Gholamreza Mokhtari, Homa Karami, Atefeh Ghanbari, Ahmad Enshaei

Submitted February 13, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Chronic renal failure; End-stage renal disease; Hemodialysis; Acquired kidney cyst

CORRESPONDENCE: Homa Karami MD, Urology Research Center, Guilan University of Medical Sciences, Sardare Jangal Street, Rasht, Guilan 41448, Islamic Republic of Iran ().

CITATION: Urotoday Int J. 2011 Jun;4(3):art42. doi:10.3834/uij.1944-5784.2011.06.12

ABBREVIATIONS AND ACRONYMS: ARCD, acquired cystic renal disease; CT, computed tomography; ESRD, end-stage renal disease.

Adrenal myelolipoma is a rare benign adrenal tumor composed of adipose tissue and hematopoietic elements. Myelolipomas are often asymptomatic. The preferred diagnostic imaging modality is computed tomography (CT), which shows focal fatty density within the mass. Surgical intervention is recommended if the mass is larger than 5 cm. A 52-year-old female patient was referred for chronic dull abdominal pain. CT demonstrated left side (6.5 cm x 7 cm) and right side (1 cm x 2.5 cm) well-outlined adrenal masses with a fat density in the suprarenal regions. They were hormonally nonfunctional. The patient underwent laparoscopic left adrenalectomy. The right mass was left intact because of its small size. There were no complications. Histopathological examination revealed myelolipoma. Laparoscopic adrenalectomy can be a safe and effective treatment for select cases.

Siavash Falahatkar, Ahmad Enshaei, Samaneh Esmaeili, Amin Afsharimoghaddam

Submitted January 31, 2011 - Accepted for Publication April 8, 2011

KEYWORDS: Myelolipoma; Adrenal; Laparoscopy

CORRESPONDENCE: Dr. Ahmad Enshaei, Urology Research Center, Guilan University of Medical Sciences, Sardare Jangal Street, Rasht, Guilan 41448, Islamic Republic of Iran ().

CITATION: Urotoday Int J. 2011 Jun;4(3):art40. doi:10.3834/uij.1944-5784.2011.06.10

ABBREVIATIONS AND ACRONYMS: CT, computed tomography; ML, myelolipoma; MRI, magnetic resonance image; US, ultrasound.

INTRODUCTION: The Ophira mini-sling system (Promedon; Cordoba, Argentina) uses a minimally invasive, midurethral low-tension tape that is anchored to the obturator internus muscles bilaterally at the level of the tendinous arc by a single vaginal incision. It minimizes surgical trauma and enables an outpatient procedure. First-year follow-up results are reported.

METHODS: The study was a prospective clinical trial conducted from February 2008 to March 2010. Participants were 149 female patients with stress urinary incontinence from Brazil and Argentina. Their mean age was 53.9 years (SD = 9.5; range, 36-71 years). All patients received a medical history, physical examination, stress test, standardized 1-hour pad test, and urodynamic study. Patients also completed the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and Urogenital Distress Inventory (UDI-6). All underwent treatment with the Ophira mini-sling system. The procedure was conducted under local (73%), general (18%), or regional anesthesia (9%). A vertical 1 cm long vaginal incision was performed at 1 cm from the urethral meatus to deliver the prosthesis. Patients repeated the presurgical tests at 1, 3, 6, and 12 months after surgery. Outcome measures were postvoid residual volume, pad and stress test results, ICIQ-SF and UDI-6 scores, and complications. Means and standard deviations were calculated and tabled.

RESULTS: The mean (SD) operative time was 12.6 (7.4) minutes. One patient receiving the procedure under local anesthesia had severe intraoperative pain and needed intravenous sedation. Severe bleeding and technical problems with the device were not observed. The mean follow-up was 9 months; 91 patients had 12 months of follow-up evaluations. Postvoid residual volumes were variable across time. Pad tests showed less urine leakage after surgery. The percentage of patients with a positive stress test dramatically decreased after surgery. ICIQ-SF and UDI-6 scores also decreased. Major complications were not observed. Minor complications were mesh exposure (n = 3), urinary retention (n = 3), urinary tract infection (n = 8), and de novo urge incontinence (n = 7).

CONCLUSIONS: The Ophira mini-sling system appears to be an effective, minimally invasive option for the treatment of stress urinary incontinence.

Paulo Palma, Cassio Riccetto, Rodrigo Castro, Sebastian Altuna, Viviane Herrmann, Ricardo Miyaoka

Submitted March 18, 2011 - Accepted for Publication April 6, 2011

KEYWORDS: Female urinary incontinence; Treatment; Minimally invasive surgery; Mini-sling

CORRESPONDENCE: Dr. Ricardo Miyaoka, Rua Durval Cardoso, 172, Jardim Guarani, Campinas, Sao Paulo, Brazil ().

CITATION: Urotoday Int J. 2011 Jun;4(3):art44. doi:10.3834/uij.1944-5784.2011.06.14.

ABBREVIATIONS AND ACRONYMS: ICIQ-SF, International Consultation on Incontinence Questionnaire-Short Form; SUI, stress urinary incontinence; TOT, transobturator tape; TVT-S, tension-free vaginal tape-Secur; UDI-6, Urogenital Distress Inventory; UTI, urinary tract infection.