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Introduction. Spontaneous perirenal hemorrhage or Wunderlich syndrome represents a rare entity in urological settings. The vast majority of the causes are represented by angiomyolipoma and renal cell carcinoma. In other cases, vascular abnormalities, polycystic kidneys, polyarthritis nodosa, or pyelonephritis could represent the cause of perirenal bleeding. The treatment depends on the clinical parameters at the presentation as well as on the possible presence of renal malignancies. Our goal was to present a rare case of a healthy men who presented the idiopathic Wunderlich syndrome. Case outline. We present a case of a 50-year-old patient with spontaneous perirenal hemorrhage that was not due to any defined cause even after a six-months follow-up. Conclusion. In some rare cases of perirenal bleeding, the cause cannot be defined at the presentation, even with today’s advanced radiological imaging methods. Thus, it is important to be aware of the fact that in those cases, a longer follow-up is needed, knowing that the presence of perirenal hematoma can always obscure the real diagnosis. Sometimes, even in cases where the proper follow-up has been done, the real cause of the bleeding remains unknown.

Background: Endoscopic incision of a ureterocele now presents a standard treatment option in the modern management of ureteroceles. In 1993 our institutions reported their experience with endoscopic incision as initial therapy for ureteroceles in 51 children. These children had a minimum post operative follow-up of at least 1-year and only 27% required further surgery. To assess the long-term efficacy of this treatment modality we re-evaluated the outcome of these patients. Methods: Forty-four of the original 51 patients had sufficient medical records for analysis. In 7 patients no extended follow-up was available excluding them from further analysis. Parameters reviewed included the patient's age at surgery, position of the ureterocele (intravesical vs. extravesical), association with a duplex system, pre and post-operative reflux, function of upper pole, and the need for additional surgical procedures. Results: The average age at the initial surgery was 1.9 years (standard deviation (SD)=3.7 years) with an average follow-up of 6.2 years (SD= 3.6 years). 22 patients had intravesical ureteroceles and 22 had extravesical ureteroceles, 31 had a ureterocele associated with a duplex collecting system while 13 had a single system ureterocele. 10 (77%) of the ureteroceles associated with a single system were intravesical while only 12 (39%) of the ureteroceles associated with a duplex system were intravesical. Of the 18 patients requiring a secondary procedure 14 had an extravesical ureterocele and 16 had duplex systems. 2 patients with a single system extravesical ureterocele underwent a secondary surgery. The average time to the secondary procedure after the initial incision was 1.4 years (SD= 1.8). Secondary procedures included 13 patients undergoing ureteral reimplantation, 7 undergoing upper pole partial nephrectomy, 3 total nephroureterectomies, 3 bladder neck reconstructions, and 1 lower pole pyeloplasty. Only 1 child required surgical intervention following a secondary procedure. This child underwent a cystoscopic urethral incision of a partial ureterocele remnant. The only operations performed in the patients with intravesical ureteroceles were reimplantations and 1 upper pole nephrectomy performed at the time of a lower pole pyeloplasty. 69% of patients known to have no preoperative reflux developed reflux following endoscopic incision (36% from intravesical and 64% from extravesical). Of these patients 45% spontaneously resolved their reflux while another 45% required reimplantation. Reflux persisted at the time of last follow-up in 10%. Of 22 patients with known function of the upper pole, 13 had intravesical and 9 had extravesical ureteroceles. All 9 patients without function of the upper pole had an associated extravesical ureterocele. Conclusions: With extended follow-up we confirm the role of endoscopic incision in the primary management of ureteroceles previously reported by our institutions. Of note, the percentage of patients requiring secondary surgery after endoscopic incision increased from our original report of 27% to 41%. Only 18% with an intravesical ureterocele required a subsequent procedure compared to 64% of those with an extravesical ureterocele. The reduction in size of the obstructed ureter following primary endoscopic decompression facilitated successful ureteral reimplantation in those requiring a secondary procedure., Christopher S. Cooper, MD, Giacomo Passerini-Glazel, MD, Joel C. Hutcheson, MD, Massimo Iafrate, MD, Cristina Camuffo, MD, Claudio Milani, MD, Howard M. Snyder, III, MD, FAAP. Division of Pediatric Urology, [...]

A 31-year old female patient was diagnosed with small right renal mass with renal vein extension immediately after her caesarian delivery. Open right radical nehprectomy was performed with tumor thrombus removal. The histological findings showed simple angiomiolypoma. We present a very rare case of a small, plain angiomiolypoma with renal vein thrombus invasion and we discuss the possible causes and therapeutical options. [ABSTRACT FROM AUTHOR]

Laparoscopic Nephron Sparing Surgery (LNSS) is a technically challenging procedure. Technical aspects and the outcome of LNSS are investigated. A total of 592 LNSS procedures were collected from 12 Centres, either in extraperitoneal or transperitoneal fashion. Mean tumor size was 2.2 cm. Eight centers reported on tumor position for a total of 407 cases with 338 exophytic tumors (83%) and 69 deep lesions (17%). Four centers, accounting for 185 cases, did not report on tumor position. All the centers performed their LNSS by clamping the hilum. The warm ischemia time was < 30 min in all the centers. The positive margin rate was 2% (12/592). Hemostatic agents and/or sealant or tissue glues were used in 86% of cases (511/592). Types of sealants used included: gelatine matrix (Floseal), fibrin gel (Tissucol), bovine serum albumin (BioGlue) and cianacrylate (Glubran). Two Centres never used sealants, one center used only sealants without suturing and 9 centers used a combination of sealants and bolstering-sutures. The intraoperative open conversion rate was 3.5% (21/592). Postoperative complications included bleeding in 15/592 (2.5%) and urine leak in 13/592 (2.1%). No tumor seeding was reported. LNSS has similar results of open partial nephrectomy. The use of hemostatic agents and/or sealants or tissue glues during LNSS is largely diffuse in European centers and may be an effective add on reducing bleeding and urine leakage when used in combination with bolstering-suturing.

We report a case of a benign testicular Leydig-Cell Tumor (LCT) that deceived us because of an estradiol (E2) plasma levels elevation 27 months after radical orchiectomy in a body builder patient with habits of red meat abuse and no steroid assumption, without any sign of tumor recurrence. The patient was therefore asked to stop red meat assumption and E2 plasma levels returned normal. The restoration of red meat assumption showed a trend of increasing E2 plasma levels above normal range. Despite the documented usefulness of E2 plasma levels evaluation during the follow-up of LCT, elevation of this hormone could be related to other causes and presence of the so-called evironmental xenoestrogens may be one of these.