A case of genital Chlamydia trachomatis infection with acute post renal failure

A 29-year-old woman presented with bilateral hydronephroses concomitant with acute renal failure. Retrograde pyelography demonstrated bilateral ureteral strictures located at the lower segment of ureters. Computed tomography revealed inflammation of the left ovary and severe colon adhesion. She received the operation, i.e. left ovariectomy and colon adhesiotomy, because of a possibility of gynecological disease including endometriosis and malignant tumors. Clinical and pathological findings showed non-specific inflammation in the pelvis and ovary. A pelvic inflammatory disease due to a genital Chlamydia trachomatis was highly suspected and she was treated with targeted antibiotics. There have been no signs of hydronephroses or renal failure during six years' follow-up after the treatment. We discus this rare case of bilateral hydronephroses due to genital Chlamydia trachomatis.     

A case of retroperitoneal fibrosis responding to steroid therapy]

A 73-year-old man presented with acute renal failure due to bilateral hydronephroses. Urography and CT scan revealed stenosis and medial deviation of the bilateral ureters surrounded by a soft tissue mass at the level of the 4-5th lumber vertebrae. Under a diagnosis of retroperitoneal fibrosis, bilateral nephrostomies were temporarily placed and prednisolone administration was initiated at a dose of 20 mg/day. Ureteral passage markedly improved within 2 weeks in association with a decrease in size of the retroperitoneal soft tissue mass. The steroid therapy was continued for 4 months with decreasing dosing schedule. The patient has been doing well without any signs of recurrence for 3 months after the cessation of the steroid therapy.     

Retroperitoneal fibrosis: report of two cases

In case 1, a 24-year-old man was admitted with left lumbago. Abdominal computed tomographic (CT) scan showed the huge mass (8 x 10 x 13 cm in diameter) in the left retroperitoneal space, which lack enhancement and had a irregular margin. Percutaneous needle biopsy guided by ultrasonography was performed. In case 2, a 74-year-old woman was admitted with right lower abdominal pain. Laboratory data showed the renal failure. Imaging study revealed bilateral hydronephroses and bilateral masses at both common iliac vessels. A retroperitoneoscopic biopsy was performed. We diagnosed both cases as retroperitoneal fibrosis and administered prednisolone for 10 months. The masses decreased in size and the symptoms disappeared in both cases.     

A case of fibroepithelial ureteral polyp in an adult patient

A 24-year-old man complaining of asymptomatic gross hematuria was referred to our hospital for treatment of bilateral hydronephroses (left > right) diagnosed at a previous clinic. Radiological examinations demonstrated a filling defect at the left uretero-pelvic junction. Cytological examination of the urine was negative. With the diagnosis of suspected benign ureteral polyp, the patient underwent endoscopic-assisted partial ureterectomy and pyeloplasty through a 5 cm flank incision. Histological examination revealed that the villous tumor in the ureter was a fibroepithelial polyp.     

The diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit by intentionally inducing hydronephrosis

We report the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit by intentionally inducing hydronephrosis. A 75-year-old man whose chief complaints were macroscopic hematuria and bladder irritabilities was diagnosed carcinoma in situ of the bladder and underwent total cystectomy and ileal conduit. 26 months after the operation, the cytological examination of ileal conduit urine revealed urothelial carcinoma. Since the radiographic findings in the upper urinary tracts and ileal conduit were negative, we constructed bilateral percutaneous nephrostomies by intentionally inducing hydronephrosis. Since two serial cytological examinations of the urine sampling from the bilateral pyeloureteral systems revealed urothelial carcinoma, we performed the percutaneous Bacillus Calmatte-Guerin perfusion of the bilateral upper urinary tracts. The therapy was repeated at weekly intervals for a total of 11 perfusions and the cytological examination of ileal conduit urine became negative 4 months after the beginning of the therapy. Intentionally induced hydronephrosis is useful for the diagnosis and treatment for carcinoma in situ of the bilateral upper urinary tracts after total cystectomy and ileal conduit.     

Reoperation cases long after Rastelli operation: right ventricular outflow tract reconstruction by means of a xenograft non-valved patch

Two cases who underwent the new procedure of treatment for extracardiac conduit stenosis after Rastelli operation are reported. They had undergone Rastelli operation 11 and 12 years ago. Because of stenotic Hancock valve of the conduit, they were reoperated. A longitudinal incision was made anteriorly over the conduit and the conduit was dissected free. The sides and posterior half of the conduit bed were preserved. The roof of the new right ventricular outflow tract was formed using a xenograft pericardium patch. Their postoperative courses were smooth.     

Anomalous origin of the pulmonary artery from the right coronary artery

A 5-year-old boy who had an anomalous origin of a stenotic pulmonary artery from the right coronary artery with ventricular septal defect and pulmonary atresia is reported. The diagnosis was made at operation. Successful repair was achieved for the complex anomaly by using a pulmonary artery homograft as a conduit and closing the ventricular septal defect.     

Balloon Dilatation of Stenotic Right Ventricle-to-Pulmonary Artery Conduits

In seven children with obstructed right ventricle-to-pulmonary artery conduits, balloon dilatation (BD) was performed 10-58 months after insertion of the conduit. Average valve gradient was reduced from 69 to 32 mmHg. Obstruction at the conduit-branch pulmonary artery connection became apparent after dilatation of the valve; these distal stenoses also were dilated. It is concluded that the useful lifetime of a right ventricle (RV) to pulmonary artery (PA) conduit may be extended by BD of an obstructed biological valve and/or BD of a stenotic conduit-pulmonary artery anastomosis.     

Bovine valved xenograft in pulmonary position: medium-term follow-up with excellent hemodynamics and freedom from calcification

Background

This study was designed to evaluate the outcome of Contegra xenograft valved conduit (Contegra, Medtronic Inc, Minneapolis, MN).

Methods

From April 1999 to December 2003, 67 patients with a mean age of 16.1 ±15.0 years (2 months to 53 years) and a mean weight of 39.7 ± 27.1 kg (4 to 95 kg) were discharged after implantation of a Contegra conduit. The diagnosis contained the following: pulmonary valve replacement during Ross operation (n = 27), pulmonary valve regurgitation (n = 9), tetralogy of Fallot (n = 7), pulmonary atresia with ventricular septal defect (n = 7), double outlet right ventricle (n = 7), truncus arteriosus (n = 5), Taussig-Bing (n = 2), obstructed conduit (n = 2), and double discordance (n = 1). Conduit size was 14 mm in 2, 16 mm in 7, 18 mm in 12, 20 mm in 13, and 22 mm in 33 patients. Mean cardiopulmonary bypass was 155 ± 48 min (65 to 337 min) and mean aortic cross clamping was 69 ± 38 min (0 to 146 min). All patients underwent echocardiography, 23 of 67 (34%) patients had cardiac catheterization, and 23 of 67 (34%) patients had electrocardiograph-gated multislice computer tomography.

Results

In a mean follow-up of 26.4 months (1 to 56 months) there was one late death (1 of 67 patients; 1.5% mortality) unrelated to the conduit. Five patients underwent reoperation; four were nonconduit-related and one was to replace a twisted conduit. Five patients underwent interventional cardiology; three were nonconduit-related and two were to stent a twisted or stenotic conduit. Echocardiography showed absent valve regurgitation in 30 of 67 (45%) patients, trivial in 21 of 67 (31%) patients, mild in 16 of 67 (24%) patients. The transconduit pressure gradient remained stable during follow-up, with peak pressure gradient 17 ± 11 mm Hg and mean gradient 8 ± 6 mm Hg. Internal diameters corresponded to 110% ± 20% of the implanted diameter at level of proximal anastomosis, 112% ± 18% at valve level, and 110% ± 14% at distal anastomosis. Calcifications were not found, with the exception of a minimal (2.3 mm) parietal calcification.

Conclusions

The Contegra valved conduit provided excellent morphology and hemodynamics, and freedom from calcification in a medium-term follow-up.     

Simultaneous Bilateral Stenosis of the Vertebral Arteries Treated by Unilateral Decompression: A Case Report

A 56-year-old man presented with a 3-month history of progressive dizziness. His dizziness was aggravated when his head was rotated to the right side. Diagnostic angiography showed that a normal right-sided vertebral artery in the neutral position became an abnormal vertebral artery with two stenotic lesions at the C3–4 and C5–6 levels when the patient’s head was turned to the right. A normal left-sided vertebral artery also showed a stenotic lesion at the C2 level when the patient’s head was turned right. The axial dimensions of the bilateral vertebral arteries were similar. The patient was successfully treated with decompression of only one level (C5–6). We conclude that if a bilateral stenosis is found upon one directional head rotation and the bilateral vertebral arteries are similarly sized, a one-sided treatment may suffice.     

先天性双侧输尿管末端狭窄性梗阻致尿闭的临床处理

目的探讨双侧输尿管末段狭窄性梗阻致尿闭的临床特点、诊断及治疗。方法先天性双侧输尿管末段狭窄患儿7例,男2例,女5例,年龄35～57d。临床表现为突发性尿闭或少尿,均行B超、膀胱造影及肾盂穿刺造影,3例行磁共振尿路水显像,诊断明确后行输尿管狭窄段切除、输尿管再植术。结果7例患儿均经肾盂穿刺造影确诊,一期手术后6例治愈,随诊2—4年未发现输尿管狭窄及返流发生,肾功能恢复良好;1例症状复发,二次手术后治愈。结论对生后突发尿闭患儿应考虑先天性双侧输尿管末段狭窄的可能,肾盂穿刺造影及磁共振尿路水显像可明确诊断,输尿管狭窄段切除、输尿管再植术是有效的治疗方法。     

Split cuff ileal stoma

Long-term patient comfort after an ileal conduit urinary diversion depends on the conduit stoma. The problem of leak-proof urine collection of the flush stoma can be overcome by using a spout stoma but this could become stenotic unless everted. Eversion is a technically difficult procedure and produces a bulky spout that tends to prolapse. The use of carefully placed myotomies in the split cuff stoma described herein facilitates eversion and produces a slim stoma that accepts a compact, leak-proof appliance and is, at the same time, free of the complications of stenosis and prolapse in the long-term management.     

Urachal signet ring cell carcinoma

Urachal adenocarcinoma is a rare neoplasm associated with poor prognosis. We report a case of urachal signet ring cell carcinoma in a 65-year-old man. He was admitted with a chief complaint of microscopic hematuria. Cystoscopic examination and transurethral biopsy showed an urachal tumor. After undergoing radical cystectomy and intravenous chemotherapy, the patient developed bilateral hydronephroses as a result of bilateral ureteral metastases and bowel obstraction because of the Para-aortic lymphnode metastasis. He has been alive for 5 years after three courses of chemotherapy and a bypass operation.     

Tracheoplasty for Congenital Tracheal Stenosis with Bilateral Tracheal Bronchus

Introduction: Congenital tracheal stenosis (CTS) with a bilateral tracheal bronchus (TB) has not been reported as a subtype of CTS. A novel technique to manage CTS in patients with a bilateral TB is described.Case Report: An infant with tetralogy of Fallot underwent repair of cardiac anomaly at age 1 month. He experienced numerous cyanosis and episodes of transient respiratory arrest. Chest computed tomography (CT) demonstrated an aberrant bilateral upper lobe bronchus arising directly from the trachea and a stenotic trachea connecting the pseudo- carina to the true carina between the common right lower and left lower bronchus. On bronchoscopy, the diameter of the lumen of the narrowed segment was estimated to be less than 2 mm. Tracheal reconstruction was undertaken when he was 2 years of age. The surgical technique using a modified slide tracheoplasty for the correction of this anomaly are described. After surgery, the patient was extubated and has had no respiratory symptoms.Discussion and Conclusion: The patient had unique anatomic considerations that made reconstruction challenging. Our technique of covering a stenotic section by normal trachea is a modification of the slide tracheoplasty technique and is useful for CTS with a unilateral and a bilateral TB.     

支架成形术治疗老年人颈动脉狭窄前后脑血流动力学评价

目的:探讨老年颈动脉狭窄相关局部脑血流量(rCBF)的影响因素,分析支架成形术前后脑血流灌注及相关临床症状的变化.方法:回顾2005年8月至2008年4月我院行SPECT检查且经血管造影证实的老年颈动脉狭窄68例,分析颈动脉狭窄程度、狭窄侧别、是否合并椎基底动脉狭窄(VBS)、侧支循环是否开放和支架成形术前后等情况时相关rCBF的变化.结果:单侧颈动脉狭窄按不同因素分组时相关rCBF下降例数的卡方检验:狭窄90%～99%分别与50%～69%和70%～89%患者比较,P值分别为0.046和0.020;合并VBS和不合并VBS患者比较,P值为0.927;侧支循环开放与无侧支循环患者比较,P值为0.222.颈动脉单侧狭窄与双侧狭窄患者比较,P值为0.046.支架成形术后狭窄相关的rCBF下降区76%的患者得到改善,神经功能状况的改良Rankin评分由入院时(1.4±0.7)分降为术后的(0.4±0.3)分(P<0.001).结论:颈动脉狭窄程度、狭窄侧别可能是影响老年颈动脉狭窄相关rCBF的因素,支架成形术可明显改善狭窄相关rCBF,临床相关症状亦显著改善.     

Coronary-coronary bypass using the internal thoracic artery: a sparing procedure of the arterial conduit

BACKGROUND: The internal thoracic artery (ITA) is well known to be the best conduit for coronary artery bypass grafting. However, the bilateral use of ITAs remains limited because in situ right ITAs (RITAs) do not possess an adequate length to be directed to the posterolateral myocardium. We thus considered using free ITAs for conduits between the two segments of the same coronary artery. METHODS: From March 1997 to May 1999, 17 patients underwent coronary-coronary bypass grafting (C-CBG) using free ITAs. Early operative results were analyzed. C-CBG was indicated when the right ITA had an inadequate length or when a distal part of the ITA was left unused. RESULTS: No patient died after C-CBG and none have experienced angina since C-CBG (mean follow-up period 27.3 +/- 19.8 months). Postoperative angiography was performed in all subjects at discharge. Only one coronary-coronary bypass graft was occluded, the other grafts were patent, and there were no stenotic changes. Bilateral ITAs were used in 75% of the patients undergoing CABG during the period of this study. CONCLUSIONS: C-CBG can expand the use of bilateral ITAs and can provide an alternative method for revascularization of the posterolateral myocardium.     

Complex vascular reconstruction of abdominal aorta and its branches in the pediatric population

Background

Subdiaphragmatic aortic diseases in children are rare and form a heterogeneous group. The pediatric patient presents unique challenges because of their size, concerns about proper timing and conduit for repair, and anticipating expected growth.

Methods

We performed a retrospective review of operations involving the abdominal aorta and called branches in children between January 2003 and April 2007, focusing on the details of preoperative evaluation, operative technique, and outcomes. The pertinent literature is reviewed.

Results

Twenty-two children (age, 2 days to 17 years) were included. Mean follow-up was 28 months. Aneurysms were seen in 5 children; the remainder had stenotic disease. Aneurysms were typically asymptomatic and diagnosed incidentally, whereas stenotic lesions most commonly presented with hypertension (HTN). Fourteen complex vascular repairs were performed. All of the children with aneurysms underwent prompt surgery. The children with stenoses had operations for poorly controlled HTN, claudication, and/or mesenteric ischemia. Most patients with stenotic disease were treated medically for HTN and were followed closely while awaiting optimal size and availability of autogenous conduit for reconstruction. Cryopreserved allograft was used in 3 of the aneurysm operations. Dacron grafts were used to repair 5 aortic stenotic lesions. Renal and mesenteric revascularizations were performed with saphenous vein grafts. Pediatric, general, and transplant surgeons and nephrologic and cardiologic teams were integral to evaluation and management. No major operative complications occurred.

Conclusion

Proper management of pediatric aortic vascular disease requires a multidisciplinary approach. It is best to use autologous grafts whenever possible. Children with stenotic disease should be treated medically for hypertension until they are large enough for an autologous graft reconstruction. Children with aneurysmal disease are at risk for embolism and thrombosis and therefore usually treated immediately using artificial graft material, if necessary.     

A case of urothelial tumors which occurred simultaneously in bilateral upper urinary tracts and bladder presenting with anuria]

A 72-year-old male was admitted with a chief complaint of anuria. Clinical examinations showed that he was in uremic state and had bilateral hydronephroses. An endoscopic examination revealed a left ureteral tumor and a bladder tumor. Left nephroureterectomy with partial cystectomy and transurethral resection of the bladder tumor were performed. Pathological examinations showed an invasive left renal pelvic tumor (pT3, G3), an invasive left ureteral tumor (pT4, G3), and a bladder tumor (pTis, G3). Following the operation, roentgenological and urinary cytological findings showed a right ureteral carcinoma. He died of multiple liver and bone metastases and local recurrence at 5 months postoperatively.     

A successful surgical treatment for original Taussig-Bing malformation 13 years after banding of the pulmonary artery

A 13-year-old girl with original Taussig-Bing malformation underwent successful intraventricular rerouting. In this congenital heart disease, the large pulmonary flow elevates pulmonary arterial pressure and progress the pulmonary vascular diseases in early infancy. Banding of the pulmonary artery helps to prevent the irreversible vascular changes, while that may result in further hypertrophy of the right ventricle. Ideally, radical repair should be performed as soon as possible after definitive diagnosis. Although, she had banding operation of the pulmonary artery at 8 months of age, there was no difference between the right ventricle and the aortic pressure. The subpulmonary space was large enough to make the tunnel with an internal conduit. Additionally, right ventricle outflow tract reconstruction was performed by a Dacron patch. The postoperative cathetherization demonstrated no stenotic region in both left and right ventricular outflow tract. The Kawashima intraventricular rerouting can be applied to the patients without the subaortic stenosis if banding of the pulmonary artery have been performed long before.     

Continent cutaneous Ileostomy (Kock pouch) prior to renal transplantation

Two patients in end-stage renal failure and with neurogenic bladders due to spina bifida complicated by myelomeningocele were considered for renal transplantation. One patient had had a right nephrectomy and urinary diversion via an ileal conduit; the other, after various external drainage procedures (cystostomy, bilateral nephrostomy), had had a tubular ileocystoplasty. Both underwent 2 surgical procedures prior to renal transplantation: in case 1 we performed a left nephrectomy and then ileal conduit removal + Kock pouch; in case 2 a bilateral nephrectomy was performed via 2 posterior incisions and then we removed the ileocystoplasty and formed the pouch. The continent ileostomy was formed according to the original technique with slight modifications. The patients have been followed up for 12 and 15 months after transplantation.