Nutcracker phenomenon treated with left renal vein transposition: a case report]

Herein is reported a case of the nutcracker phenomenon with severe gross hematuria which was surgically treated. A 14-year-old boy had been suffering from left flank pain and recurrent gross hematuria causing urinary retention with blood clots. Radiological images including three-dimensional computed tomography (CT) and angiography disclosed the nutcracker phenomenon with left renal venous hypertension. Since the aforementioned symptoms could not be managed conservatively, he underwent transposition of the left renal vein at 5.5 cm caudal from the original position. Postoperative course was uneventful and the patient has had no further hematuria after the surgery.     

Hematuria due to circumaortic left renal vein

A patient with benign recurrent hematuria underwent selective renal venography, manometric registration of pressure levels in the renal veins, and renal biopsy which indicated the circumaortic left renal vein was responsible for intermittent hematuria and proteinuria.     

Stab wound to the left solitary kidney: report of a case

A forty-four-years old man with a left solitary kidney presented a stab wound in the left lumbar region. Upon admission, the patient was hemodynamically stable, the abdominal ultrasonography showed a small perirenal hematoma and the intravenous pyelography was normal. Two days later, he had no hematuria and was discharged from the hospital, with a computed tomography scan control two weeks later. Unfortunately, seven days later, the patient was admitted to emergency for left lumbar pain, a 40 degrees C fever and pyuria. The creatinine level was 72 ng/mL, and the computed tomography scan showed a large urohematoma. The patient was operated and required partial upper polar nephrectomy for distorted upper pole with infected hematoma. A large hematoma was removed and a nephrostomy tube was introduced. The renal function returned to normal six days postoperatively and the nephrostomy tube was removed after nephrostogram at 12 days. Concerning this uncommon case, we emphasize the advantage of the computed tomography scan and the necessity of emergency management in a patient with solitary traumatic kidney.     

左肾静脉压迫综合征的手术治疗(附四例报告)

目的　探讨左肾静脉压迫综合征 (胡桃夹现象 )的临床特点及诊治方法。　方法　左肾静脉压迫综合征男性患者 4例 ,年龄 16～ 2 2岁。临床主要表现为反复发作肉眼血尿 ,1例合并左侧精索静脉曲张。膀胱镜下均可发现左侧输尿管口喷血尿 ,B超及CT三维重建示腹主动脉与肠系膜上动脉夹角处左肾静脉明显受压 ,肾静脉近端扩张。结合文献讨论其发病特点 ,影像学特征和治疗。　结果　 4例患者术前均明确诊断 ,均行左肾静脉重建手术 ,术后血尿消失 ,痊愈出院。术后 6个月及 9个月分别复查B超、CT三维血管重建 ,4例患者肾脏大小正常 ,重建肾静脉通畅 ,受压现象消失 ,尿常规正常。　结论　左肾静脉压迫综合征临床特点为肾静脉高压 ,肉眼或镜下血尿 ,精索静脉曲张。左肾静脉重建手术是治疗血尿的有效方法。     

左肾静脉下移术治疗左肾静脉压迫综合征(附3例报告)

目的 探讨改进治疗左肾静脉压迫综合征（即胡桃夹综合征-NCS）的手术方法。方珐对3例明确诊断为左肾静脉压迫综合征的患者采用左肾静脉下移与下腔静脉端侧吻合术。结果术中肾动脉阻断时间分别为20min、21min及16min。肉眼血尿消失时间分别在术后第3天、第5天及第4天，镜下血尿消失时间分别在术后第5天、第7天及第6天。随访4—6月，血尿均未复发。结论左肾静脉下移与下腔静脉行端侧吻合治疗左肾静脉压迫综合征，疗效满意。     

Abdominal aortic aneurysm with aorta-left renal vein fistula with left varicocele

Abdominal aortic aneurysm with spontaneous aorto-left renal vein fistula is a rare but well-described clinical entity usually with abdominal pain, hematuria, and a nonfunctioning left kidney. This report describes a 44-year-old man with left-sided groin pain and varicocele who was treated with conservative measures only. The diagnosis was eventually made when he returned with microscopic hematuria, elevated serum creatinine level, and nonfunction of the left kidney; computed tomography scan demonstrated a 6-cm abdominal aortic aneurysm, a retroaortic left renal vein, and an enlargement of the left kidney. This patient represents the youngest to be reported with aorto-left renal vein fistula and the second case with a left-sided varicocele.     

Intrapelvic migration of a guide pin during fixation of a hip fracture: who and what is to blame?

The authors report the case of a 61-year-old patient who underwent internal fixation with a dynamic hip screw for a stable intertrochanteric fracture of the right hip. The immediate postoperative radiograph showed complete intrapelvic migration of the threaded guide pin, which has gone unnoticed during operation. The pin was removed by laparotomy, and was found to have damaged no pelvic viscera; the patient made an uneventful recovery. The authors analyse the mechanism of such iatrogenic complications and the possible means to avoid them.     

A case of superior mesenteric artery syndrome after left nephrectomy

Postoperative superior mesenteric artery syndrome is a rare complication of left nephrectomy. We treated a case of superior mesenteric artery syndrome that occurred 7 days after radical left nephrectomy for renal cell carcinoma. The patient was a 54-year-old Japanese man who presented with gross hematuria. Abdominal computed tomography showed a 3.8 x 3.8 x 5 cm heterogeneous cystic mass in the left kidney. Transperitoneal left radical nephrectomy was performed because renal cell carcinoma was suspected. The patient resumed oral intake 3 days after surgery, but he began vomiting repeatedly from the 7th day after surgery. Gastroduodenography showed an abrupt vertical linear obstruction of the third portion of the duodenum. Superior mesenteric artery syndrome was diagnosed. Conservative therapy (indwelling nasogastric tube, intravenous hyperalimentation and postural changes) was effective.     

Psoas abscess associated with infected total hip arthroplasty

A 65-year-old man with a left uncemented total hip arthroplasty performed 11 years previously was admitted with a history of progressive low back pain, left hip pain, and sepsis that had begun 6 months earlier. On physical examination, a gross, fluctuant mass was palpated in the left thigh. A computed tomography (CT) scan revealed a 6.5 x 3 cm left retrofascial psoas abscess communicating with the hip joint. The patient underwent irrigation and débridement of the hip with removal of the components. The psoas abscess was drained through the iliopsoas bursa. A residual psoas abscess was drained percutaneously under CT guidance. Cultures isolated Escherichia coli, and the patient responded to 6 months of ciprofloxacin therapy. After 1 year, the patient had no evidence of infection. Pathways of infection spread, diagnosis, and treatment of a patient with this rare association are discussed with a review of the literature.     

Renal pelvic tumor in chronic renal failure: report of a case

A 44-year-old female was admitted because of gross hematuria six years after beginning hemodialysis for chronic renal failure. There was a past history of hematuria one year before admission. Retrograde pyelography, computed tomographic scan and angiography had been performed, and a probable malignant tumor of left renal pelvis had been found in 1986. We recommended surgery at the time, but she refused treatment and was followed up. On June 22, 1987, the patient had a second attack of gross hematuria resulting in bladder tamponade, and hematuria from the left ureteric orifice was confirmed at cystoscopy. Ultrasound showed left obstructive nephropathy. Left nephrectomy was performed because of the presumptive diagnosis of malignant tumor. The histological diagnosis was transitional cell carcinoma of the left renal pelvis. Two courses of M-VAC (methotiexate, vinblastine, adriamycin and cisplatin) chemotherapy were accordingly given postoperatively. The incidence of renal pelvic tumor and its chemotherapy in patients with chronic renal failure are discussed.     

Halo pin intracranial penetration and epidural abscess in a patient with a previous cranioplasty: case report and review of the literature.

STUDY DESIGN: Report of a patient with an epidural abscess after halo pin intracranial penetration at the site of a previous cranioplasty. OBJECTIVES: To report a rare case of intracranial penetration at the site of a previous cranioplasty associated with epidural abscess, and to discuss the diagnostic and therapeutic approach to its management. SUMMARY OF BACKGROUND DATA: The most serious complications associated with use of halo device occur when pins penetrate the inner table of the skull, resulting in cerebrospinal fluid leak and rarely in an intracranial abscess. However, no mention of intracranial halo pin penetration at the site of a previous cranioplasty was found in the literature. METHODS: A 64-year-old man with ankylosing spondylitis had a halo vest placed for management of a fracture dislocation through the C5-C6 intervertebral disc space associated with left C6 radiculopathy. One week later, the patient experienced fever and headache associated with pain, redness, and drainage at the site of the insertion of the left posterior pin. Computed tomography of the brain showed a 1.5-cm intracranial penetration of the halo pin through a previous cranioplasty of the temporal bone, associated with epidural abscess and cerebral edema in the left temporoparietal lobe. The pins and the halo vest were removed, the pin site was cleaned, and a Philadelphia cervical collar was applied. Staphylococcus epidermidis grew on the culture of drainage from the pin site. The patient started immediate intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 2 additional weeks. RESULTS: The patient had gradual improvement of his symptoms within the first 48 hours. At the latest follow-up visit, he had fully recovered and his fracture had healed. CONCLUSIONS: The halo device should not be used for patients with a previous cranioplasty, especially if the pins cannot be inserted at other safe areas of the skull. A thorough medical history and physical examination of the skull are important before the application of a halo device. Computed tomography of the skull may be necessary before elective halo application for patients with concomitant head trauma, confusion, or intoxication and for patients with a previous cranioplasty to ascertain the safest pin sites.     

不同术式治疗胡桃夹综合征所致左侧精索静脉曲张的疗效分析

目的探讨不同术式治疗胡桃夹综合征所致左侧精索静脉曲张的临床疗效。方法回顾性分析郑州大学第一附属医院在2015年7月至2018年9月期间诊治的胡桃夹综合征所致左侧精索静脉中重度曲张患者的临床资料。56例患者共分为3组,24例患者行显微镜下左侧精索静脉低位结扎术+精索外静脉剥离切除术为低位结扎组;19例患者行开放性左侧精索静脉高位结扎术为高位结扎组;13例患者左侧精索静脉中重度曲张并有血尿和/或蛋白尿,行腹腔镜下左肾静脉外支架固定术+生殖静脉结扎术,为血蛋白尿组。术后随访6~30个月,平均(11.5±6.5)月,患者于术前及术后6个月复查阴囊彩超及精液分析,对比精索静脉直径和精液恢复情况。结果①3组患者组内比较:精索静脉直径术后显著小于术前,精子浓度、精子活率术后显著高于术前,差异均有统计学意义(P均<0.01);组间比较:精子浓度3组间术前术后差异均无显著性统计学意义(P均>0.05);而精索静脉直径低位结扎组优于其他2组,精子活率的提高低位结扎组优于其他2组,差异均有统计学意义(P均<0.05)。②血蛋白尿组患者术后随访血尿、蛋白尿症状消失,左肾静脉受压状况明显改善,低位结扎组、高位结扎组左肾静脉受压状况无明显改善。结论显微镜下左侧精索静脉低位结扎术是治疗胡桃夹综合征所致左侧精索静脉中重度曲张的一种姑息、有效的手术方式。     

The posterior "nutcracker": hematuria secondary to retroaortic left renal vein

Retroaortic left renal vein is an uncommon variant in the renal venous system. Recently a patient with such anomaly presented to us with hematuria.     

Methicillin-sensitive Staphylococcus aureus infection after steroid hip injection

Infection after intra-articular steroid injection of the hip is rare, occurring in <1 of 15,000 cases. Septic arthritis following intra-articular injection is even rarer. This is the only documented case of systemic septicemia following intra-articular injection.The patient received an intra-articular steroid injection to the left hip under fluoroscopic guidance, which resulted in reduced pain and increased mobility. Two weeks after the injection, the patient noticed sharp pain in the left hip and groin and malaise. Over a 48-hour period, he became progressively ill and was hospitalized for severe groin and thigh pain, inability to extend his hip, and diaphoresis. He underwent aspiration of the hip, which revealed Gram-positive cocci in clusters.At admission, the patient underwent incision and drainage of the left hip with removal of approximately 25 cc of fluid. The patient was started on intravenous vancomycin, then converted to nafcillin as the cultures and sensitivities revealed methicillin-sensitive Staphylococcus aureus. After 6 days of intravenous methicillin, the blood cultures were negative, and the patient was discharged. The patient's laboratory findings were normal, and cultures for aerobic anaerobic bacteria were negative. The patient underwent hip resurfacing and aggressive rehabilitation and was able to return to work. Thirty months after hip resurfacing, the patient had no evidence of infection, walked without a limp, had normal laboratory findings, and was pain free.     

A case of sudden gross hematuria caused by an iliac artery-ureteral fistula

A 51-year-old male patient, who had been treated for nonspecific angitis with pulselessness in the upper extremities, was found to have stenosis of the left common iliac artery. Patch grafting was performed for the stenotic lesion of the artery. Sixteen months after the operation, the patient developed a sudden massive hematuria for which he was immediately admitted. He required blood transfusions and bed rest. Pyelography and arteriography revealed almost complete impairment of the left kidney function. During subsequent left retrograde ureterography , the patient again developed massive hematuria and fell in shock. The ureterogram revealed left hydronephrosis and the adhesive left ureter to the site of the patch graft. Extraluminal outflow of contrast medium into the artery was also noted. These findings were considered to indicate the hematuria being an extravasation of blood from an arterio-ureteral fistula formed in the patch graft region. An emergency operation was performed. Contamination was avoided by construction of the femoro-femoral arterial bypass graft to the left lower extremity, prior to the radical removal of the potentially infected fistula and left kidney. The surgical procedures have saved the patient and his lower extremities.     

Non-invasive imaging diagnosis of left renal vein compression causing hematuria. Part 1. Ultrasonography

Left renal veins of 100 out-patients were examined by transabdominal ultrasonography to evaluate its usefulness in determining left renal vein compression which is causing renal bleeding. Ultrasonography revealed the left renal vein in 86 patients. In 61 of the 86 cases, the internal cavity of left renal vein was opened at least in diastolic phase, but in 23 cases, the internal cavity was closed between the abdominal aorta and the superior mesenteric artery in both systolic and diastolic phases. In the remaining 2 cases, left renal vein was compressed at a point where it intersected the right renal artery. Left renal vein compression was observed in 18 (69%) of the 26 cases which had been classified as idiopathic renal bleeding and in 7 (26%) of the 27 cases which had urinary tract diseases causing hematuria. In 33 cases which did not have hematuria, left renal vein compression was not observed. These results suggest that diagnosis of left renal vein compression causing renal bleeding is possible by transabdominal ultrasonography.     

Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of Nutcracker syndrome

Nutcracker syndrome is an entity resulting from left renal vein compression by the superior mesenteric artery and the aorta, leading to symptoms of left flank pain and hematuria. Conventional treatment has been surgical, commonly through transposition of the left renal vein to a more caudal location on the inferior vena cava. Additionally, endovascular approaches, primarily via renal vein stenting, have been described for treatment of this syndrome. We report the case of a patient with Nutcracker syndrome who underwent successful left renal vein transposition but then developed recurrent symptoms 10 months postoperatively and was successfully treated with angioplasty and stenting.     

Rupture of an aortic anastomotic aneurysm into a ureter

A case of rupture of a false aneurysm of the distal aorta into the left ureter is reported. The patient presented with purulent hydronephrosis and hematuria. A left aorto-femoral graft had been inserted 3 years earlier, which became infected and was then removed. After 2 years a false distal aortic aneurysm developed, and in the last 6 months recurrent episodes of hematuria have occurred. An aorto-ureteric fistula was confirmed at surgery, and a left nephrostomy was performed with proximal and distal ligation of the ureter and then aneurysmectomy followed by aorto-bifemoral bypass.     

Posterior nutcracker syndrome with left renal vein duplication: An uncommon cause of hematuria

INTRODUCTIONPosterior Nutcracker syndrome (NCS) is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney.PRESENTATION OF CASEA 46 year-old lady presented with intermittent painless hematuria for 6 years. Urinalysis showed microscopic hematuria. An abdominal CT scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior NCS. There were multiple small cortical cysts, sand-like stones in the left kidney and duplication of both right and left renal arteries.DISCUSSIONPosterior NCS in a patient with a duplicated left renal vein may not show all the clinical features of a typical NCS as the elevated pressure due to compression is dissipated through the pre-aortic branch of the duplicated renal vein. CT Angiography can be helpful in such a patient with multiple abnormalities. Management can range from simple surveillance to nephrectomy depending on the symptoms and renocaval pressure gradient.CONCLUSIONAlthough posterior NCS is a rare anomaly of the left renal vein, it should be considered in the differential diagnosis of haematuria.     

Non-invasive imaging diagnosis of left renal vein compression causing hematuria. Part 2. CT

Left renal veins of 77 patients were examined by computed tomography (CT) to evaluate its usefulness in determining the left renal vein compression which is causing renal bleeding. From CT image, left renal vein compression was observed in 6 (86%) of the 7 cases which had been classified as idiopathic renal bleeding, in 9 (21%) of the 42 cases which had urinary tract diseases causing hematuria, and in 3 (11%) of the 28 cases which did not have hematuria. In 15 of the 18 cases of left renal vein compression, left renal vein was compressed between the superior mesenteric artery and the abdominal aorta, showing so-called nutcracker phenomenon. In the remaining 3 cases, however, the superior mesenteric artery provided sharp delineation from the abdominal aorta. The superior mesenteric artery and the abdominal aorta made the mean angle of 35.5 degree in patients with normal left renal vein, the mean angle of 45.4 degrees in those with left renal vein compression without nutcracker phenomenon, and the mean angle of 11.9 degrees in those with nutcracker phenomenon. CT was superior to ultrasonography, in revealing left renal vein compression.