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Background: Background: Epithelial tumors are the most common subgroup and are seen in 60-70% of all ovarian tumors. Serous cystadenoma and mucinous cystadenoma are the most common benign epithelial tumors. Serous cystadenomas are ovarian tumors with the highest bilateral incidence. The coexistence of tumors with different histopathology in the ovaries is extremely rare and has only been reported in a few cases in the literature. We present a case of bilateral ovarian tumor that was diagnosed as serous and mucinous cystadenoma after laparoscopic surgery. Case report: A 45-year-old female patient was admitted to our center with swelling in the pelvic region and pain in the left lumbar region. US imaging showed a cystic lesion in the right adnexal area, 4x2 cm in size, well-circumscribed, containing a few thin septa, and a low echo fluid content. A cystic lesion with 6x4cm sized multilocular, well-circumscribed, slightly high echo fluid content was observed in the left adnexal area. On CT, a complex cystic lesion measuring 6x4cm was observed in the left adnexal area, pushing the left ureter laterally and causing the hydroureter. In addition, a 4x2 cm cystic lesion was observed in the right adnexal area and hydroureter was observed on the right side proximal to this lesion. Both lesions were removed by surgery. On histopathologic examination, the left-sided cystic lesion was diagnosed as mucinous cystadenoma, and the right-sided cystic lesion was diagnosed as serous cystadenoma. Conclusion: The coexistence of different ovarian tumor subtypes is rare. In this article, we presented a case in which serous and mucinous cystadenoma lesions were seen together for the fourth time in the literature, according to our knowledge.

Lateral lumbar defects are rarely encountered and difficult to manage because of the limited reach of loco-regional flaps and the unfavorable position of recipient vessels for microsurgical transfer. The purpose of this report is to describe the innovative application of an extended latissimus dorsi (LD) flap with propeller ascending design in the field of lumbar reconstruction, reviewing current reconstructive options accepted for lateral lumbar defect. A 68-year-old male patient underwent wide full thickness resection for a solitary hepatocellular carcinoma metastatic lesion arising in the left lumbar region, resulting in an extensive soft-tissue defect (20 x 13 cm) with deep structures exposure. An extended LD flap with propeller ascending orientation was obliquely designed, with the distal third of the skin island laying over the trapezius muscle. The skin paddle measured 34 x 9 cm. The flap, including a cuff of proximal LD muscle spared by the oncological resection and a fasciocutaneous superior extension, underwent 90°clockwise rotation on the main thoracodorsal artery perforator and further caudal advancement allowed by section of the LD cranial tendinous insertion. The rotation-advancement movement allowed tension-free flap insetting, while donor site was closed by primary intention. The post-operative course was uneventful without any complications registered. At 12-months follow-up, a satisfactory result and a stable coverage were achieved. Due to the surgical complexity traditionally associated with the repair of defects located in the lumbar region, the case reported may help to provide a new alternative solution to extend the indications of local flaps in similar cases and simplify such reconstructions.

Nesterenko Iryna. Polymorphism of Clinical Manifestations in Patients with “the Nutcracker Syndrome”. Journal of Education, Healthand Sport. 2021;11(8):381-391. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2021.11.08.042 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2021.11.08.042 https://zenodo.org/record/5303677 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2021; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 05.08.2021. Revised: 15.08.2021. Accepted: 28.08.2021. Polymorphism of Clinical Manifestations in Patients with “the Nutcracker Syndrome” Nesterenko Iryna Romanivna Ivano-Frankivsk National Medical University Assistant Professor at the Department of General Surgery Vascular surgeon, Ivano-Frankivsk Regional Clinical Hospital 76018,Ivano-Frankivsk, Halytska Str. 2 nesterenko-irenka@ukr.net orcid 0000-0002-8358-291X Resume Introduction. “The nutcracker syndrome” occurs due to abnormal compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta. Clinical manifestations range from hematuria, proteinuria, pain in the left lumbar region, left sided varicocele in men, and left sided pudendal varicosity in women to the development of severe anemia and renal failure in some cases due to progressive phlebohypertension. Materials and methods. The study included 210 patientswith suspected “nutcracker syndrome” . The age of the patients ranged from 12 to 52. All patients were interviewed for specific complaints. All referred patients underwent color Doppler ultrasound.The patients with confirmed left renal veinstenosis underwent CT angiography. Results of the research According to color Doppler ultrasound, different degree of aorta mesenteric clamp (AMC) was confirmed in 138 (65.7%) patients, critical LRVstenosis was observed in 35 of them. The predominant complaints of the patients with AMC included pain in the left half of the abdomen and left lumbar region, left sided varicocele and left sided pudendal varicosity, hematuria.. More than half of the patients with AMC complained of dysmenorrhea, and one in four patients with AMC complained of erectile dysfunction. Conclusions. There is no consensus on the diagnostic algorithm for this pathology detection. There is a lack of evidence base (multicenter clinical randomized trials) regarding the clinical selectivity of treatment approaches. The pathology is rarely diagnosed due to a number of objective and subjective reasons, nonspecific symptoms, and therefore it deserves special attention in the study of pathogenesis, diagnosis and choice of treatment approach. Keywords: “the nutcracker syndrome”, phlebohypertension, aorta mesenteric clamp.

Background Primitive neuroectodermal tumor commonly occurs in bones and is equivalent to Ewing’s sarcoma. Very few cases have been reported in the literature and they had a very different presentation and very aggressive behavior. Case presentation We present a case of a young 23-year-old male who presented with complaints of pain in left lumbar region of abdomen since 8 months and hematuria off and on. CT scan of the abdomen was done which revealed a large heterogeneously enhancing mass lesion in the left lumbar region arising from the superior and mid-pole of left kidney showing multiple non-enhancing necrotic areas. A diagnosis of left renal cell carcinoma was kept. Through the transperitoneal approach, the left kidney was approached and a left radical nephrectomy was done. The histopathology report revealed the tumor cells to be positive for CD99 and focally positive for Vimentin and negative for cytokeratin thereby making a diagnosis of primary neuroectodermal tumor (PNET). Conclusions Renal PNET is a rare renal malignancy that should be kept in the differential diagnosis of a renal SOL especially when it is a presenting feature in adolescent and young adult. It has a very aggressive course and multimodal therapy has to be considered in its treatment

We report an unusual case of a malignant granular cell tumor of the left lumbar region in 63-year old woman – diagnosed, consulted and treated with surgical resection (R1) and radiotherapy, followed up for 2 years with lung metastases after 22 months. Furthermore, we discuss histopathological differential diagnosis and current criteria for malignancy, as well as available options for systemic treatment in view of cytogenetic and molecular genetic characteristics of the tumor.

Diaphragmatic hernia can be congenital or acquired. Usual clinical presentation may range from asymptomatic cases to serious respiratory or gastrointestinal symptoms. This case report discusses a middle-aged male presenting to us with a radiological diagnosis of lumbar hernia turning out to have diaphragmatic hernia intraoperatively. A 58-year-old gentleman presented to us, 6 months back, with a slowly progressing painless lump in the left lumbar region. The ultrasonography was suggestive of lipoma. The lump was excised under general anaesthesia, and intraoperatively it was a giant lipoma of size around 12 × 10 cm2 in subcutaneous plane. Two months later, he developed swelling at the same site where he had been subjected to ambulatory excision of a lipoma. The swelling was insidious in onset and gradually progressing over the period of next 4 months, and he again visited to us. Examination revealed an ill-defined fullness in the left lumbar region with suspicious positive cough impulse. Computed tomography scan of abdomen reported it to be a large incisional hernia in the left lumbar region (in view of history of lipoma surgery in the past). The chest X-ray revealed slight blunting of left costophrenic angle, and baseline blood investigation were normal. He was electively posted and proceeded for diagnostic laparoscopy. He had a rent in left hemidiaphragm anterolaterally, and only a part of omentum was adhered to its edge. The defect was laparoscopically suture repaired with polypropylene and strengthened with a polypropylene mesh with ProTack fixation. The postoperative recovery was uneventful. This paper describes a unique presentation of spontaneous diaphragmatic hernia mimicking a lumbar hernia. To our knowledge, no similar case has been reported and published.

Highlights • Duplication cysts can occur anywhere in the gastrointestinal tract but duplication cyst within the pancreas is rare. • The most common presentation reported is abdominal pain secondary to pancreatitis. • The present case presented with abdominal pain, non-bilious vomiting and ill-defined lump in the left lumbar region. • USG showed a target sign and intussusception was suspected. • At operation, there was a thick-walled cyst in relation to tail of pancreas, covered with necrotic omentum. Histology confirmed enteric gastric duplication., We report a case of a 2-year-old girl who presented to us with complaints of pain abdomen and non-bilious vomiting. USG was suggestive of intussusception with necrotic bowel and free fluid in the left lumbar region. Operative findings were of enteric duplication cyst of the pancreas which was later confirmed on histopathology. Enteric duplication cysts can occur anywhere in the gastrointestinal tract but duplication cyst within the pancreas is rare. The most common presentation in other reported cases is pain abdomen due to pancreatitis but in our case, we had findings of intussusception. Children usually present with a severe complication like perforation of duplication cyst as in our case. Excision of the cyst and the duplicated pancreatic tail is the mainstay of treatment.

Introduction and importance Castleman's disease is not so commonly diagnosed worldwide due to non-specific symptoms Clinical findings are variable. No definite blood investigation or any biomarkers are established to diagnose this disease. Radiological investigations do not play much role in diagnosing. It can be unicentric or multicentric. Etiological factors are not well understood except predilection of this disease towards immune-compromised persons. Surgery is considered as a prime modality to treat, if resectable. Case presentation Patient had recurrent abdominal pain in left lumbar region which was intermittent for last 6 months, dull aching with no aggravating and relieving factors. There was no history of abnormal bowel habits, urinary complaints, fever, night sweats, weight loss, rashes in body, joint pains and loss of appetite. On examination, there was a single, firm, non-tender, intra-abdominal, retroperitoneal mass of approximately size 10 ∗ 7 cm in left lumbar region encroaching inferiorly towards left inguinal region. Digital rectal examination (DRE) and external genitalia were normal. Clinical discussion All routine blood investigations along with relevant tumour markers were normal. Magnetic Resonance Imaging (MRI) abdomen showed a well-defined mass suggestive of stromal tumour or retroperitoneal sarcoma. Patient underwent surgery in which complete excision of the mass was done. Postoperative event was uneventful and currently doing well. Conclusion Take away lesson in this case report is that we should not presume all retroperitoneal mass as cancer or sarcoma, we have to think about other rare causes like Castleman's disease, if clinical picture, blood and radiological investigation are discordant., Highlights • Castleman’s disease is not commonly diagnosed world wide • Radiological investigations do not play much role in diagnosis. • Role of tissue diagnosis preoperatively definitely helps in diagnosing, but it is not routinely practiced. • Surgery is a prime modality to treat. • Role of radiotherapy and Chemotherapy is not clearly established.

Congenital lumbar hernia is a rare disease affecting mainly infants. Its association with lumbo-costo-vertebral syndrome (LCVS) is hardly seen in the literature. We present a case of LCVS in a 1-month-old female infant presenting with a soft bulge in left lumbar region. Abdominal X-ray revealed absence of multiple ribs with a mild lumbar scoliosis and defective ninth vertebra. Ultrasonography showed absence lateral abdominal wall muscles in left lumbar region and 2.5 cm diameter lumbar hernia. Primary repair of the adnominal wall defect was performed without meshplasty and no recurrence was reported. We hope to enhance the literature of this rare disease with our case.

The tuberous sclerosis complex (TSC) is highly variable as far as its clinical presentation is concerned. For the implementation of appropriate medical surveillance and treatment, an accurate diagnosis is compulsory. TSC may affect the heart, skin, kidneys, central nervous system (epileptic seizures and nodular intracranial tumors—tubers), bones, eyes, lungs, blood vessels and the gastrointestinal tract. The aim of this paper is to report renal manifestations as first clinical signs suggestive of TSC diagnosis. A 20-year-old patient was initially investigated for hematuria, dysuria and colicky pain in the left lumbar region. The ultrasound examination of the kidney showed bilateral hyperechogenic kidney structures and pyelocalyceal dilatation, both suggestive of bilateral obstructive lithiasis, complicated by uretero-hydronephrosis. The computer tomography (CT) scan of the kidney showed irregular kidney margins layout, undifferentiated images between cortical and medullar structures, with non-homogenous round components, suggestive of kidney angiomyolipomas, bilateral renal cortical retention cysts, images of a calculous component in the right middle calyceal branches and a smaller one on the left side. The clinical manifestations and imaging findings (skull and abdominal and pelvis CT scans) sustained the diagnosis.

Acute destructive pancreatitis refers to severe surgical pathology with high mortality. Destructive changes in this case cover both adjacent and distant structures. The aim of the study was to achieve a more accurate injection of the liquid contrast agent to the tissues of the retroperitoneal space affected by the purulent-necrotic process. We have developed a method that involves the use of a special device with a metal goniometer with a gradation of up to 180° with clamps to fix the syringe with a needle. Syringe with a needle is fixed in the device at an angle of 40° to 50° depending on the figure and the nature of the nutrition patients. The paper presents the results of contrast study of retroperitoneal tissue using the proposed device. The results of 63 cases of retroperitoneal space contrasting study through the right and left lumbar regions are considered. The use of the proposed method of contrast retroperitoneal area taking into account the figure and the nature of nutrition allows more accurately determine the variant of lesion of the pancreas and adjacent adipose tissue. The previously proposed methods of retroperitoneal tissues puncture in acute destructive pancreatitis (ADP) did not fully take into account the figure and the nature of nutrition of the subjects. A significant number (35%) of patients have an excess weight, especially among mesomorphs and endomorphs (91,4%). The figure and the nature of the nutrition of the subject should be provided in bringing the contrast into the retroperitoneal tissue, since this determines the angle of fixation of the needle in the device and the depth of its advancement. Puncture through the right lumbar region was carried out at I and II, through the left lumbar region - at III and IV types of ADP. Purulent necrotic lesions often equally cover the right and left parts of retroperitoneal tissue with type V of ADP.

Aim This study reports a successful minilaparoscopic treatment of a 62 years old male patient with a Grynfeltt hernia, and outlines a new minimally invasive way to do the procedure. A patient presented with a left lumbar herniation of two years duration with no other symptoms. Physical examination showed a 5 cm soft mass on the left lumbar region, which was confirmed as a hernia by an ultrasound. Method A minilaparoscopic approach to surgery was chosen, using a 10 mm trocar inserted in the umbilical region for pneumoperitoneum and the optics, a 3 mm minilaparoscopy trocar inserted in the preperitoneal region in the left iliac region and another 3 mm trocar inserted more dorsally in the lumbar region. Results The polypropylene mesh was placed in the preperitoneal space without need for any mesh fixation. The total time of surgery was 41 min and the patient was discharged on the next day. Conclusion The proposed novel approach is not only feasible, but offers advantages as it appears to be safer, less invasive, cost-effective and above all eminently reproducible.

Segmental neurofibromatosis (SNF) is a rare manifestation of neurofibromatosis. Very few cases have been reported in older population. Here, we present a case of 73 year old male with four years history of multiple, skin coloured, dome shaped, soft nodules situated over left lumbar region. The histopathological evaluation of the excised nodule revealed neurofibroma. Recognition of this condition is important, as there may be associated systemic involvement, malignancies and possibility of transmission to the offspring.

Summary Background Kidney tumors account for about 3% of tumors in adults. The primary therapy of renal cancer is the surgical removal. Traditionally, and also modern procedures are performed to remove the kidneys, especially when the tumor involves the entire kidney. In the cases of unresectable tumors embolization is used as a palliative procedure. Case Report The aim of this study is to present the case of endovascular treatment of renal cell carcinoma in patient with solitary kidney. 77-years old patient had an ultrasound examination because of the pain in left lumbar region. MRI confirmed the presence of tumor size 29×45 mm in the left kidney. The right kidney had been removed eight years earlier because of clear cell carcinoma. Histopathological diagnosis was renal clear cell carinoma. The patient did not consent to surgical treatment. Tumor embolization was proceeded as a minimally invasive procedure. Pathological tumor vessels were closed using particles filling the entire vascular tumor. Next, the blood vessels supplying the tumor were closed using a mixture of lipiodolu and glubranu. Control angiographiy of the left renal artery confirmed the effective closure of all vascular pathology. In a recent ultrasound examination which was done 15 months after surgery no evidence of vascular pathology was found. Conclusions Embolization of kidney cancer in particular cases may be an alternative way of treatment and give a good result in the form of stopping the growth of the tumor with simultaneous retaining the remaining parenchyma and renal function.

Bowen’s disease also known as squamous cell carcinoma in situ, a rare form of progressive, intraepidermal carcinoma, first described by John T. Bowen in 1912.We report a case of 62-year-old elderly male, retired teacher who presented with history of gradually expanding, asymptomatic, Pinkish-reddish raised lesion present on right thigh and left lumbar region since five years. Examination revealed sharply-demarcated, slightly elevated, erythematous, scaly and crusted plaque with dry and rough surface. Histological examination showed Hyperkeratosis, parakeratosis, with moderate lymphocytic infilterate in upper dermis. There was full Thickness anaplasia of the epidermis and atypical keratinocytes which are disorderly arranged. Keywords: Squamous cell carcinoma in situ, Erythroplasia of Queyrat, Solar damage, Arsenic, Cauasian.

Modelo do estudo: relato de caso; Importância do Problema: O presente relato de caso tem como objetivo relatar o caso de paciente do sexo masculino, 40 anos, com quadro de dor em região lombar esquerda há seis meses, sem massas palpáveis e sem achados de massas retroperitoneais à Ultrassonografia de abdome. A investigação diagnóstica constatou, através de Tomografia Computadorizada de abdome, imagem de lesão retroperitoneal acoplada medialmente à artéria aorta, com suposto diagnóstico de Sarcoma Retroperitoneal e, por conseguinte, indicação de tratamento cirúrgico. Durante o período intraoperatório, o paciente apresentou sintomas adrenérgicos, que cessaram após a ressecção completa da lesão e ligadura de parte das aderências do tumor ao retroperitônio. A biópsia evidenciou se tratar de um Paraganglioma Retroperitoneal. A partir do estudo de caso supracitado, é possível perceber a importância de incluir o Paraganglioma como diagnóstico diferencial de tumores retroperitoneais, em consequência de sua raridade, difícil diagnóstico e importância clínica. Comentários: Os Paragangliomas, frequentemente chamados de feocromocitomas extra-adrenais, são tumores raros, na sua maioria benignos, produtores de catecolaminas, com origem em células provenientes do Sistema Nervoso Autônomo e das células da crista neural.1 A sintomatologia clássica desses tumores, em função da capacidade secretora, inclui palpitações, cefaleias e diaforese, associados a Hipertensão Arterial (HTA).

Iatrogenic complications due to renal biopsy majorly include formation of an arterio-venous fistula, pseudoaneurysm or arterio-ureteral fistula. These complications are observed within a span of few days post biopsy and are rare after few years. We reported a case of 32-year-old renal allograft recipient male presenting 6 years post biopsy of the left kidney with left lumbar region pain who was eventually diagnosed with arterio-venous fistula and pseudoaneurysm involving inferior interlobular branch of left renal artery. Superselective embolization was achieved using coils and high concentration glue and transient placement of a venous occlusion balloon with complete technical and clinical success. Keywords: renal arterio-venous fistula; renal biopsy; renal pseudoaneurysm.

A 50-year-old woman, smoker, with a body mass index of 29 kg/m2, presented to the emergency department with a history of sudden-onset abdominal pain localised to the left hypochondrium and the left lumbar region. The pain was severe, sharp and constant, and was associated with nausea and vomiting. Physical examination revealed tenderness in the left upper quadrant and epigastrium and hypoactive bowel sounds. Blood tests revealed leucocytosis (17.5×109/L). An abdominal CT with intravenous contrast showed acute mesenteric ischaemia. An ECG and cardiac monitoring showed normal sinus rhythm, and a transthoracic two-dimensional echocardiogram showed no evidence of general cardiac pathology or valvular heart disease, excluding a cardiac source of emboli. A CT …

Malignant peripheral nerve sheath tumor (MPNST) is a soft-tissue sarcoma arising from or differentiating toward peripheral nerve sheath cells. It accounts for 5%–10% of soft-tissue sarcomas. The most common sites of origin are proximal portion of upper, lower limbs and trunk. MPNST arising from the nerve plexus of gastrointestinal tract is extremely rare, and only very few cases have been reported in literature. In this report, we are describing a case of MPNST from mesocolon. An 82-year-old male presented to hospital with complaint of pain abdomen and feeling of lump on the left side of lower abdomen for the past 2 months. On contrast-enhanced computed tomography (CECT) of chest and abdomen, there was 15 cm × 10 cm mass palpable in left lumbar region without ascites and multiple random subpleural nodules in bilateral lung. Intraoperatively, there was 15 cm × 10 cm hard irregular mass in left paracolic gutter infiltrating mesentry of descending colon. Left hemicolectomy was performed with end-to-end anastomosis. Histopathological examination revealed malignant peripheral nerve sheath tumor, and on immunohistochemistry, tumor cells were positive for S-100 and negative for C-kit and Smooth Muscle Actin (SMA). The patient was started on tamoxifen in view of old age and lung metastasis. The patient is on follow-up from 2 years with stable disease. In this report, we highlight the possibility of clinical differential diagnosis of MPNST arising from mesocolon should be kept while dealing with mesenchymal tumors of colon. Radical surgery with negative margins is required for achieving palliation, and adjuvant tamoxifen could offer advantage in patient who cannot tolerate chemotherapy.

Balloon cell malignant melanoma (BCMM) is a very rare malignant melanoma subtype. The clinical appearance of BCMM varies; it may be nodular, ulcerated, polypoid, papillomatous and often non-pigmented. The tumor cells histologically appear large, polygonal or round and contain abundant granular or vacuolated cytoplasm. We herein report the case of a 32-year-old female who presented with a focal eccentric pigmented mass in the left lumbar region of 15 mm in diameter that had been present for several years. She underwent tumor excision. The histopathological analysis showed epithelioid melanocytes with clear cytoplasm. An immunohistochemical analysis revealed that the cells were positive for HMB-45 and S-100 protein and negative for cytokeratin. The balloon cell component stained negative for Fontana-Masson. A month later, the patient underwent excision of the bilateral inguinal lymph nodes and metastatic BCMM was revealed. The lymph node metastases showed the complete replacement of lymph nodes by balloon cells. A diagnosis of BCMM (Breslow depth 10 mm, Clark level V) without ulcer was rendered. Staining with Ki-67 was positive in almost 44% of the balloon cells.

Primary adrenal lymphoma (PAL) is an infrequent malignant tumor, occurring in the bilateral adrenal glands as a mass in the majority of cases. The current study presents a case of bilateral primary adrenal diffuse large B cell lymphoma in a 52-year-old female patient, who presented with abdominal pain in the left lumbar region for ~2 weeks. Abdominal ultrasound examination and computed tomography scanning revealed a mass of 132×119×101 mm on the left adrenal gland and a mass of 53×27 mm on the right adrenal gland. A percutaneous biopsy was performed and histopathological examination further confirmed this lesion as diffuse large B cell lymphoma. The present study highlights the importance of early diagnosis of PAL, and performs a literature review of the subject.

Renocutaneous fistulae may occur as a result of chronic infection, especially in the setting of calculous disease.1 Spontaneous renocutaneous is rare.2 Usually nephrocutanous fistula developed in patient with previous renal surgery, trauma, tumors, and chronic urinary tract infection with abscess formation. We report a case of spontaneous nephrocutaneous fistula. A 37-year-old women previously well presented to ER department with purulent discharge and a palpable mass on the left lumbar area. CT scan with IV contrast fistulous tract seen within the subcutaneous plane in Left lumbar region tracking towards retroperitoneal space, and in continuity with of left kidney. The patient underwent ‘Left nephrectomy with excision of fistulous tract’ after long course of antibiotics.

We report a case of a 65-year-old man who developed an asymptomatic bluish spot that affected the flank and left lumbar region with the onset 10 years prior. He had a history of diffuse systemic sclerosis with anti-Scl-70-positive antibodies. The appearance of the skin lesion coincided with the onset of his disease. The skin biopsy was consistent with the diagnosis of acquired dermal melanocytosis. The relationship between the appearance of acquired pigmented macules and spots and systemic sclerosis has been known for years, although it is an infrequent finding.

Irtieru is a male mummy enclosed in cartonnage, dating to the Third Intermediate Period in the Egyptian collection of the Museu Nacional de Arqueologia in Lisbon. The computed tomography scans of this mummy showed a small dense bean-shaped structure at the left lumbar region. Its anatomical location, morphologic and structural analysis support a diagnosis of end-stage renal tuberculosis. If this diagnosis is correct, this will be the oldest example of kidney tuberculosis, and the first one recorded in an intentionally mummified ancient Egyptian.

Kidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

INTRODUCTION: Adrenal masses discovered by imaging techniques for reasons unrelated to adrenal diseases are documented as incidentalomas with pheochromocytoma accounting for about 20% of adrenal masses. Clinically silent, biochemically negative Pheochromocytomas are rare. Close intra and postoperative monitoring is the key to success while operating on a mass lesion in suprarenal area. CASE REPORT: A 38 years female patient presented with dull aching pain & lump in left hypochondrium and left lumbar region of four months duration. Patient was normotensive and did not have any comorbid conditions. Abdominal examination revealed a smooth surfaced, firm, ballotable lump of 14 X 10 cm in the left lumbar region. Adrenal function tests including urinary and plasma catecholamines and metanephrine were within normal limits. CT scan of abdomen revealed a left retroperitoneal mass arising from left adrenal gland of benign nature. Left adrenalctomy was performed. Per operatively patient had unexpected hypertensive episode which was managed. Histopathological examination was reported as Benign Pheochromocytoma. CONCLUSION: Clinically silent pheochromocytoma is a rare condition and with normal catecholamines and metanephrines is even rarer. Possibility of pheochromocytoma should be kept in mind while operating on a mass in the suprarenal region even in a normotensive patient with normal hormonal parameters so that operating team can deal with an unexpected hypertensive crisis. Adrenalectomy should be done for such patients because of concern of malignant transformation and or development of subsequent functional abnormality.

The most serious complication of renal biopsy is vascular damage with subsequent haemorrhage. To our knowledge, we present a first ever case of lumbar artery (LA) rupture accompanied by massive retroperitoneal bleeding, which developed after a significant amount of time following the biopsy itself. In a 63-year-old Caucasian female patient, a percutaneous left kidney biopsy was performed under continuous ultrasound guidance. On the fourteenth day after the procedure, she was examined for a sudden onset of left lumbar region pain. Computed tomography angiography showed a large retroperitoneal hematoma with active bleeding from the fourth left LA. Successful endovascular superselective embolization was performed immediately. The predisposing factor for the late haemorrhage could have been anticoagulation therapy, renal insufficiency and older age. Our case report highlights the need for caution, especially when performing kidney biopsy in a group of high-risk patients, particularly if they are indicated for subsequent anticoagulant therapy.

Klippel Trenaunay Weber syndrome (KTWS) is a rare disease characterized by hemihypertrophy, variceal enlargement of the veins, and arteriovenous (AV) malformations. Renal involvement in KTWS is not known except in rare case reports. Herein, we present a case of KTWS with unilateral polycystic kidney. A 52-year-old male was admitted due to pain left lumbar region for the last three months. The physical findings were increased diameter and increased length of the left leg compared with the right one, diffuse variceal enlargements on left leg, portwine stain on left side on neck, thorax, abdomen, left upper limb and left lower limb and a few hemangiomatous lesions on the left leg. Radiographic findings were cystic lesions in the left kidney, varicose veins in left leg, and hypertrophy of the soft tissues of the proximal left leg. Color Doppler of left lower limb showed incompetence of the saphenofemoral junction. He was diagnosed to have KTWS with these findings. Renal function tests of the patient were in the normal range. Patient’s only complain was left lumbar region pain, mild in intensity. Patient was managed symptomatically.

A rare case of nephrococutaneous fistula due to spontaneous expulsion of renal calculi is described. A 45-year-old man presented with urinary leakage from an ulcer over the left lumbar region for the last 3 months after a history of spontaneous expulsion of stones from this area. Ultrasonography abdomen revealed a small contracted kidney with multiple calculi in the kidney and renal pelvis, sinus tract from the lower pole of the left kidney with a ruptured calyceal calculus in the sinus tract. CT urography revealed a non excreting left kidney with multiple renal calculi, with hyperdense collection in the renal parenchyma extending to the subcutaneous tissue and left lung suggesting a xenthogranulomatous pyelonephritis (XGP). We performed a left-sided simple nephrectomy with excision of the fistulous tract. Histopathological examination revealed XGP. There have been a few case reports of XGP forming nephrocutaneous fistula in the back.

The retroperitoneal space (retroperitoneum) is a potential space in the posterior peritoneal cavity that lies between the parietal peritoneum internally and the fascia of posterior abdominal wall externally. The space extends from the diaphragm superiorly to the sacral promontory and to the arcuate line inferiorly, which communicates with the pelvic extraperitoneal space inferiorly, with mediastinal connective tissue superiorly through the lumbocostal triangles, as well as with extraperitoneal fat bilaterally. Therefore, a primary tumor located in the retroperitoneal space may spread or invade to the posterior mediastinum, lateral abdominal wall, or pelvic extraperitoneal space. The retroperitoneal space can be divided into left lumbar region (left flank), right lumbar region (right flank), prevertebral region, left iliac fossa (RIF), and right iliac fossa (LIF) areas.

Rationale: Primary renal pelvis squamous cell carcinoma (SCC) is an extremely rare neoplasm. In many patients, the SCC was associated with renal calculi. Patient concerns: A 61-year-old male presented with intermittent pain at the left lumbar region for 3 days. The PET/CT images demonstrated increased 18F-FDG uptake in the upper pole of the left kidney and left renal hilar lymph nodes. Diagnoses: Pathologic examination revealed well-moderately differentiated renal pelvis SCC with lymphatic metastasis. Interventions: The patient underwent a left nephrectomy a few days after the initial staging PET/CT study. Outcomes: No growing lesion or metastasis was observed during a 6-month follow-up. Lessons: Our case demonstrates that 18F-FDG PET/CT is a useful diagnostic tool to evaluate primary renal pelvic SCC and detect metastatic lymph nodes in patients with long-standing calculi.

Background: Lumbar hernias are rare. Usually manifest with reducible volume increase in the post-lateral region of the abdomen and may occur in two specific anatomic defects: the triangles of Grynfelt (upper) and Petit (lower). Despite controversies with better repair, laparoscopic approach, following the same principle of the treatment of inguinal hernias, seems to present significant advantages compared to conventional/open surgeries. However, some technical and anatomical details of the region, non usual to general surgeons, are fundamental for proper repair. Aim: To present systematization of laparoscopic transabdominal technique for repair of lumbar hernias with emphasis on anatomical details. Method : Patient is placed in the lateral decubitus. Laparoscopic access to abdominal cavity is performed by open technique on the left flank, 1.5 cm incision, followed by introduction of 11 mm trocar for a 30º scope. Two other 5 mm trocars, in the left anterior axillary line, are inserted into the abdominal cavity. The peritoneum of the left paracolic gutter is incised from the 10th rib to the iliac crest. Peritoneum and retroperitoneal is dissected. Reduction of all hernia contents is performed to demonstrate the hernia and its size. A 10x10 cm polypropylene mesh is introduced into the retroperitoneal space and fixed with absorbable staples covering the defect with at least 3-4 cm overlap. Subsequently, is carried out the closure of the peritoneum of paracolic gutter. Results: This technique was used in one patient with painful increased volume in the left lower back and bulging on the left lumbar region. CT scan was performed and revealed left superior lumbar hernia. Operative time was 45 min and there were no complications and hospitalization time of 24 h. Conclusion: As in inguinal hernia repair, laparoscopic approach is safe and effective for the repair of lumbar hernias, especially if the anatomical details are adequately respected. RESUMO Racional: As hérnias lombares são raras. Geralmente se manifestam com aumento de volume redutível na região póstero-lateral do abdome e podem ocorrer em dois defeitos anatômicos específicos: os triângulos de Grynfelt (superior) e Petit (inferior). Apesar de controvérsias com relação a melhor forma de reparo, a abordagem laparoscópica, seguindo o mesmo princípio do tratamento das hérnias inguinais, parece apresentar vantagens significativas em relação às operações convencionais/abertas. Entretanto, alguns detalhes técnicos e anatômicos desta região, não usual aos cirurgiões gerais, são fundamentais para o adequado reparo. Objetivo: Apresentar sistematização da técnica laparoscópica transabdominal para a correção das hérnias lombares com ênfase nos detalhes anatômicos. Método: Paciente é colocado em decúbito lateral. O acesso laparoscópico à cavidade abdominal é realizado pela técnica aberta no flanco esquerdo, incisão de 1,5 cm, seguida pela introdução de trocárteres de 11 mm para ótica de 30º. Dois outros trocárteres de 5 mm, na linha axilar anterior esquerda, são inseridos na cavidade abdominal. O peritônio da goteira paracólica esquerda é incisado desde a 10ª costela até a crista ilíaca. O peritônio e o retroperitoneal são dissecados. A redução de todo o conteúdo de hérnia é realizada para demonstrar a hérnia e seu tamanho. Tela de polipropileno de 10x10 cm é introduzida no espaço retroperitoneal e fixada com grampos absorvíveis cobrindo o defeito com pelo menos 3-4 cm de sobreposição. Posteriormente, realiza-se o fechamento do peritônio da goteira paracólica. Resultados: Esta técnica foi utilizada em um paciente com aumento doloroso de volume na região lombar esquerda e abaulamento na região lombar esquerda. Tomografia computadorizada foi realizada e revelou hérnia lombar superior esquerda. O tempo operatório foi de 45 min e não houve complicações; o tempo de hospitalização de 24 h. Conclusões: Assim como no reparo das hérnias inguinais, a abordagem laparoscópica é segura e efetiva para as hérnias lombares, especialmente se os detalhes anatômicos forem adequadamente respeitados.

A 42-year-old female presented with a complaint of abdominal pain for 3 months. Deep palpation revealed tenderness in the left lumbar region. Ultrasonography and contrast-enhanced computed tomography revealed a multiloculated cyst in the left kidney. The results of guided fine needle aspiration cytology were inconclusive. On exploration, the renal lump was found to be a smooth, well-circumscribed swelling protruding from the anterior surface of the left kidney, with no extrarenal infiltration. Left nephrectomy was performed. The cut surface of the resected specimen showed a well-circumscribed tumor containing large cystic spaces within the renal tissue. Histopathological examination revealed cystic nephroma, which is a rare neoplasm of the kidney. The postoperative course was uneventful. The patient was discharged on the 5th postoperative day. Now, at 1-year follow-up, the patient is well without any signs of recurrence on imaging.

A 76-year-old-man with a medical history of hypertension presented in the emergency department with a 3-month history of lumbar pain, associated with the appearance of a mass in the left lumbar region. He also described a 2-week history of progressive dyspnoea and productive cough. He had no history

A 36 year old gentleman presented with recurrent urinary tract infections, hematuria and lump in the left side of abdomen for 4 months. Clinically a soft, non-tender lump in left lumbar region with well-defined margins was palpable. CT scan of abdomen revealed a calculus of size 45 mm at the left vesico-ureteric junction with gross left hydronephrosis. Patient underwent open ureterolithotomy in view of the large size of calculus and due to stone impaction. Post-operative period was uneventful. Patient was followed up for 6 months and remained asymptomatic.

A 54-year-old diabetic woman presented to emergency department with high-grade fever, chills and left lumbar pain for 10 days duration. She had tenderness in left lumbar region and hypotension (blood pressure 90/60 mm Hg). Investigations showed anaemia (haemoglobin 8.1 g/dL), leucocytosis (24.3 x 109/L), numerous pus cells in urine microscopy and normal renal functions (creatinine 1.3 mg/dL). Plain radiograph of abdomen showed reniform air shadow in the left lumbar region (arrow …

Unilateral renal cystic disease (URCD) of kidney is a non-familial, extremely rare condition, characterized by replacement of the renal parenchyma of one kidney by a cluster of multiple cysts of varying size with a normal contralateral kidney. It is morphologically indistinguishable from autosomal dominant polycystic kidney disease (ADPKD); as such, hepatic and pancreatic cysts is not seen and shows no progressive deterioration in renal function; thus, differentiating ADPKD from URCD becomes important. We report a case of URCD documented by clinical and radiological imaging. A 21 year-old female, presented with history of mild lancinating pain in the left flank for 6 years which aggravated in the past 3 days, with no history of lower urinary tract symptoms. No significant family illnesses reported. Examination showed normal vitals and ballotability present and associated tenderness on deep palpation in left lumbar region. Laboratory findings were within normal limits. Ultrasonography of abdomen and pelvis showed left hydronephrosis with multiple cysts. CECT Abdomen revealed an enlarged left kidney (∼15×16×10 cm) filled with variable sized round, well-marginated multiple cysts. Renal ultrasound was performed on patient’s parents and her siblings and ruled out cystic renal disease. Hence, authors considered the diagnosis of URCD in this patient. In conclusion, treatment and managing guidelines of URCD have not been mentioned in any of the medical literatures. There is little information regarding the progression of URCD. Hence there is a need for further understanding of pathogenesis, progression and management of these patients.

Introduction: A mesenteric cyst is a cystic lesion that arises in the mesentery of the gastrointestinal tract from the duodenum to the rectum but most commonly developed in the small bowel mesentery. They develop in both adults and children but usually diagnosed during the fifth decade of life. Case Report: A 31-year-old male presented to Emergency Department with left iliac fossa pain without any other associated symptoms. His medical, surgical and family history was not significant. No history of previous abdominal operation. Abdominal ultrasonography showed mass in right iliac. Computed tomography revealed a large rounded mesenteric cyst seen in the left lumbar region measuring 10x10x9 cm with thin enhancing wall. The mass was excised by laparoscopy with healthy margins and the specimen was sent for pathological examination. The histopathological findings were suggested of pseudocyst. Conclusion: A mesenteric cyst in adult is extremely rare benign intra-abdominal pathology. Surgical excision is optimal treatment of mesenteric cyst with either laparotomy or laparoscopy.

Emphysematous pyelonephritis is a severe infection characterized by the presence of gas within the renal parenchyma tissues. It is a life threatening complication of bacterial interstitial nephritis, and it mainly occurs in patients with diabetes mellitus. We report a case of a 37 year old female who complained of fever and pain in left lumbar region on admission. Her past medical history included uncontrolled type 2 diabetes mellitus. On USG (ultrasonography), left kidney swollen and show echogenic linear specs with dirty shadowing suggestive of air in pelvicalyceal system (PCS). She was treated with intensive antibiotic therapy in high doses. On repeat USG there was marked reduction in air shadow in kidney and patient improved clinically.Bangladesh Journal of Medical Science Vol.14(3) 2015 p.305-307

Emphysematous pyelonephritis is fatal necrotizing infection where life saving emergency nephrectomy is recommended for severe cases, but we performed nephron sparing surgery. Elderly diabetic female presented with left flank pain and fever for 15 days. On examination tender lump was palpable in left lumbar region. Investigations showed hyperglycemia, leucocytosis and creatinine 3.0 mg/dl. NCCT-KUB suggested class 3B-EPN. Following emergency pigtail, a repeat CT-scan suggested upper and lower pole destruction. In open drainage both poles debrided with sparing of middle pole. Follow-up CECT-KUB showed spared kidney with normal function. No literature for nephron sparing surgery in similar cases of EPN was found.

Common location of teratomas in children are sacrococcygeal, gonadal, mediastinal and retroperitoneal, but teratomas may also occur at very unusual locations. A six-month-old boy presented with a large swelling at his left lumbar region. He presented with gradually increasing lump at his back, involving more on left lumbar region and midline since birth. Clinical examination revealed a solitary, non-tender, soft to firm, irregular mass, occupying more on his left lumbar and midline region and also crossing the midline. Radiological investigations revealed a well defined mass of 9.6 x 7.5cm, with bony elements and spina bifida at L1 and L2 levels. His Computed Tomography (CT) scan finding was consistent with mature teratoma. Complete surgical excision of the tumour was done without any difficulties. Histology of the excised tumour was conclusive of mature teratoma. His post-operative period was excellent, but he lost to follow-up after discharge.

We describe a patient with nephrotic syn-dromewhopresentedwithhypertensionandpainin the left lumbar region. Ultrasonography andmagnetic resonance imaging (MRI) showed amassive subcapsular collection around the leftkidney.Thepatientwastreatedsuccessfullywithultrasonography-guided drainage of the collec-tion and medical treatment. The kidney biopsyspecimen showed changes of focal segmentalglomerulosclerosis.

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous slow growing soft tissue sarcoma associated with a high local recurrence rate. Common site of presentation is trunk followed by proximal extremity and head and neck region. A case of recurrent DFSP of left lumbar region with metastasis in lung in a 50-year-old woman presented here. Absence of symptoms often leads to a delay in diagnosis. DFSP is often mistaken for other skin conditions, particularly in its early stages.

A 30-year-old female presented with a 3-month history of erosive stomatitis and bullous lesions, along with recurrent episodes of abdominal pain. She was found to have a retroperitoneal lump in left lumbar region. Skin biopsy revealed bullous disorder. CT guided biopsy of the retroperitoneal mass was suggestive of inflammatory myofibroblastic tumor (IMT). She was started on oral steroids and supportive care, and surgery was being planned when she developed respiratory failure. CT chest revealed vertebral metastases. PET/CT for whole body work up revealed a left para-aortic mass along with multiple skeletal metastases. The patient was kept on conservative management. After 3 months, the patient has shown clinical improvement, and an exploratory laparotomy is now being planned for the excision of the tumor, followed by chemotherapy. This case of retroperitoneal IMT is rare in terms of skeletal metastases with paraneoplastic pemphigus.

Highlights • We present a case of giant lipoma in the left lumbar region. • Movements were hindered, especially rotation, flexion and extension of the trunk. • The size of the bulk presents differential diagnostic problems with liposarcoma. • Surgical excision was performed to confirm diagnosis with histological evaluation., Introduction Lipomas are the most common benign tumors of the adipose tissue and can be located in any region of the body. In most cases lipomas are small and asymptomatic, but they can at times reach considerable dimensions and, depending on their anatomic site, hinder movements, get inflamed, cause lymphedema, pain and/or a compression syndrome. Presentation of case We here report the case of an otherwise healthy patient who came to our observation with a giant bulk in the left lumbar region which had been showing progressive growth in the previous 5–6 years. Physical examination, ultrasound and MRI were carried out in order to characterize the size, vascularization and limits of the lesion. Due to the pain and restriction of movement that this bulky lesion caused, surgical excision of the lesion was performed. Discussion Giant lipomas display an important differential diagnosis problem with malignant neoplasms, especially liposarcomas, with which they share many features; often the final diagnosis rests on histological evaluation. We here discuss the diagnostic problems that arise with a giant lipoma and all the possible approaches concerning treatment of such a big lesion, explaining the reasons of our approach and management of a common tumor in our case presenting unusual dimensions and location. Conclusion Our approach revealed to be successful in order to nurse our patient's pain, restore the mobility and address the aesthetic issues that this lesion caused. Postoperative checkups were carried out for one year and no signs of relapse have been reported.

A 20 day-old full-term vaginally delivered baby boy, weighing 3.25 kg, presented to the surgical department with deformity of spine and lower limbs, swelling in left groin and left lumbar region since birth. Antenatal ultrasound was not available. On examination, the child was active, crying well, lips were cyanosed and there was no pedal oedema. Cardiovascular examination revealed the presence of systolic murmur. Abdominal examination showed the presence …

We report a rare case of adenocarcinoma in retroperitoneal teratoma in a 38 year old female patient who attended surgical OPD with complaints of dragging pain and heaviness in left lumbar region. Straight x-ray abdomen showed few irregular calcifications in left lumbar region. USG and CT showed it to be adrenal tumor and retroperitoneal teratoma respectively. Excised specimen confirmed it as mucin secreting adenocarcinoma in a case of retroperitoneal teratoma.