A 68-year-old patient with no relevant medical history was admitted to our service for treatment of left pyelic lithiasis.
The patient reported nocturia 3-4, pollakiuria, voiding and isolated episodes of hematuria.
Physical examination, blood tests and biochemistry are normal.
In a simple x-ray of the urinary tract, a radiopaque image is visualized at the level of the left kidney.
Abdominal ultrasound showed an anechoic image affecting the entire right kidney, consistent with hydronephrosis and significant cortical damage.
In the left kidney left hydronephrosis is visualized, with echogenic images in the pelvis, medial and inferior kidneys compatible with calculi.
These findings are obtained by intravenous urography, which distinguishes a non-functioning right kidney from a pyeloureteric junction with a staghorn stone in the left lower pyelone.
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On CT scan of the kidney-pelvic junction, the right kidney appears as a large cystic cavity, with no evidence of functioning cortical bone.
The left kidney presents hypertrophy with multiple cystic cortical lesions in the upper pole and calculi in the lower pole.
It was decided to perform bilateral percutaneous puncture, observing large dilation of the right kidney, without passage of contrast to the ureter and bifidity pyeloureterus of the left kidney, with coral lithiasis inferior pyelone.
A nephrostomy tube was left on the left side and antibiotic treatment was started, with purulent urine being extracted from the lower pyelone.
Renal scintigraphy confirmed the poor right kidney function (11%).
Cystoscopy did not reveal new bladder malformations.
After normal preoperative studies, the patient underwent surgery with left percutaneous nephrolithotomy, fragmenting stones with lithoclast and fragment removal.
Fifteen days later a new nephrolithotomy was performed in order to eliminate all lithiasic remains.
The patient continues to eliminate purulent urine by percutaneous nephrostomy tube.
Digital subtraction angiography (DIVAS) shows little vascularization of the lower pole of the left kidney.
The patient underwent a left inferior polar heminephrectomy.
In the immediate postoperative period there is a worsening of renal function, with fever and leukocytosis, a process compatible with sepsis of urinary origin that improves with serum therapy and parenteral antibiotics.
The removed specimen corresponds to a 452 gram left kidney accompanied by abundant adhesive kidney to the renal parenchyma.
When cutting, parenchyma is replaced by large cystic cavities occupied by a white softened material.
Histologically, there is a tumor composed of large solid masses, neither solid nor abundant remnants of habitual cells, which present large vecamous and irregular nuclei, with clearly defined individual cytoplasm, with prominent corneal formation.,
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In the follow-up urography after surgery a normal function of the left upper hemi-rain without obstructive uropathy was observed.
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One year and six months later the patient was admitted from the emergency department with macroscopic hematuria.
Urography showed a repletion defect in the right lateral face, which was corroborated by cystoscopy.
Transurethral resection of a solid tumor was performed on the right lateral side of the bladder, with pathological diagnosis of bladder carcinoma with areas of squamous differentiation of the urinary bladder radical cystectomy (Main derivation).
In the same surgical procedure a right nephroureterectomy is performed, where a hydronephrotic kidney is observed, with a pyeloouret junction syndrome due to a polar vessel.
Histological examination revealed squamous cell carcinoma, pT3a stage, pNx, pMx.
The patient died four months later, with pulmonary and hepatic metastases.
