Case Reports in Urology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. It Suddenly Occurred: Extensive Subcutaneous Emphysema after Bipolar Transurethral Resection of Prostate Mon, 28 Sep 2015 06:44:50 +0000 Subcutaneous emphysema is a very rare and good-natured complication after transurethral resection of prostate (TURP). It has been reported as colon perforation, diverticulitis, and bladder perforation associated complication previously. We report the first case of a wide subcutaneous emphysema due to microperforations of prostatic capsule, without a bladder perforation after TURP. Any sign of clinic situation should lead to ceasing of the procedure immediately; otherwise, it can cause a life-threatening problem of abdominal compartment syndrome. Murat Bagcioglu, Mert Ali Karadag, Ramazan Kocaaslan, Cafer Mutlu Sarikas, Mustafa Gok, and Omer Erkam Arslan Copyright © 2015 Murat Bagcioglu et al. All rights reserved. Urinary Incontinence due to Overactive Detrusor Muscle: A Rare Side Effect of Venlafaxine Sun, 27 Sep 2015 06:47:55 +0000 We report a case of reemergence of urinary incontinence (UI) in a patient with benign prostatic hyperplasia (BPH) after starting treatment with venlafaxine who was stabilized on tamsulosin and finasteride for about 6 years. A 66-year-old Caucasian male with prior history of major depressive disorder developed UI within a week of starting venlafaxine 75 mg per day. He described symptoms in the form of involuntary leakage of urine both during the day and at night. His symptoms of UI resolved after stopping the venlafaxine. To the best of our knowledge, there are only four case reports of venlafaxine induced urinary incontinence which have been published. Vithyalakshmi Selvaraj, Palanikumar Gunasekar, Suneel Kumar, and Imad Alsakaf Copyright © 2015 Vithyalakshmi Selvaraj et al. All rights reserved. Testicular Interposition Flap for Repair of Perineal Urinary Fistulae: A Novel Surgical Technique Mon, 21 Sep 2015 11:54:45 +0000 Rectourinary fistulae and urinary-cutaneous fistulae are a rare yet devastating complication. Current options for tissue interposition include rectus, gracilis, or gluteal muscle, omentum, or intestine for use in coloanal pull-through procedures. In elderly patients, testicular interposition flaps may be an excellent tissue option to use when vitalized tissue is necessary to supplement fistula repair. Elderly patients frequently have increased spermatic cord length, potentially offering a longer flap reach than use of a muscle flap. Additionally, mobilizing one of the testicles and developing it through the external inguinal ring may be a less morbid and less costly procedure than harvesting and tunneling a muscle flap. Longer follow-up and further studies are needed to determine the outcomes of this novel technique. Valary T. Raup, Jairam R. Eswara, Stephen D. Marshall, and Steven B. Brandes Copyright © 2015 Valary T. Raup et al. All rights reserved. Surgical Intervention for Penile Methamphetamine Injections Tue, 15 Sep 2015 12:10:24 +0000 Methamphetamine is a central nervous system stimulant and is the second most commonly used illicit drug after cannabis. Methamphetamine use for sexual pleasure is well documented. In this case report, we describe two cases presenting to our urban county hospital associated with complications related to penile injection of methamphetamine. Both patients developed penile abscesses and required urgent surgical incision and drainage. Penile abscesses represent a rare complication associated with IV drug administration into the penile corpora. Resultant penile abscesses require broad-spectrum antibiotics and surgical drainage. Further understanding of methamphetamine abuse along with the role it plays in sexual enhancement would be an invaluable addition to understanding of the rationale behind this self-administered stimulant. Drainage of penile abscesses associated with IV drug users may be hazardous to healthcare providers who are at risk from a needle stick injury. Thomas W. Gaither, E. Charles Osterberg, Mohannad A. Awad, and Benjamin N. Breyer Copyright © 2015 Thomas W. Gaither et al. All rights reserved. Pannus Is the New Prepuce? Penile Cancer in a Buried Phallus Sun, 13 Sep 2015 12:22:16 +0000 Two males presented to our urology department with complaints of bleeding and malodor from buried phallus within a suprapubic fat pad. Although both men had neonatal circumcisions, advanced penile carcinoma was found in both men. Formal penectomies showed high grade, poorly differentiated squamous cell carcinoma invading the corporal bodies and urethra. Buried penis represents a difficulty in early detection of suspicious lesions but may also provide an environment susceptible to poor hygiene and subsequent chronic inflammation. Patients with buried penis may be at a higher risk for development of invasive penile cancer and may benefit from regular and thorough genital exams. Jared Manwaring, Srinivas Vourganti, Dmitriy Nikolavsky, Alfredo L. Valente, and Timothy Byler Copyright © 2015 Jared Manwaring et al. All rights reserved. Stereotactic Body Radiotherapy for Localized Ureter Transitional Cell Carcinoma: Three Case Reports Wed, 09 Sep 2015 09:46:38 +0000 The gold standard management for ureter transitional cell carcinoma (UTCC) is radical nephroureterectomy with excision of the bladder cuff. However, some patients cannot undergo this procedure for several reasons. In the case reports described herein, we performed stereotactic body radiotherapy (SBRT) on three patients with inoperable or surgery-rejected localized UTCC. Two out of the three patients did not develop local recurrence or distant metastasis during the observation period. However, recurrence was detected in the bladder of one patient 22 months after the treatment. No acute or late adverse events occurred in any of the three patients. SBRT may become one of the treatment options for inoperable or surgery-rejected UTCC patients. Yoshiyasu Maehata, Kengo Kuriyama, Shinichi Aoki, Masayuki Araya, Kan Marino, and Hiroshi Onishi Copyright © 2015 Yoshiyasu Maehata et al. All rights reserved. Xanthogranulomatous Pyelonephritis of a Lower Pole Moiety in a Duplicated Collecting System Kidney Tue, 08 Sep 2015 09:04:18 +0000 Xanthogranulomatous pyelonephritis (XGP) is a destructive inflammatory process which is frequently caused by recurrent urinary tract infections or chronic obstruction by kidney stones. We present a 56-year-old female with an extensive retroperitoneal urinoma and xanthogranulomatous pyelonephritis of the lower pole moiety in a kidney with a duplicated collecting system due to obstructive nephrolithiasis. After drainage of the urinoma, the patient underwent a definitive lower pole heminephrectomy with preservation of the functional upper pole. We review important clinical features of xanthogranulomatous pyelonephritis and considerations for surgery on a duplicated kidney. Jean Paul Wuilleumier, Ariel Schulman, Antonio Montgomery, and Ervin Teper Copyright © 2015 Jean Paul Wuilleumier et al. All rights reserved. Palpable Penile Metastases: A Bizarre Presentation of Rectal Adenocarcinoma Tue, 08 Sep 2015 08:51:39 +0000 Metastasis to the penis is an uncommon occurrence, with only about 370 cases reported in the literature to date. The majority of the primary tumors are genitourinary in origin. We report on a patient with undiagnosed disseminated rectal adenocarcinoma, who first presented with lesions of the corporal bodies. A review of the literature indicates that corporeal metastasis as an initial presentation of malignancy is an extremely rare occurrence and carries a very poor prognosis. Liza Cholin, Sarah Perz, Furman Mahmood, and Saleem Zafar Copyright © 2015 Liza Cholin et al. All rights reserved. Mucinous Bladder Adenocarcinoma: Case Report and Literature Review Tue, 01 Sep 2015 09:13:02 +0000 Primary mucinous adenocarcinoma is an extremely rare type of bladder cancer, with aggressive behavior and poor response to chemotherapy and radiotherapy. The symptoms are similar to those of other bladder tumors. Surgery is the main treatment and remains the only curative option. There may be a progression from mucinous metaplasia to mucinous adenoma and then mucinous adenocarcinoma. We present the case of a 40-year-old woman with recurrent lower urinary tract infections, submitted to imaging tests, which showed a bladder tumor. After transurethral resection, pathology showed intestinal mucinous carcinoma. Metastatic work-up was negative. New surgical procedure showed metaplasia but no recurrence of the carcinoma. The patient is now using antibiotic prophylaxis and will undergo a cystoscopy every 3 months and computed tomography in one year. Bruno Mello R. Santos, Julia Duarte de Souza, Rachel Silviano Brandão Correa Lima, and Enaldo Melo de Lima Copyright © 2015 Bruno Mello R. Santos et al. All rights reserved. Extraperitoneally Ruptured, Everted, and Prolapsed Bladder: A Very Rare Complication of Pelvic Injury Mon, 31 Aug 2015 11:59:07 +0000 Traumatic rupture of the bladder with eversion and protrusion via the perineum is a rare complication of pelvic injury. We present a 36-year-old lady who sustained severe pelvic injury with a bleeding right-sided deep perineal laceration. She had closed reduction of pelvic fracture with pelvic banding and primary closure of perineal laceration at a private hospital. She subsequently had dehiscence of repaired perineal laceration with protrusion of fleshy mass from vulva and leakage of urine per perineum five weeks later. Examination revealed a fleshy mucosa-like mass protruding anteriorly with a bridge of tissue between it and right anterolateral vaginal wall. Upward pressure on this mass revealed the bladder neck and ureteric orifices. She had perineal and pelvic exploration with findings of prolapsed, completely everted bladder wall through a transverse anterior bladder wall rent via the perineum, and an unstable B1 pelvic disruption. She had repair of the ruptured, everted, and prolapsed bladder, double-plate and screw fixation of disrupted pelvis and repair of the pelvic/perineal defect. She commenced physiotherapy and ambulation a week after surgery. Patient now walks normally and is continent of urine. We conclude that the intrinsic urethral continent mechanism plays a significant role in maintaining continence in females. Rufus Wale Ojewola, Kehinde Habeeb Tijani, Olakunle Olaleke Badmus, Abisola Ekundayo Oliyide, and Chukwudi Emmanuel Osegbe Copyright © 2015 Rufus Wale Ojewola et al. All rights reserved. A Case of Giant Cowper’s Gland Syringocele in an Adult Male Patient Sun, 30 Aug 2015 11:00:29 +0000 Cowper’s gland syringocele is an uncommon, underdiagnosed cystic dilatation of Cowper’s gland ducts showing various radiological patterns. Herein we report a rare case of giant Cowper’s gland syringocele in an adult male patient, with description of MRI findings and management outcome. Santosh Surana, Mohamed Elshazly, Adel Allam, Sateesh Jayappa, and Deena AlRefai Copyright © 2015 Santosh Surana et al. All rights reserved. Abnormal Cystic Tumor in a Patient with Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome: Evidence of a Precursor Lesion? Tue, 25 Aug 2015 11:54:38 +0000 The hereditary leiomyomatosis and renal cell cancer (HLRCC) association is a rare syndrome caused by mutation of the Kreb’s cycle enzyme, fumarate hydratase (FH). It is characterized by unusually aggressive type 2 papillary renal cell histology. FH is responsible for catalyzing the conversion of fumarate to malate. Its absence leads to a state of “pseudohypoxia,” inducing hypoxia inducible factor 1α (HIF-1α) and leading to increased growth factor transcription (e.g., vascular endothelial growth factor, VEGF; glucose transporter 1, GLUT1). Ultimately, this results in tumorigenesis. We present a patient who was diagnosed with HLRCC and underwent bilateral nephrectomies. One of the nephrectomy specimens was notable for benign cystic lesions that stained positive immunohistochemically for succinated proteins, a finding only noted in FH-deficient cells. Thus, we posit a potential precursor lesion to type 2 papillary renal cell carcinoma in the HLRCC syndrome. Benjamin T. Ristau, Sonal N. Kamat, and Tatum V. Tarin Copyright © 2015 Benjamin T. Ristau et al. All rights reserved. Comment on “Necrotizing Urethritis due to Aerococcus urinae” Tue, 18 Aug 2015 13:05:20 +0000 Magnus Rasmussen Copyright © 2015 Magnus Rasmussen. All rights reserved. Sneezing during Micturition: A Possible Trigger of Acute Bacterial Prostatitis Tue, 18 Aug 2015 11:07:25 +0000 A perfectly well 39-year-old man sneezed during micturition and developed classic features of acute bacterial prostatitis corroborated by laboratory evidence of prostatic inflammation/infection. The prostate-specific antigen level at presentation was 9.6 ng/mL and declined to 1.23 ng/mL one month later on levofloxacin. This is the first report in the medical literature of sneezing while voiding being a possible trigger of acute bacterial prostatitis. A biologically plausible mechanism is provided. William Derval Aiken Copyright © 2015 William Derval Aiken. All rights reserved. Mixed Germ Cell Tumor of Testis with Isolated Scapular Metastasis: A Case Report and Review of the Literature Sun, 16 Aug 2015 13:16:54 +0000 Bone metastasis is a rare entity in germ cell tumor of testis and is a poor prognostic site. It is usually associated with synchronous metastasis at other sites. Till now very few cases of isolated bone metastasis of germ cell tumor of testis have been reported but none have reported scapular metastasis. We are reporting a case of nonseminomatous germ cell tumor of right testis that was operated eight months ago and now presented with isolated scapular metastasis. Histopathology of the scapular tissue revealed rhabdomyosarcoma or poorly differentiated synovial sarcoma. Immunohistochemistry with serum markers concluded it to be metastatic germ cell tumor. To the best of our knowledge this is the first reported case of scapular metastasis of testicular germ cell tumor. This case is being reported here due to dilemmatic way of presentation and also to emphasize that histopathology may sometimes misguide and immunohistochemistry is necessary in such cases. Dipti Rani Samanta, Chaitali Bose, Roopesh Krishnappa, Saumyaranjan Mishra, Sulagna Mohanty, Ashish Upadhyay, and Surendra Nath Senapati Copyright © 2015 Dipti Rani Samanta et al. All rights reserved. Acute Respiratory Distress Syndrome after Treatment of Metastatic Prostate Cancer with Taxotere: A Case Report and Literature Review Thu, 13 Aug 2015 09:45:24 +0000 Prostate cancer is the most common cancer in men. Docetaxel is a common chemotherapeutic agent that has proven its efficacy in the treatment of patients with both castration sensitive and resistant metastatic prostate cancer. We report a case of acute respiratory distress syndrome (ARDS) in a patient with metastatic prostate cancer treated with docetaxel (Taxotere). ARDS is very rare but life threatening complication of docetaxel which requires aggressive supportive care and close monitoring. Better awareness and prompt diagnosis of this treatment related ARDS will improve the effectiveness and outcome of its management. Ali Raufi, Jennifer Dotson, and Mohamad Khasawneh Copyright © 2015 Ali Raufi et al. All rights reserved. Osseous Metaplasia in Mucinous Tubular and Spindle Cell Carcinoma of the Kidney: A Case of Massive, Bilateral Tumors Wed, 12 Aug 2015 09:38:31 +0000 Renal cell carcinoma (RCC) is the most common kidney malignancy, with many histologic subtypes. One of the rare forms of RCC is mucinous tubular and spindle cell carcinoma (MTSCC), which is newly described with limited information on clinical picture and outcome. Heterotopic bone formation (osseous metaplasia) is a rare finding within any renal mass. Here we report a case of a massive, bilateral MTSCC with histologic findings of heterotopic bone formation, which has not been described before. Aeen M. Asghar, Matthew A. Uhlman, Laila Dahmoush, and Sundeep Deorah Copyright © 2015 Aeen M. Asghar et al. All rights reserved. Thoracic Kidney: Extremely Rare State of Aberrant Kidney Sun, 02 Aug 2015 08:14:31 +0000 The thorax is the rarest place among all forms of renal ectopia. We report a rare case of an unacquired thoracic kidney. Only about 200 cases of the thoracic kidney have ever been reported in medical literature worldwide. In this paper we present the rarest form of nontraumatic nonhernia associated, truly ectopic thoracic kidney. The differential diagnosis and management options and classification of this rare form of aberrant kidney are discussed. Mahdi Khoshchehreh, Omalbanin Paknejad, Mehrdad Bakhshayesh-Karam, and Marzieh Pazoki Copyright © 2015 Mahdi Khoshchehreh et al. All rights reserved. Radical Cystectomy with Ileal Conduit Urinary Diversion in a Patient with a Left Ventricular Assist Device Tue, 28 Jul 2015 09:05:32 +0000 Left ventricular assist device (LVAD) is an option for the surgical management of severe heart failure, and radical cystectomy remains the standard of care for muscle-invasive bladder cancer. Given a complicated population in terms of comorbidities and management for patients with an LVAD, there is little experience with major urologic procedures, which require balancing the benefits of surgery with considerable perioperative risks. We report our experience performing the first radical cystectomy with ileal conduit in a patient with an LVAD and muscle-invasive bladder cancer. Joseph J. Pariser, Adam B. Weiner, and Gary D. Steinberg Copyright © 2015 Joseph J. Pariser et al. All rights reserved. Papillary Renal Cell Carcinoma Seeding along a Percutaneous Biopsy Tract Tue, 28 Jul 2015 08:52:24 +0000 We report a case of tumour seeding caused by percutaneous biopsy of a papillary renal cell carcinoma detected on pathological assessment of the partial nephrectomy specimen in a 50-year-old male. Whilst percutaneous biopsy of renal masses is considered to be safe and can be a valuable tool in the assessment of certain renal lesions, it is not without risks. This rare complication should be taken into consideration before contemplating its use in a patient. Deanne Soares, Nariman Ahmadi, Oana Crainic, and John Boulas Copyright © 2015 Deanne Soares et al. All rights reserved. Prelaminated Gracilis Flap with Buccal Mucosal Graft for Salvage of Devastated Urethra Thu, 16 Jul 2015 10:17:07 +0000 In patients with devastated bulbous urethra, that is, bulbar necrosis, failed fasciocutaneous repairs and “watering can perineum” repair options are limited by paucity of reliable local tissue suitable for reconstruction. In this case report we demonstrate a novel variation of a two-stage technique for reconstruction of a devastated bulbous urethra in a 57-year-old male who suffered penetrating trauma to his previously reconstructed urethra. Because of extensive loss of local tissue from the prior reconstruction and subsequent trauma and infection a 2-stage technique with use of gracilis was employed. This technique involved creation of two independently vascularized urethral hemi-plates prelaminated with buccal mucosa graft (BMG). In the first stage the dorsal plate was created by quilting buccal graft onto corpora cavernosa to create a temporary augmented perineal urethrostomy. In the same stage the future ventral neourethral plate was created by grafting another BMG onto the exposed distal gracilis muscle. Eight weeks later the two prelaminated plates were anastomosed by tunneling the gracilis-BMG composite into the perineum. At 8-month follow-up patient has normal voiding and continence. To our knowledge this is the first report of reconstructing an entire segment of devastated urethra in such a manner. Dmitriy Nikolavsky Copyright © 2015 Dmitriy Nikolavsky. All rights reserved. Sarcomatoid Renal Cell Carcinoma Metastasis to the Penis Tue, 14 Jul 2015 11:51:12 +0000 Secondary cancers of the penis are extremely uncommon with less than 300 cases reported in the past 100 years. These cancers are most frequently a result of an aggressive or poorly managed primary prostate or bladder cancer and rarely a metastasis from a primary kidney tumor. Currently, there is no published literature which describes the spread of sarcomatoid renal cell carcinoma (SRCC) to the penis. In this report, we present a 55-year-old-man who presented with a large right-sided SRCC which metastasized to the base of his penis within 1 month of symptom onset. We also discuss the possible route of metastasis based on primary tumor size and location within the retroperitoneum. Victor D. Liou, Oussama M. Darwish, Mary M. Henry, Ik C. Jun, and Sameer A. Siddiqui Copyright © 2015 Victor D. Liou et al. All rights reserved. A Major Complication in Micropercutaneous Nephrolithotomy: Upper Calyceal Perforation with Extrarenal Migration of Stone Fragments due to Increased Intrarenal Pelvic Pressure Tue, 14 Jul 2015 07:37:08 +0000 Micropercutaneous nephrolithotomy is a safe and efficient technique for appropriate sized stones. It is performed through a 4.85 Fr all-seeing needle and stones are fragmented into dust, without the need for tract dilatation, unlike other percutaneous nephrolithotomy types. Even though micropercutaneous nephrolithotomy has many advantages, increase in intrapelvic pressure during surgery may cause rare but serious complications. Herein we report a case of micropercutaneous nephrolithotomy in a 20-year-old woman with a 20 mm right renal pelvis stone and present an undesired outcome of this complication, upper calyceal perforation. Right lower calyceal access was performed with 4.85 Fr all-seeing needle and 2 cm renal pelvis stone was fragmented by 272 μm Holmium-Yag laser system. Upper calyceal perforation and infrahepatic accumulation of stone fragments were detected by fluoroscopy during the surgery. Postoperative imagings revealed perirenal urinoma, perirenal and infrahepatic stone fragments, and lower calyceal stone fragments inside the system. On second postoperative day, minipercutaneous nephrolithotomy and double J catheter insertion procedures were applied for effective drainage and stone clearance. Risk of calyceal perforation and urinoma formation, due to increased intrapelvic pressure during micropercutaneous nephrolithotomy, should be kept in mind. Fatih Akbulut, Burak Ucpinar, Metin Savun, Onur Kucuktopcu, Faruk Ozgor, Abdulmuttalip Simsek, and Gokhan Gurbuz Copyright © 2015 Fatih Akbulut et al. All rights reserved. Intravesical Migration of Missed Intrauterine Device Associated with Stone Formation: A Case Report and Review of the Literature Mon, 13 Jul 2015 06:36:48 +0000 Intrauterine device is the most widely used method of reversible contraception. It may cause various complications including perforation of uterus. In this case, 44-year-old woman was presented with lower urinary tract symptoms after six years of insertion. Patient has no remarkable physical or laboratory finding but abdominal ultrasound revealed a 27 mm hyperechogenicity, suggestive of foreign body or calculus on the posterior bladder wall which was removed endoscopically. This case highlights the need of immediate and periodic evaluation of women with intrauterine device to avoid missing serious complications. Mücahit Kart, Turgay Gülecen, Murat Üstüner, Seyfettin Çiftçi, Ufuk Yavuz, and Cüneyd Özkürkçügil Copyright © 2015 Mücahit Kart et al. All rights reserved. Adult Patient with Synchronous Gastrointestinal Stromal Tumor and Xp11 Translocation-Associated Renal Cell Carcinoma: A Unique Case Presentation with Discussion and Review of Literature Mon, 13 Jul 2015 05:56:54 +0000 Gastrointestinal stromal tumor (GIST) is the most common primary mesenchymal tumor of the gastrointestinal tract. This entity comprises a wide spectrum of tumors that vary from benign to overtly malignant, with the majority of these tumors harboring oncogenic mutations of the KIT receptor tyrosine kinase that can aid in diagnosis as well as in targeted therapy. Although the majority of GISTs are sporadic, there are forms that are associated with a variety of syndromes including Carney-Stratakis syndrome and neurofibromatosis type 1, as well as a subset of familial GIST syndromes that are caused by germline mutations in KIT or PDGFRA. Here, we describe an unusual case of a patient who was found to have a large abdominal GIST with an incidentally found Xp11 translocation-associated renal carcinoma. The karyotype of the renal carcinoma revealed an unbalanced rearrangement involving an (X;22) translocation at Xp11.2 and 22p11.2, which has not been reported in the literature. Although GISTs have shown an association with other primary malignant neoplasms, including simultaneous presence with unilateral clear cell renal cell carcinoma and bilateral papillary renal cell carcinomas, we describe the first reported case of synchronous GIST and Xp11 translocation-associated renal cell carcinoma. Vanda Farahmand Torous, Albert Su, David Y. Lu, and Sarah M. Dry Copyright © 2015 Vanda Farahmand Torous et al. All rights reserved. Huge Pyogenic Granuloma of the Penis Thu, 02 Jul 2015 10:21:51 +0000 Pyogenic granulomas are benign vascular disorders of the skin and mucose membranes, generally developed by trauma and irritation. The lesions are generally small. They are most commonly seen in the skin and oral mucosa and rarely seen on penis. We present the case of a huge pyogenic granuloma on the penis. Fatih Akbulut, Tugba Akbulut, Faruk Kucukdurmaz, Erkan Sonmezay, Abdulmuttalip Simsek, and Gokhan Gurbuz Copyright © 2015 Fatih Akbulut et al. All rights reserved. Delayed Recognition of an Ureteropelvic Junction Obstruction in a Young Adult Female Sun, 28 Jun 2015 06:57:26 +0000 A percentage of ureteropelvic junction obstruction cases are clinically silent in childhood and manifest symptoms in adults. Herein we present a 25-year-old female with several years of intermittent flank pain and abdominal symptoms with prior inconclusive diagnostic workup including abdominal imaging without hydronephrosis. Ultimately, a CT scan performed during an acute pain crisis clearly identified right-sided hydronephrosis. The keys to diagnosis are awareness of this entity, a detailed history, and obtaining imaging studies during a crisis. The patient subsequently underwent a right robotic-assisted laparoscopic pyeloplasty with preservation of a lower pole crossing vessel. We highlight noteworthy features of the clinical presentation and surgical repair. Ariel Schulman, Jean Paul Wuilleumier, and Ervin Teper Copyright © 2015 Ariel Schulman et al. All rights reserved. Epinephrine Injection Associated Scrotal Skin Necrosis Mon, 22 Jun 2015 14:18:53 +0000 Male circumcision is among the most frequent surgical interventions throughout history. Although considered as a minor intervention, it may have complications ranging from insignificant to catastrophic. These complications can be attributed to the surgical procedure and anesthesia. In this report we present two cases of scrotal skin necrosis after lidocaine with epinephrine injection using subcutaneous ring block technique prior to circumcision. Murat Gul, Mehmet Kaynar, Tamer Sekmenli, Ilhan Ciftci, and Serdar Goktas Copyright © 2015 Murat Gul et al. All rights reserved. A Rare Case of a Renal Cell Carcinoma Confined to the Isthmus of a Horseshoe Kidney Mon, 22 Jun 2015 06:45:56 +0000 Horseshoe kidney (HSK) is the most common renal anomaly. Reports of the incidence of renal cell carcinoma (RCC) in HSK are conflicting. Very few cases of isthmus-located RCC have been reported in the literature. We report a unique case of an isthmus-located RCC. Proper vascular and tumor imaging prior to surgery is key to successful tumor removal. Michael Kongnyuy, Daniel Martinez, Anthony Park, Barrett McCormick, Justin Parker, and Mary Hall Copyright © 2015 Michael Kongnyuy et al. All rights reserved. Chikungunya Virus Infection and Acute Elevation of Serum Prostate-Specific Antigen Wed, 17 Jun 2015 12:49:35 +0000 A man with prostate cancer on a regime of active surveillance had a laboratory-confirmed acute Chikungunya virus infection. The patient experienced a sudden increase in serum Prostate-Specific Antigen (PSA) during the acute illness that caused him anxiety and confounded interpretation of the PSA test. Six weeks after the onset of Chikungunya Fever symptoms, the elevated serum PSA returned to baseline. The association of Chikungunya Fever and elevated serum PSA may result in misinterpretation of the PSA test, triggering unnecessary prostate biopsy or other management errors. William Derval Aiken and Joshua J. Anzinger Copyright © 2015 William Derval Aiken and Joshua J. Anzinger. All rights reserved.