Congenital ureteropelvic junction (UPJ) obstruction may remain clinically compensated until young adulthood despite prenatal or early childhood diagnosis. Distinguishing morphological hydronephrosis from functionally significant obstruction is crucial for therapeutic decision-making. Case: A 25-year-old woman was found to have mild right-sided pelvicalyceal dilatation as an incidental finding during a routine primary care evaluation. Several weeks later, following a urinary tract infection accompanied by flank pain, repeat imaging demonstrated marked progression of hydronephrosis. Further evaluation with computed tomography and Tc-99m-MAG3 renography revealed a urodynamically significant right-sided urinary outflow obstruction despite preserved split renal function. Owing to the documented progression, functional obstruction, and persistent urinary stasis, robot-assisted pyeloplasty was performed. Postoperatively, urinary drainage improved while renal function remained stable. Conclusion: In adults with hydronephrosis, therapeutic decisions should not be based solely on the degree of morphological dilatation. Clinical evolution and functional assessment of urinary drainage are essential for appropriate management.

Patients with a renal transplant present unique anatomical challenges during pelvic surgery. The graft is typically located in the iliac fossa with vascular anastomoses to the iliac vessels and a short ureter implanted into the bladder. These features increase the risk of graft injury during radical prostatectomy, especially when lymph node dissection is planned. This case describes the experience in one of the few cases performed in our department. A 66-year-old man with localized prostate cancer (Gleason 3 + 4 = 7a) and a functioning renal transplant in the right iliac fossa. His history included end-stage renal disease due to IgA nephropathy (retroperitoneal transplants in 1990 on the left side and 2009 on the right side), coronary artery disease with stenting, and atrial fibrillation on new oral anticoagulation (NOAC). He underwent nerve-sparing robot-assisted radical prostatectomy (RARP) with bilateral pelvic lymphadenectomy. Histopathology confirmed organ-confined acinar adenocarcinoma (pT2c) with negative margins and no lymph node metastases. Postoperative cystogram confirmed a satisfactory vesicourethral anastomosis. When the intraoperatively inserted suprapubic catheter was clamped to enable natural urination, renal parameters temporarily increased. This was resolved after reopening the catheter for a few days. Ultrasound showed preserved graft perfusion without hydronephrosis or lymphocele. This case supports the feasibility of RARP in renal transplant recipients when meticulous technique is used to protect graft function.

A late preterm male infant born at 36 weeks and 2 days of gestation with birth weight of 2.5 kg and prenatally diagnosed bilateral hydronephrosis, megaureter, urinomas, and failed fetal shunt placement in the setting of anhydramnios developed severe hypoxemic respiratory failure shortly after birth. Despite surfactant, inhaled nitric oxide, and vasoactive support, refractory hypoxemia with severe pulmonary hypertension (oxygenation index of 56) necessitated venoarterial extracorporeal membrane oxygenation (ECMO) at 9 h of life. His course was complicated by hemodynamic instability, transfusion requirements, anticoagulation titration, and fluid overload necessitating continuous renal replacement therapy. Serial echocardiograms showed worsening right ventricular dysfunction, and he failed multiple clamp trials. Rapid Exome Sequencing, drawn on day of ECMO initiation confirmed de novo pathogenic variant in FOXF1, diagnostic of congenital alveolar capillary dysplasia with misaligned pulmonary veins (ACDMPV). Given the universally fatal prognosis, care was redirected after multidisciplinary discussions. This case highlights the importance of early genomic testing in certain ECMO candidates to guide timely clinical decision-making and resource stewardship while also underscoring the need for deeper investigation into CAKUT-ACD (CACD) overlap phenotypes, an area that remains poorly characterized and that may influence prognosis and management strategies.

Antenatal hydronephrosis (ANH), fetal kidney dilation, is a common prenatal diagnosis with variable prognosis that complicates counseling; however, its impact on maternal anxiety remains unknown. This study aimed to assess maternal anxiety and experience following a diagnosis of ANH and examine its relationship to severity. Data were collected from 30 mothers of infants diagnosed prenatally with ANH using the Spielberger State Trait Anxiety Inventory (STAI), an investigator-developed questionnaire, and open-ended questions. Regression and thematic analysis were performed. Results indicated moderate clinically significant anxiety (mean STAI-S 41.5 ± SD). Postnatal anxiety was higher in infants with mild dilation compared to those with moderate and severe dilation (p < 0.05). Qualitative themes included communication, maternal response, prenatal impact, and worry about baby. Mothers with higher STAI were more likely to report anxiety about surgery (p = 0.02) and prenatal management (p = 0.04). Future studies will examine anxiety in larger cohorts of mothers with and without fetal ANH.

Failed ureteroscopic access (FA) in unstented patients remains a significant clinical challenge. We aimed to identify preoperative clinical, laboratory, and CT-based predictors of FA, determine optimal cutoff values, and develop a clinically applicable risk-stratification model. This prospective cohort study enrolled 141 consecutive patients with ureteral stones undergoing unstented ureteroscopy (83 semi-rigid, 58 flexible) at a tertiary center (January 2024-January 2025). Preoperative demographics, pain characteristics, inflammatory markers (TLC, ESR, CRP, procalcitonin), and NCCT parameters (stone size, density, ureteral wall thickness [UWT], perinephric fat stranding [PFS] grade, hydronephrosis grade, HU of hydronephrosis, renal parenchymal thickness) were compared between successful access (SA, n = 112) and failed access (FA, n = 29) groups. Firth's penalized logistic regression, ROC analysis with DeLong comparison, and decision curve analysis (DCA) were performed. FA occurred in 29 patients (20.6%). UWT demonstrated the highest discriminatory power (AUC 0.965; cutoff ≥ 2.7 mm; sensitivity 96.6%, specificity 99.1%), followed by PFS grade (AUC 0.963; cutoff ≥ 2; sensitivity 100%, specificity 89.3%) and procalcitonin (AUC 0.957; cutoff ≥ 0.2 ng/mL). On Firth's penalized multivariate analysis, the primary two-variable Firth model identified UWT (OR 62.20 per mm; p < 0.001) and upper ureteral location (OR 14.27; p = 0.040) as independently associated with failed access (apparent AUC 0.986; 5-fold cross-validated AUC 0.967). The combined model achieved an AUC of 0.997 as an exploratory model with adequate calibration (Hosmer-Lemeshow test, p = 0.936). Exploratory DCA suggested potential net benefit across clinically relevant threshold probabilities. UWT ≥ 2.7 mm and PFS grade ≥ 2 on preoperative NCCT may be useful predictors of FA during unstented ureteroscopy, although these findings require external validation before clinical application. Incorporating these readily measurable CT parameters into a proposed preoperative risk-stratification algorithm may optimise surgical planning and patient counselling.

A man in his early 40s presented with urinary symptoms and was diagnosed with a right ureteric calculus, hydronephrosis and urinary tract infection. A non-contrast CT scan of the kidneys, ureters and bladder revealed an incidental pelvic mass in the rectovesical pouch, initially suspected as a gastrointestinal stromal tumour/fibroma. Multidisciplinary management prioritised cystoscopy-guided double-J stenting for obstruction and infection. In a second admission, ureteroscopic lithotripsy with stenting and a laparoscopic low anterior resection were planned simultaneously. Following ureteroscopic lithotripsy, diagnostic laparoscopy identified a large peritoneal loose body (PLB), which was retrieved laparoscopically, avoiding resection. Peritoneal loose bodies are extremely rare, benign entities prone to misdiagnosis as malignancy on imaging, leading to unnecessary major surgery and psychological distress. This case highlights the pathogenesis, clinical features, differential diagnoses and characteristic imaging findings of PLB, emphasising the value of preoperative recognition and diagnostic laparoscopy to prevent unnecessary major surgery.

Pelvic ectopic kidney with pelviureteric junction obstruction is rare and poses significant reconstructive challenges. We report a 35-year-old man presenting with a giant palpable abdominal mass caused by congenital obstruction in a malrotated pelvic ectopic kidney. Diuretic renography showed 11.6% split renal function. The patient underwent successful transperitoneal laparoscopic Anderson-Hynes pyeloplasty with Butler flap reconstruction and double-J stenting. Recovery was uneventful. Six-month renography demonstrated improved drainage with split renal function increasing to 22%, while the patient remained asymptomatic at one-year follow-up. This case highlights the feasibility of laparoscopic renal-preserving reconstruction even in poorly functioning ectopic kidneys with complex anatomy.