Retained encrusted ureteral stents represent a complex urologic problem, particularly in patients with limited healthcare access. We present a 28-year-old undocumented female with a 10-month retained ureteral stent who developed massive right-sided encrustation, including a 3 cm proximal renal stone near the renal pelvis and a 5-6 cm bladder stone, classified as FECal Grade IV-V. A single-session combined approach consisting of robot-assisted cystolithotomy, intraoperative ureteroscopy with stent exchange, and robot-assisted pyelolithotomy was performed successfully. Intraoperative ureteroscopy between operative phases confirmed ureteral clearance and enabled immediate stent placement without repositioning delay. This case supports the use of combined robotic approaches for high-grade disease and illustrates how structural barriers drive late presentation and increased surgical complexity.

Living donor kidney transplantation provides superior outcomes compared with deceased donor transplantation, but unexpected allograft injury during donor nephrectomy can threaten graft viability. Reports describing back-table repair of iatrogenic donor kidney injuries are limited, particularly for full-thickness parenchymal defects involving the collecting system. We report a case of a 69-year-old male with end-stage renal disease secondary to type 2 diabetes mellitus and hypertension who underwent planned living-related kidney transplantation from his 43-year-old son. The donor underwent robotic-assisted left donor nephrectomy without an identified intraoperative complication. During back-table preparation, the allograft was found to have a large subcapsular hematoma and an approximately 2 cm parenchymal defect communicating with the calyces and renal pelvis. After clot evacuation and exposure of the injury, a three-layer repair was performed. The collecting system was closed with interrupted 6-0 polydioxanone sutures (PDS), the renal cortex and medulla were reapproximated with running 6-0 PDS, and the capsule was closed with running 6-0 Prolene with Surgicel as a pledget. The kidney was then implanted in the recipient's right iliac fossa using standard vascular anastomoses and ureteroneocystostomy over a double-J stent. A perinephric drain was placed. The recipient had immediate graft function without the need for renal replacement therapy. Drain output was minimal, and the drain was removed on postoperative day 15. This case demonstrates that a structured multilayer back-table repair can salvage a living donor kidney with full-thickness parenchymal and collecting system injury. Careful injury assessment, multilayer reapproximation, and capsular reinforcement may support successful transplantation.

An 8-mo-old Japanese Black beef heifer calf was presented with anorexia, dysuria, and abdominal pain. Ultrasonographically, the left renal pelvis and calyces were markedly dilated and contained numerous calculi; the right renal pelvis was filled with hyperechoic material without obvious calculi. Despite supportive care and antimicrobial treatment with ceftiofur, the calf died 4 d after presentation. Autopsy revealed severe hydronephrosis with numerous struvite calculi in the left kidney and advanced pyonephrosis in the right kidney. Proteus mirabilis was isolated antemortem from urine and postmortem from purulent material in both kidneys, ureters, urinary bladder, and an associated urachal remnant abscess. As found in our case, P. mirabilis infection in cattle can be associated with both obstructive and suppurative renal lesions within a single animal. Our case emphasizes the importance of comprehensive diagnostic investigation, including bilateral renal ultrasonography and thorough bacteriologic evaluation, and offers diagnostic insight into the variable pathologic manifestations of P. mirabilis-associated urinary tract disease in cattle.

Hemorrhage is a leading cause of preventable death after trauma, with direct pressure, appropriate tourniquet application, and volume resuscitation established as principles of hemorrhage management. In recent years, several junctional tourniquet devices have been proposed as adjuncts for groin and axillary hemorrhage control, including the Abdominal Aortic Junctional Tourniquet-Stabilized (AAJT-S), which has been marketed for non-compressible torso hemorrhage. To date, evidence supporting its use has been primarily limited to studies on cadavers, porcine models, healthy human subjects, and a few case reports. We present the case of a young adult male with multiple gunshot wounds to the pelvis and lower extremities who presented to a level I trauma center with an AAJT-S in place. Device removal in the trauma bay was followed by cardiac arrest and subsequent complications to include metabolic acidosis, compartment syndrome, rhabdomyolysis, renal and liver infarcts, pulmonary emboli, and stroke. This case highlights the potential harm of the device. We review and contrast these outcomes with the limited available literature and present our recommendation for future evaluation and caution with application of this device.

Background: Fragility fractures of the pelvis (FFP) are increasingly encountered in older adults, yet early deterioration is difficult to anticipate because fracture instability interacts with frailty and systemic vulnerability. We developed and validated an admission-based multimodal framework to predict 90-day treatment failure (TF90) before definitive management. Methods: This multicentre retrospective prediction study included 1684 consecutive patients aged ≥65 years with FFP treated at five tertiary hospitals. TF90 was defined as persistent fracture-related pain or immobility, delayed conversion to operative stabilisation, secondary displacement, FFP-related unplanned readmission, revision or unplanned reoperation, or all-cause mortality within 90 days. Only predictors available within 24 h of admission and before the definitive treatment decision were eligible, including CT-defined fracture morphology, frailty, clinical characteristics and routine laboratory biomarkers; DXA and specialised bone metabolism measurements were evaluated separately in an extended model. Four prespecified models were developed in 985 patients, temporally validated in 520 patients and evaluated in a completely held-out Centre E internal-external validation cohort of 179 patients, with additional leave-one-centre-out internal-external cross-validation. Results: TF90 occurred in 307 patients (18.2%) and increased from 8.1% in FFP I to 37.1% in FFP IV. Higher risk was associated with advanced age, greater frailty, impaired prefracture mobility, bilateral posterior ring injury, greater displacement, systemic inflammation, hypoalbuminaemia and renal dysfunction. In temporal validation, AUROCs were 0.732 for the simple logistic model, 0.763 for the core logistic model, 0.759 for the core random forest and 0.755 for the extended random forest. Neither greater algorithmic complexity nor specialised skeletal measurements provided reproducible incremental value. A development-derived high-risk stratum had a TF90 incidence of 32.2% and contained 70.0% of all events. At the fixed threshold of 0.209, sensitivity was 71.3%, specificity 70.0% and negative predictive value 93.1%. Conclusions: Pretreatment integration of pelvic ring mechanics, frailty and routinely available systemic biomarkers enables clinically relevant enrichment of older patients at risk of TF90. The model is best positioned to support intensified surveillance and structured reassessment rather than determine operative treatment. Independent prospective external validation, recalibration and clinical impact evaluation are required before routine implementation.

Pyonephrosis is a rare, life-threatening suppurative disease of the kidney characterised by the accumulation of purulent exudate within the renal pelvis and the destruction of renal parenchyma. It is typically associated with azotaemia and urinary tract obstruction. Extreme leucocytosis (>100 × 10[3]/µL), known as a leukemoid reaction, has been rarely reported in feline pyonephrosis. A 13-year-old neutered domestic shorthair female cat was brought to a veterinary clinic with symptoms of lethargy and apathy, as well as a significantly enlarged abdominal cavity. Physical examination revealed dehydration and a large, non-painful mass occupying the left abdominal cavity. Haematology revealed severe leucocytosis of 123.22 × 10[3]/µL and anaemia with haematocrit (HCT) 18.6% and serum biochemistry showed elevated SDMA 17 µg/dL, AST 97 U/L, with hypokalaemia, hypochloraemia and hypoproteinaemia. Creatinine (1.5 mg/dL) and blood urea nitrogen (BUN) (23 mg/dL) remained within reference values. Abdominal X-ray and ultrasound revealed a large mass of anechoic structure encompassing the entire left side of the abdominal cavity, consistent with pyonephrosis. Microbiological studies of purulent material obtained by ultrasound-guided fine-needle aspiration and culturing revealed the presence of Escherichia coli. The day after admission, the patient underwent surgical laparotomy with unilateral nephrectomy. Histopathology confirmed severe inflammatory infiltration of the mucosa, connective tissue proliferation and fibrosis, with partial glomerular hyalinisation and without cellular atypia. Six days after surgical intervention, the leukocyte count decreased to 44.81 × 10[3]/µL. The patient was alive and clinically healthy 3 months after surgery. This case illustrates that massive unilateral pyonephrosis can occur in geriatric cats without azotaemia due to the compensatory function of the contralateral kidney. Marked leucocytosis of 123.22 × 10[3]/µL probably represents a leukemoid reaction secondary to severe suppurative inflammation. Moreover, pyonephrosis should be considered in the differential diagnosis of large abdominal masses in cats, even in the presence of a normal creatinine level.

Pancake kidney is an extremely rare renal fusion anomaly characterised by a single discoid parenchymal mass situated within the pelvic cavity. Due to its anomalous rotation and location, it is highly susceptible to urinary stasis, resulting in nephrolithiasis and infections. This report describes the clinical course and management of a man in his 20s who presented with chronic episodic lower abdominal pain and intermittent gross haematuria. Diagnostic imaging revealed a 2.5×2.2 cm obstructive calculus in the renal pelvis of a pancake kidney, causing significant hydronephrosis. Due to the unusual location in the abdominal pelvis, which predisposes to a high risk of bowel injury, the patient underwent a successful laparoscopic-assisted percutaneous nephrolithotomy. This approach allowed for safe bowel mobilisation and direct visualisation during renal access, resulting in a stone-free status without postoperative complications. The case highlights the necessity of tailored surgical strategies when addressing nephrolithiasis in the context of rare anatomical anomalies, emphasising the role of combined minimally invasive techniques in optimising patient outcomes and minimising surgical morbidity.

To investigate the effects of coupling fluid tonicity on pain, stone fragmentation success and complications in extracorporeal shock wave lithotripsy (ESWL). This prospective, controlled clinical trial included 294 patients with renal pelvis stones (5-20 mm) allocated to three groups: hypotonic degassed water (n = 97), isotonic 0.9% NaCl (n = 99) and hypertonic 3% NaCl (n = 98). Primary endpoints were post-ESWL Visual Analogue Scale (VAS) pain scores and stone fragmentation success (< 4 mm residual fragments) on follow-up non-contrast computed tomography at 2-4 weeks. Baseline demographic and stone characteristics were comparable across groups. VAS pain scores differed significantly among the three groups (p = 0.005), with the hypertonic group showing the lowest median score (4.0 vs. 5.0 in both other groups). Post-hoc analysis confirmed that this reduction was statistically significant only between the isotonic and hypertonic groups (Bonferroni-corrected p = 0.004), whereas the difference versus hypotonic water did not remain significant after correction. Multivariable regression confirmed that the pain reduction was independent of the recorded energy level (p < 0.001). Stone fragmentation success rates were similar (56.7%, 59.6% and 57.1%; p = 0.907). The incidence of skin petechiae and/or ecchymosis decreased numerically with increasing tonicity (6.2% to 1.0%) but did not reach statistical significance (p = 0.161). Hypertonic 3% NaCl coupling fluid may significantly reduce ESWL-related pain, particularly compared with isotonic fluid, with no statistically significant difference in clinical stone fragmentation success observed among the groups. Validation through larger, multicentre randomised trials is recommended.