• Users Online: 196
  • Print this page
  • Email this page


 
 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 68-74

Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review


1 Department of Nephrology, Affiliated Hospital of Jiangnan University, Wuxi, China
2 Department of Radiology, Affiliated Hospital of Jiangnan University, Wuxi, China
3 Department of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China

Date of Submission01-Oct-2021
Date of Acceptance18-Jun-2022
Date of Web Publication8-Nov-2022

Correspondence Address:
Gen Yan
Department of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, Fujian
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/RID.RID_9_21

Rights and Permissions
  Abstract 


Emphysematous pyelonephritis (EPN) is a rare but serious infectious disease caused by anaerobic bacteria that is characterized by necrotizing renal parenchymal infection and has a high mortality rate. The initial management of EPN includes resuscitation, antibiotics, management of any diabetes, and minimally invasive procedures, such as percutaneous drainage. Surgery is required in the most severe cases. Here, we describe a male patient with type 2 diabetes who presented with fever and abdominal pain and was diagnosed with EPN based on laboratory results and a computed tomography (CT) scan showing distension of the left kidney, several small air bubbles in the perirenal space, and thickening of the perinephric fascia. A subcutaneous insulin infusion and meropenem were administered. Repeat CT imaging 13 days later showed gas and necrotic tissue in the renal parenchyma. Therefore, CT-guided renal puncture was performed, and Escherichia coli was cultured from the drained pus. Antibiotic treatment was continued for 20 days after admission when the patient's kidney function and clinical symptoms had significantly improved. Sixty days after diagnosis, left nephrectomy was performed. The perinephric abscess was under high tension, and the left kidney was very soft. Histopathological examination revealed severe inflammation and necrosis of the renal pelvis, with fibrosis. The patient recovered well after surgery and remained alive 5 months later. EPN is a very rare disease with a high mortality rate and is more likely to occur in patients with diabetes. Early diagnosis and treatment of the infection are extremely important. For patients in whom gas and/or necrosis continue to accumulate after conservative treatment, we recommend nephrectomy.

Keywords: Acute kidney injury, antibiotic, diabetes mellitus, emphysematous pyelonephritis, nephrectomy


How to cite this article:
Peng J, Ge Y, Yan G. Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review. Radiol Infect Dis 2022;9:68-74

How to cite this URL:
Peng J, Ge Y, Yan G. Conservative treatment of emphysematous pyelonephritis and diabetes: A case report and literature review. Radiol Infect Dis [serial online] 2022 [cited 2022 Dec 4];9:68-74. Available from: http://www.ridiseases.org/text.asp?2022/9/2/68/360507




  Introduction Top


Emphysematous pyelonephritis (EPN) is an acute, severe, and necrotizing disease caused by gas-producing bacteria, such as Escherichia coli and Klebsiella pneumoniae, which infect the kidney parenchyma and surrounding tissues. EPN is more common in patients with diabetes and in women.[1] The most common clinical manifestations are fever, abdominal pain, and pyuria; most patients present with several symptoms. If a patient develops sepsis, the risk of mortality increases dramatically.[2] At present, there is no consensus regarding the diagnosis and treatment of EPN, but computed tomography (CT) is the current gold standard diagnostic test.[3] EPN treatment mainly comprises antibiotics, hypoglycemic drugs, percutaneous catheterization and drainage, and surgery. However, there is controversy regarding the indications for and optimal timing of surgical interventions.


  Case Presentation Top


A 55-year-old male was admitted to the hospital because of left-sided lumbago and gross hematuria of 2 weeks' duration, accompanied by obvious fatigue, frequent micturition, and fever. He also had a history of diabetes. His vital signs on admission were as follows: temperature, 37.7°C; pulse rate, 90 beats/min; respiratory rate, 15 breaths/min; and blood pressure, 112/67 mmHg. Physical examination revealed dull abdominal pain but no rebound tenderness or percussion tenderness in the left renal area.

Laboratory examination revealed the following: white blood cell count, 30 × 109/L; neutrophils, 93%; fasting glucose concentration, 23.48 mmol/L; creatinine concentration, 247.7 μmol/L; glycosylated hemoglobin level, 10.4%; C-reactive protein concentration, 448.39 mg/L; and procalcitonin concentration >100.0 ng/ml. Urinalysis revealed the following: glucose, 4+; white blood cell count, 1460.9/μl; and red blood cell count, 3487.7/μl. Blood and urine cultures were negative. Abdominal CT demonstrated that the left kidney was distended, with low renal parenchymal density. In addition, several small air bubbles that were consistent with anaerobic infection were present in the upper part of the perirenal space, with a minor effusion in the perirenal space and thickening of the perirenal fascia [Figure 1]. Therefore, the patient was diagnosed with a renal parenchymal infection.
Figure 1: Computed tomography scan, showing a distended left kidney with perirenal exudation and thickening of the perirenal fascia

Click here to view


After admission, the patient was administered a continuous subcutaneous insulin infusion to control his glucose concentration, and meropenem was used to treat the infection. His fasting blood glucose concentration was maintained in the range of 5–6 mmol/L and the postprandial blood glucose was maintained in the range of 7–8 mmol/L. Twelve days following diagnosis, the patient's blood count, procalcitonin, C-reactive protein, sedimentation rate, and liver enzymes had returned to normal, and his creatinine had improved to 105.9 μmol/l. The meropenem was replaced by ceftriaxone tazobactam because of the improvements in the laboratory parameters. A repeat CT scan performed on day 13 revealed an abscess in the left kidney, as evidenced by a thick-walled cavity filled with gas, accompanied by surrounding exudate and thickened fascia [Figure 2]. Therefore, CT-guided percutaneous renal puncture drainage was immediately performed and 300 ml of turbid fluid was drained. E. coli was cultured from the pus, and this was found to be sensitive to cephalosporins, including ceftriaxone tazobactam. The patient's inflammatory markers and urinalysis results gradually returned to normal (creatinine, 101.4 μmol/L), and his abdominal pain had improved by day 14.
Figure 2: Computed tomography scan, performed 13 days after the diagnosis of emphysematous pyelonephritis, showing the formation of a thick-walled cavity filled with gas, surrounded by exudate and thickened fascia, in the left kidney

Click here to view


A repeat CT scan on day 20 showed no improvement [Figure 3]. The urologist recommended left nephrectomy, but the patient refused and was discharged. Subsequently, his fasting and postprandial blood glucose concentrations were controlled between 5–6 mmol/L and 7–8 mmol/L, respectively, and his serum creatine was between 120 μmol/L and 140 μmol/L. Two further CT scans performed on days 30 and 60 showed no reductions in gas or necrotic tissue in the renal parenchyma [Figure 4] and [Figure 5]. Although the patient had no obvious abdominal pain, he experienced weight loss of 5 kg. A renal dynamic test was performed on day 60: the right kidney was visualized using renal dynamic imaging, but the left kidney could not be. The glomerular filtration rate (GFR) of the left kidney was 5.19 ml/min·1.73 m2, whereas that of the right kidney was 30.47 ml/min·1.73 m2. Therefore, 2 months after discharge, the patient was re-hospitalized for left nephrectomy. A perirenal abscess causing high tension in the renal capsule was identified intraoperatively, and the left kidney was very soft [Figure 6]. Histopathological examination revealed severe inflammation and necrosis of the renal pelvis, with fibrosis [Figure 7]. The patient recovered well after the surgery and remained alive 5 months later.
Figure 3: Computed tomography scan performed 20 days after the diagnosis, showing the left kidney, which contains a thick-walled gas-containing cavity

Click here to view
Figure 4: Computed tomography scan performed 30 days after the diagnosis, showing a large amount of necrotic tissue and thinning of the renal cortex

Click here to view
Figure 5: Computed tomography scan performed 60 days after diagnosis, showing a large amount of necrotic tissue

Click here to view
Figure 6: The left kidney of the patient after removal, showing distension and a huge abscess

Click here to view
Figure 7: Haematoxylin and eosin-stained sections of the left kidney, showing fibroblasts and numerous inflammatory cells. Original magnification ×200

Click here to view



  Results Top


To review the epidemiology, characteristics, and treatment of EPN, the PubMed database was searched for reports of EPN published within the last 18 years using the following keywords: EPN (all fields) or pyelonephritis (MeSH term). After filtering for unrelated results and duplicates, data from 43 patients reported in 39 publications between 2002 and 2020 were collected and analyzed [Table 1]. The characteristics and treatments of these patients are summarized in [Table 2].
Table 1: Clinical and demographic data extracted from case reports (n=43) of emphysematous pyelonephritis published between 2002 and 2020

Click here to view
Table 2: Characteristics of 43 patients with emphysematous pyelonephritis reported between 2005 and 2020

Click here to view


The mean age of the patients diagnosed with EPN was 59.0 ± 12.4 years, and approximately 88% (38/43) had diabetes. E. coli was the most common organism cultured (20 patients, 46%). The most frequent site was the left kidney (77%, 33/43), and bilateral renal involvement was noted in 30% (13/43) of the patients. A transplanted kidney was affected in 14% of the patients (6/43), and in eight patients (19%) multiple organs were involved. All 43 patients were treated with antibiotics, the most common of which was meropenem. Because of a poor response to antibiotics, 37% of the patients (16/43) eventually required nephrectomy. The overall mortality rate associated with the EPN was 26% (11/43), but the mortality rate of the patients who underwent surgical treatment (19%, 3/16) was lower than that of patients who underwent conservative treatment (30%, 8/27). Of the patients who had EPN involving multiple sites according to radiological imaging, 29% (5/17) died. The mortality rate was 83% (5/6) among patients who had undergone kidney transplantation.


  Discussion Top


EPN is a rare, life-threatening disease that was first reported by Kelly and MacCallum in 1898[43] as renal emphysema. The nomenclature “emphysema pyelonephritis” was introduced by Schultz and Klorfein in 1962.[44] EPN is often associated with severe sepsis, which has a mortality rate as high as 40%–50%.[45] In the present study, the mortality rate calculated was slightly lower than that reported in the literature, likely because of the prompt use of antibiotics and early surgery in recent years. EPN is more likely to occur in patients with diabetes because their high blood glucose concentrations provide nutrition for the bacteria. We found that 88% of the reported patients with EPN had diabetes. Misgar et al.[46] analyzed the characteristics of 26 patients with EPN in a single-center study, all but two of whom were women. Previous studies have shown that women have a higher prevalence of EPN because of their greater susceptibility to urinary tract infection.[47] The only caveat to this predisposition is that men who undergo renal transplantation are more likely to develop EPN,[48] and this is consistent with the results of the present analysis.

CT is considered the most appropriate means of diagnosing EPN. The accumulation of gas can be rapid and is always indicative of persistent infection and the inefficacy of treatment.

Despite increasing awareness of EPN and greater diagnostic accuracy in recent years, the most appropriate treatment is controversial. The conventional treatment for patients with severe disease is nephrectomy;[4] however, this has been gradually replaced by drainage via the percutaneous catheter.[9] We found that the mortality rate of patients who underwent surgery is lower than that of patients who only undergo conservative treatment. We also found that patients with a history of renal transplantation or involvement of more than two sites, such as both kidneys, were more likely to die than those of patients with unilateral kidney infection. This implies that renal transplantation and multi-organ involvement are risk factors for mortality.

In summary, we have described the clinical course of a patient with EPN who did not respond to conservative treatment, and summarized the available literature concerning EPN. We found that EPN occurred more frequently and was associated with a higher mortality rate in patients with diabetes. E. coli is the most common pathogen. The surgical treatment of EPN is associated with a lower mortality rate than conservative treatment. Finally, the mortality rate is higher in patients who had undergone transplantation or showed multi-site involvement on radiological imaging.

Our experience highlights the importance of commencing antibiotic treatment as soon as EPN is diagnosed. Furthermore, when renal parenchymal necrosis is identified, CT-guided percutaneous renal puncture drainage should be performed because this rapidly improves kidney function. We have also demonstrated the value of CT and renal function tests for the evaluation of the efficacy of conservative treatment during the course of the disease. If there is a significant decrease in renal GFR, or the accumulation of gas and necrotic tissue in the kidney parenchyma on CT worsens or does not improve, nephrectomy should be performed as soon as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Mark Cleasby, PhD from Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the language of a draft of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kuchay MS, Laway BA, Bhat MA, Mir SA. Medical therapy alone can be sufficient for bilateral emphysematous pyelonephritis: Report of a new case and review of previous experiences. Int Urol Nephrol 2014;46:223-7.  Back to cited text no. 1
    
2.
Momin UZ, Ahmed Z, Nabir S, Ahmed MN, Al Hilli S, Khanna M. Emphysematous prostatitis associated with emphysematous pyelonephritis and cystitis: A case report. J Clin Urol 2017;10:286-9.  Back to cited text no. 2
    
3.
Hiremath R, Mahesh, Padala KP, Swamy K, Pailoor A. A rare case of pneumoureter: Emphysematous pyelitis versus emphysematous pyelonephritis. J Clin Diagn Res 2015;9:TD03-5.  Back to cited text no. 3
    
4.
Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 4
    
5.
Mohsin N, Budruddin M, Lala S, Al-Taie S. Emphysematous pyelonephritis: A case report series of four patients with review of literature. Ren Fail 2009;31:597-601.  Back to cited text no. 5
    
6.
Deoraj S, Zakharious F, Nasim A, Missouris C. Emphysematous pyelonephritis: Outcomes of conservative management and literature review. BMJ Case Rep 2018;2018:bcr2018225931.  Back to cited text no. 6
    
7.
Wang Q, Sun M, Ma C, Lv H, Lu P, Wang Q, et al. Emphysematous pyelonephritis and cystitis in a patient with uremia and anuria: A case report and literature review. Medicine (Baltimore) 2018;97:e11272.  Back to cited text no. 7
    
8.
Flores G, Nellen H, Magaña F, Calleja J. Acute bilateral emphysematous pyelonephritis successfully managed by medical therapy alone: A case report and review of the literature. BMC Nephrol 2002;3:4.  Back to cited text no. 8
    
9.
Cavol GL, Finazzo F, Carollo C, Li Cavoli TV, Zagarrigo C, Azzolina V, et al. Emphysematous pyelonephritis. Saudi J Kidney Dis Transpl 2019;30:1485-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Tatakis FP, Kyriazis I, Panagiotopoulou IE, Kalafatis E, Mantzikopoulos G, Polyzos K, et al. Simultaneous diagnosis of emphysematous osteomyelitis and emphysematous pyelonephritis in a diabetic patient. Am J Case Rep 2019;20:1793-6.  Back to cited text no. 10
    
11.
Ideguchi S, Yamamoto K, Ikeda A, Hashimoto K, Takazono T, Saijo T, et al. A case of bilateral emphysematous pyelonephritis caused by Candida albicans. J Infect Chemother 2019;25:302-6.  Back to cited text no. 11
    
12.
Kashiura M, Sugiyama K, Akashi A, Hamabe Y. Emphysematous pyelonephritis. Intern Med 2014;53:2557.  Back to cited text no. 12
    
13.
Lotfali E, Abolghasemi S, Gatmirimotahhari FS, Alizadeh M, Arab-Mazar Z. Complicated bilateral fungal emphysematous pyelonephritis in a 55-year-old diabetic female: A case report and review of literature. Curr Med Mycol 2018;4:32-5.  Back to cited text no. 13
    
14.
Kazempour M, Oroei M, Shabani M, Faghihi T. Emphysematous pyelonephritis and hiccups, a case report. Iran J Kidney Dis 2020;14:235-8.  Back to cited text no. 14
    
15.
Yamaguchi H, Yamaguchi Y, Hadano Y, Hayashi K, Nagahara C, Muratani T, et al. The first case report of emphysematous pyelonephritis and bacteremia due to Oligella urethralis. Int J Med Microbiol 2017;307:151-3.  Back to cited text no. 15
    
16.
Dellavedova T, Racca ML, Ponzano R, Sarría JP, Minuzzi F, Minuzzi G. Emphysematous pyelonephritis. Case report. Arch Esp Urol 2009;62:406-9.  Back to cited text no. 16
    
17.
Cheng ML, Nording H, Lim CH. Bilateral emphysematous pyelonephritis with hepatic portal venous gas: Case report. Malays J Med Sci 2015;22:71-4.  Back to cited text no. 17
    
18.
Strofilas A, Manouras A, Lagoudianakis EE, Kotzadimitriou A, Pappas A, Chrysikos I, et al. Emphysematous pyelonephritis, a rare cause of pneumoperitoneum: A case report and review of literature. Cases J 2008;1:91.  Back to cited text no. 18
    
19.
Nana GR, Brodie A, Akhter W, Karim O, Motiwala H. Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review. Int J Surg Case Rep 2015;10:179-82.  Back to cited text no. 19
    
20.
Bansal RK, Lambe S, Kapoor A. Emphysematous pyelonephritis in failed renal allograft: Case report and review of literature. Urol Ann 2016;8:111-3.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Abed El Rahman D, Zanetti G, Ferruti M, Acquati P, Maggioni A, Oliva I, et al. Emphysematous pyelonephritis in decompensated diabetes: A case report and review of the literature. Arch Ital Urol Androl 2011;83:108-11.  Back to cited text no. 21
    
22.
Park SH, Kim KH. Treatment of a case of emphysematous pyelonephritis that presented with acute abdomen and pneumoperitoneum: A case report. BMC Nephrol 2015;16:124.  Back to cited text no. 22
    
23.
Vollans SR, Sehjal R, Forster JA, Rogawski KM. Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic. Cases J 2008;1:192.  Back to cited text no. 23
    
24.
Hamouda M, Aloui S, Skhiri H, Letaif A, Frih MA, Ben Dhia N, et al. Emphysematous pyelonephritis in a diabetic patient on maintenance hemodialysis: A case report. Arab J Nephrol Transplant 2014;7:109-11.  Back to cited text no. 24
    
25.
Stein JP, Spitz A, Elmajian DA, Esrig D, Freeman JA, Grossfeld GD, et al. Bilateral emphysematous pyelonephritis: A case report and review of the literature. Urology 1996;47:129-34.  Back to cited text no. 25
    
26.
Shigemura K, Yasufuku T, Yamashita M, Arakawa S, Fujisawa M. Bilateral emphysematous pyelonephritis cured by antibiotics alone: A case and literature review. Jpn J Infect Dis 2009;62:206-8.  Back to cited text no. 26
    
27.
Khaladkar SM, Jain KM, Kuber R, Gandage S. Necrotizing fasciitis of thoracic and abdominal wall with emphysematous pyelonephritis and retroperitoneal abscess. J Clin Imaging Sci 2018;8:7.  Back to cited text no. 27
[PUBMED]  [Full text]  
28.
Davies SJ, Dargan J, Sved P. Literature review and case of medically managed bilateral emphysematous pyelonephritis. Urol Case Rep 2018;17:73-5.  Back to cited text no. 28
    
29.
Mongha R, Punit B, Ranjit DK, Anup KK. Emphysematous pyelonephritis – Case report and evaluation of radiological features. Saudi J Kidney Dis Transpl 2009;20:838-41.  Back to cited text no. 29
[PUBMED]  [Full text]  
30.
Brown N, Petersen P, Kinas D, Newberry M. Emphysematous pyelonephritis presenting as pneumaturia and the use of point-of-care ultrasound in the emergency department. Case Rep Emerg Med 2019;2019:6903193.  Back to cited text no. 30
    
31.
Ozawa M, Ichiyanagi O, Fujita S, Naito S, Fukuhara H, Suenaga S, et al. Risk of SOFA deterioration in conservative treatment for emphysematous pyelonephritis: Pitfalls of current trends in therapeutics from multicenter clinical experience. Curr Urol 2019;12:134-41.  Back to cited text no. 31
    
32.
Lee IK, Hsieh CJ, Liu JW. Bilateral extensive emphysematous pyelonephritis. A case report. Med Princ Pract 2009;18:149-51.  Back to cited text no. 32
    
33.
Yeung A, Cheng CH, Chu P, Man CW, Chau H. A rare case of asymptomatic emphysematous pyelonephritis. Urol Case Rep 2019;26:100962.  Back to cited text no. 33
    
34.
Hayashi T, Yanaihara H, Kaguyama H, Hanashima F, Sakamoto H, Nakahira Y, et al. Emphysematous pyelonephritis with successful renal preservation using open drainage surgery: A case report. Urol Case Rep 2018;17:76-8.  Back to cited text no. 34
    
35.
Holbrook C, Kalaidina E. Concurrent emphysematous pyelonephritis and emphysematous cholecystitis due to community-acquired ESBL E. coli. BMJ Case Rep 2018;2018:bcr2018224989.  Back to cited text no. 35
    
36.
Saxena D, Aggarwal L, Tudu SK, Thomas S. Emphysematous pyelonephritis – A rare surgical emergency presenting to the physician: A case report and literature review. Indian J Surg 2013;75:272-4.  Back to cited text no. 36
    
37.
Ramos LD, Lima Mde M, Carvalho Md, Silva Júnior GB, Daher Ede F. Emphysematous and xanthogranulomatous pyelonephritis: Rare diagnosis. Braz J Infect Dis 2010;14:374-6.  Back to cited text no. 37
    
38.
Torres H, Sharma P. Bilateral emphysematous pyelonephritis. Urol Case Rep 2018;17:119-21.  Back to cited text no. 38
    
39.
Vivek V, Panda A, Devasia A. Emphysematous pyelonephritis in a renal transplant recipient-is it possible to salvage the graft? Ann Transplant 2012;17:138-41.  Back to cited text no. 39
    
40.
Yamamichi G, Tsutahara K, Kuribayashi S, Kawamura M, Nakano K, Kishimoto N, et al. Emphysematous pyelonephritis with cardio-pulmonary arrest: A case report. Hinyokika Kiyo 2016;62:415-9.  Back to cited text no. 40
    
41.
Alhajjaj FS, Pasha F. Emphysematous pyelonephritis in renal allograft – A case report. Int J Health Sci (Qassim) 2016;10:311-3.  Back to cited text no. 41
    
42.
Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int 2007;71:462-5.  Back to cited text no. 42
    
43.
Kelly HA, WG MC. Pneumaturia. JAMA 1898;31:375-81.  Back to cited text no. 43
    
44.
Schultz EH Jr., Klorfein EH. Emphysematous pyelonephritis. J Urol 1962;87:762-6.  Back to cited text no. 44
    
45.
Dutta P, Bhansali A, Singh SK, Gupta KL, Bhat MH, Masoodi SR, et al. Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus. Urol Int 2007;78:13-22.  Back to cited text no. 45
    
46.
Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA. Emphysematous pyelonephritis: A 10-year experience with 26 cases. Indian J Endocrinol Metab 2016;20:475-80.  Back to cited text no. 46
    
47.
Schutz EA, Zabott AP, Boaretto RB, Toyama G, Morais CF, Moroni JG, et al. Emphysematous pyelonephritis caused by C. glabrata. J Bras Nefrol 2021. doi: 10.1590/2175-8239-JBN-2020-0184.  Back to cited text no. 47
    
48.
Tienza A, Hevia M, Merino I, Velis JM, Algarra R, Pascual JI, et al. Case of emphysematous pyelonephritis in kidney allograft: Conservative treatment. Can Urol Assoc J 2014;8:E256-9.  Back to cited text no. 48
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Presentation
Results
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed222    
    Printed16    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]