Group Title: Cases Journal 2009, 2:7780
Title: Holmium YAG laser ablation of a hemangioma involving a lower pole renal calyx - using the new-generation flexible ureteroscope URF type P5®: a case report
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Title: Holmium YAG laser ablation of a hemangioma involving a lower pole renal calyx - using the new-generation flexible ureteroscope URF type P5®: a case report
Series Title: Cases Journal 2009, 2:7780
Physical Description: Archival
Creator: Nakamura K
Yamada Y
Rosser CJ
Aoki S
Taki T
Honda N
Publication Date: 39981
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Bibliographic ID: UF00100224
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: Open Access: http://www.biomedcentral.com/info/about/openaccess/

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CASES

JOURNAL


Case report
Holmium YAG laser ablation of a hemangioma involving a lower
pole renal calyx using the new-generation flexible ureteroscope
URF type P5 : a case report
Kogenta Nakamura *, Yoshiaki Yamada', Charles J Rosser2, Shigeyuki Aoki',
Tomohiro TakiI and Nobuaki Honda'

Addresses: 'Department of Urology, Aichi Medical University School of Medicine, Nagakute-cho, Aichi 480-1195, Japan and 2Department of
Urology, University of Florida, Gainesville, FL, USA
Email: KN* kogenaka@aichi-med-u.ac.jp; YY yy1124@aichi-med-u.ac.jp; CJR Charles.Rosser@urology.ufl.edu;
SA shige39@aichi-med-u.ac.jp; TT tomotaki@aichi-med-u.ac.jp; NH uro@aichi-med-u.ac.jp
* Corresponding author

Received: 22 August 2008 Accepted: 9 May 2009 Published: 17 June 2009
Cases journal 2009, 2:7780 doi: 10.4076/1757-1626-2-7780
This article is available from: http://casesjournal.com/casesjournal/article/view/7780
2009 Nakamura et al; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Hemangioma of the renal calyx is a rare disease, which is difficult to diagnose and an even greater
challenge to treat. We report the use of the new-generation flexible ureteroscope, in the
management of a 37-year-old Asian male with a lower pole renal calyx hemangioma, which was
previously inaccessible.


Introduction
Renal hemangioma involving the collecting system is a
rare disease [1] and is difficult to diagnose and treat.
Previous reports discussed the need for a more radical
approach (total or partial nephrectomy) to treat these
hemangiomas. The need for less invasive surgery should
be considered in this cohort. However, there have been
significant advances in the technology related to uretero-
scopy over the past decade, limited data are available for
the use of endoscopic treatment of hemangiomas invol-
ving the collecting system. We report a case of a previously
inaccessible lower pole calyx hemangioma that we gained
access with the new-generation flexible ureteroscope, URF
type P5 (OlympusTM Corp., Tokyo, Japan), and effec-
tively ablated the hemangioma with the Holmium YAG
(HoYAG) laser.


Case presentation
A 37-year-old Asian male presented to his local urologist
with a primary complaint of painless, gross, intermittent
hematuria of two years duration. The previous urologist
had performed and attempted ureteroscopy but was
unable to fully examine the right collecting system. On
presentation to our institute, the patient had abdominal
ultrasonography, CT scanning and MRI, which demon-
strated no abnormality. His urinary cytology was negative.
Bloody efflux was observed from the right ureteral orifice
on cystoscopy. The rest of the bladder appeared normal.
Retrograde pyelogram of the right collecting system was
within normal limits. The patient underwent right flexible
ureteroscopy using flexible ureteroscope URF-P5. Dilation
of the ureteral orifice was not necessary. The use of the URF
type P5 ureteroscope allowed maximum mobility within


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Table I. Angles of deflection of URF-P3 and URF-P5
URF-P3 URF-P5
Device Down/Up (o) Down/Up (o)
Empty 185/175 275/180
Niica) 250 pm 155/160 265/165
Niic 300 pm 135/135 240/145
Lumenisb) 200 Pm 155/145 245/150
Lumenis 365 pm 100/100 200/110
FB-56D- Ic) 155/150 260/165


Figure I. Ureteroscopy showed a hemangioma (A).
Findings after HoYAG laser ablation (B).



the collecting system. This combined with fluoroscopic
examination of the right collecting system confirmed
complete pyeloscopy. As a result, a hemangioma of the
right lower pole renal calyx was identified (Figure 1A). No
papillary masses or another other lesions or stones were
identified in the collecting system. Subsequently, we
employed the HoYAG laser (laser probe Lumenis 200pm
and a laser generator Versa Plus 80 W, Lumenis Inc., CA) to
completely ablate this lesion in a rather bloodless field
(laser settings-0.5 J, 5 Hz, total: 0.52 kJ). At the conclusion
of the case, a double J ureteral stent was placed. Two weeks
later, the ureteral stent was removed. Here 15 months after
the procedure, the patient is asymptomatic. Furthermore,
microscopic urinalysis and urinary cytology are negative
for blood or malignancy, respectively.

Discussion
Renal hemangioma is a rare disease and is difficult to
diagnose. Daneshmand et al. reported the effectiveness of
ureteroscopy and laser treatment [1]. They used a HoYAG
laser or a neodymium YAG laser in 15 cases, and 11 of them
were became symptom free (mean follow periods:
20.2 months) [1]. Though recent reports demonstrate how
this entity can be handled endoscopically, a significant
number of these patients will require repeat surgery.
Recently, our institute started to use the new and smaller-
diameter, URF type P5 ureteroscope, because of its
improved maneuverability. As shown in Table 1 and Figure
2, the URF type P5 is superior in its angle of deflection
compared to the URF type P3. Both ureteroscopes are 8.9 Fr
in outer diameter, but the tip diameter of the URF type
P5 is 5.3 Fr, smaller than that of the URF type P3, and
therefore, smooth insertion can be expected. Kourambas et
al. reported that 58% of cases needed dilation of the urinary
tract [2]. The present case, however, did not require dilation
of the urinary tract using a ureteral access sheath.

The URF type P5 has a smaller diameter than the URF
type P3, but has the same irrigant flow rate of
approximately 37 ml/min. However, as others have


* It is not guarantee value.
a) Niic: Laser probe (Niic, Japan).
b) Lumenis: Laser probe (Lumenis, USA).
c) FB-56D- : 3Fr biopsy forceps (OlympusTM, Japan).


reported [3], with an increase in the number of uses, the
decrease in irrigant flow rate and angle of deflection have
to be taken into account. In addition, the smaller the
diameter, the more faults that can occur, and an increase in
cost may become a cause of concern [4]. This needs to be
kept in mind when treating patients.

Conclusion
We report on the use of the new-generation flexible
ureteroscope, URF type P5 (OlympusT) in the manage-
ment of a patient with a lower pole renal calyx
hemangioma which was previously inaccessible.

List of abbreviations
CT, Computed Tomography; MRI, Magentic Resonance
Imaging.


URF-P5

LTRF-P3


LTRF-P5 C,*

URF-P3



URF-P5

URF-PB

URF-P5
"77 a A~


URF-P3 -- C


Figure 2. Angles of deflection of URF-P3 and URF-P5. Down
angles (A), Up angles (B).


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Cases Joumnal 2009, 2:7780






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Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review from the journal's Editor-in-Chief.

Competing interests
The authors declare that they have no competing interests.

Authors' contributions
KN cared for the patient, drafted the report, and approved
the final version of the manuscript. YY cared the patient,
drafted the report, and approved the final version of the
manuscript. CJR reviewed the ureteroscopic findings of
hemangioma and photo of ureteroscopy, and approved
the final version of the manuscript. SA cared for the
patient, rafted the report, and approved the final version of
the manuscript. TT cared for the patient, rafted the report,
and approved the final version of the manuscript. NH ared
for the patient, rafted the report, and approved the final
version of the manuscript.

References
I. Daneshmand S, Huffman JL: Endoscopic management of renal
hemangioma. i Urol 2002, 167:488-489.
2. Kourambas J, Byrne RR, Preminger GM: Does a ureteral access
sheath facilitate ureteroscopy? Urol 2001, 165:789-793.
3. Traxer O, Dubosq F, Jamali K, Gattegno B, Thibault P: New-
generation flexible ureterorenoscopes are more durable
than previous ones. Urology 2006, 68:276-279.
4. LandmanJ, Lee DI, Lee C, Monga M: Evaluation of overall costs of
currently available small flexible ureteroscopes. Urology 2003,
62:218-222.


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