“Iliosacral bridging” - A new alternative minimal invasive fixation of unstable pelvic ring fractures
Published on: 20th November, 2018
Introduction: Fractures of both the anterior and posterior pelvic ring are common injuries in polytrauma and the elderly that extend beyond those of simple low-impact trauma. While conventional X-rays predominantly show the ventral aspect of the injury, computed tomography often detect additional fractures of the sacrum. A large number of these fractures are B-injuries by AO, mainly compression fractures at an advanced age. In addition, the prevalence of pelvic insufficiency fractures caused by osteoporosis rather than subsequent to an obvious trauma is increasing, with such an injury often associated with pain that impairs mobilization. The standard sacroiliac screw fixation is often characterized by loosening and thus failure of the osteosynthesis especially in osteoporotic bone of elderly patients.
Method: A new alternative surgical minimal invasive technique, the “iliosacral bridging”, stabilizes the fractures of the sacrum with an internal fixation from S1 pedicle of the uninjured side to the ilium on the affected side. The combination of this internal fixation with the standard single sacroiliac screw on the injured side allows an immediate full weight bearing and pain free mobilization. We present a case series of 8 patients.
Results: The clinical and radiological analysis analogous to the pelvic-outcome-score brought forward that 2 patients showed an excellent and 2 patient a good result. The other 4 patients achieved sufficient results.
Conclusions: The “iliosacral bridging” we have introduced in the present study provides evidence of an expected increased stability of the pelvis after B-injuries
Squamous cell carcinoma developed on neglected, mistreated and delayed diagnosed chronic venous leg ulcer
Published on: 4th February, 2019
OCLC Number/Unique Identifier: 8022276860
Chronic venous leg ulcers (VLU), especially long-lasting non-healing ulcers, are among the risk factors for squamous cell carcinoma (SCC) with particularly aggressive behaviour. We present a case of a 71-year-old female patient with a relevant personal history of multiple SCC and basal cell carcinoma (BCC) excision and chronic venous insufficiency showing for about three years a ulcerated lesion located on the anteromedial distal third of the left leg non-responsive to specific treatment, which subsequently increased their size and merged. Biopsy sample was taken. Histopathology revealed a G2 SCC in all biopsy samples. After the staging, a left inguino-femoral lymphadenectomy and the excision were done. The treatment of bone exposure with a soleus muscle flap in the upper half of the defect and skin graft for all the defect and a specific oncologic treatment were proposed as possible curative solutions. Patients with chronic venous leg ulcers and clinically suspicious lesions should be evaluated for malignant transformation of the venous lesion. When diagnosed, malignancy complicating a chronic venous leg ulcer requires a resolute treatment as it may be fatal.
Brain changes in Hypothermia: Surface-versus Core-cooling in pigs
Published on: 31st October, 2017
OCLC Number/Unique Identifier: 7286428120
The process of hypothermia in the clinical setting has been practiced for 50 years and is known for its neuroprotective properties. This paper describes histopathological changes either by an ice sludge mimicking accidental hypothermia (S-group n=7) or by endovascular core-cooling (C-group n=7). Focal infiltrates of neutrophilic granulocytes were found in five of seven brains in the S-group and in one of seven brains in the C-group. These granulocytes were found in the arachnoids, in vessels, in vessel walls, and in the cerebral cortex. Fungi, bacteria, lymphocytes or plasma were not found.
This experimental study, mimicking accidental hypothermia, reported histopathologic features of aseptic inflammation. To our knowledge, such findings have not been described in hypothermic animals or humans before. We suggest that a local inflammatory response may be triggered in such cases of hypothermia.
Dendritic cells and TNF-Related apoptosis inducing ligand (TRAIL) represent new possibilities for sepsis treatment
Published on: 14th November, 2017
OCLC Number/Unique Identifier: 7317654646
Sepsis refers to a generalized inflammatory response of the organism to an infection or to bacterial products in circulation, rather than the development of an infection per se. Despite recent advances in clinical practice and overall medical care, sepsis remains a great health care problem and is still the most common cause of death in critically ill patients with infection. We suppose that during the course of sepsis the expression of TRAIL in different organs correlates with acute mortality and further development of multiple organ dysfunction syndrome (MODS). It is expected that dendritic cells (DCs) might become targets for apoptotic processes in a result of elevated TRAIL expression. This hypothesis is a bias for detailed investigations for in vivo studies in animal models and for in vitro studies of septic patients.
The Immunitary role in chronic prostatitis and growth factors as promoter of BPH
Published on: 25th April, 2018
OCLC Number/Unique Identifier: 7666286870
In the actual medical therapy of BPH, we can see: antibiotics, alpha blockers, 5-ARI, fitotherapeutics/natural products (Serenoa repens) with different which display clinical activities and other molecules such as FANS (local or systemic dosage forms) cortisones and others. Relationship between immune systems and chronic prostatitis are strictly involved in BPH progression. A vicious cycle that involve chronic flogosis, tissue remodeling, grow factors, inhibition of apoptosis, and other phenomena. Observing BPH pathogenesis under an immunologic point of view make possible to search new pharmacological strategies, to improve actual therapy.
The aim of this work is to observe some relevant literature in our opinion related the management of BHP and its progression under a pharmaceutical and immunological point of view. A deep knowledge in the pharmaceutical properties of some molecules (antimicrobials, anti-phlogosis agents, Anti-androgenic agents, alpha blockers, 5-ARI and other treatments, techniques, interventions or instruments) can help the physicians to pick the right choice.
Idiopathic post-operative biliary duct system dilatation; potential etiology and management
Published on: 22nd July, 2019
OCLC Number/Unique Identifier: 8206632092
What is called “idiopathic biliary duct system dilatation” or better to name it “un-explained biliary dilatation” is mostly following surgical procedures related to upper gastrointestinal and hepato-bilio-pancreatic systems. Having such situation, adaptive physiology of the biliary duct system has to be considered and rational has to be explained. The vast multimodal progress in techniques of investigations that has been applied on studying the hepato-bilio-pancreatic system has been utilized to clear the clinical ambiguity of biliary duct system dilatation for no logic reason but missing the correlation between both fields; the technical and the clinical ones. This clinical review is trying to fill this gap and introduce a comprehensive discussion of the subject. Mechanical, biochemical and immune causes constitute a wide diversity of etiology related to biliary system dilatation that in some situations is really difficult to verify clinically. On the least, even we could not verify the etiology we need to identify that reaching a closed road is different than postulating suspicions that never exist. This review is a trial collecting all subject-related data that might be related to etiology mechanisms and utilize to find a correlation rationale. At some point verification of such correlation is really a far target that might be even impossible clinically with availing technical tools and hope in the future could be achieved.
Altitude sickness and Antarctic polar plateau: A review
Published on: 27th June, 2019
OCLC Number/Unique Identifier: 8172446568
Antarctica is known for its extreme environmental conditions. It is the best model to study multiple stress factors at a time on human physiological responses. Although the coastal Antarctica is on Sea level but the Antarctic plateau or pole at high altitude. Since Antarctica is also becoming tourist site it is pertinent to have a proper understanding of altitude induced illnesses. In this review we have described the human acclimatization process at high altitude of Antarctic polar plateu and South Pole. The review also highlighted the symptoms, clinical features and prevention of altitude induced diseases.
Use of MicroRNAs to Screen for Colon Cancer
Published on: 31st August, 2017
OCLC Number/Unique Identifier: 7317598451
Colon cancer (CC) screening is important for diagnosing early stage for malignancy and therefore potentially reduces mortality from this disease because the cancer could be cured at the early disease stage. Early detection is needed if accurate and cost effective diagnostic methods are available. Mortality from colon cancer is theoretically preventable through screening. The Current screening method, the immunological fecal occult blood test, FOBTi, lacks sensitivity and requires dietary restriction, which impedes compliance. Moreover colonoscopy is invasive and costly, which decreases compliance, and in certain cases could lead to mortality. Compared to the FOBT test, a noninvasive sensitive screen that does not require dietary restriction would be more convenient. Colonoscopy screening is recommended for colorectal cancer (CRC). Although it is a reliable screening method, colonoscopy is an invasive test, often accompanied by abdominal pain, has potential complications and has high cost, which have hampered its application worldwide.
A screening approach that uses the relatively stable and nondegradable microRNA molecules when extracted from either the noninvasive human stool, or the semi-invasive blood samples by available commercial kits and manipulated thereafter, would be more preferable than a transcriptomic messenger (m)RNA-, a mutation DNA-, an epigenetic-or a proteomic-based test. That approach utilizes reverse transcriptase (RT), followed by a modified quantitative real-time polymerase chain reaction (qPCR). To compensate for exosomal miRNAs that would not be measured, a parallel test could be performed on stool or plasma’s total RNAs, and corrections for exosomal loss are made to obtain accurate results. Ultimately, a chip would be developed to facilitate diagnosis, as has been carried out for the quantification of genetically modified organisms (GMOs) in foods. The gold standard to which the miRNA test is compared to is colonoscopy. If laboratory performance criteria are met, a miRNA test in human stool or blood samples based on high throughput automated technologies and quantitative expression measurements currently employed in the diagnostic clinical laboratory, would eventually be advanced to the clinical setting, making a noticeable impact on the prevention of colon cancer.
Anterior Abdominal Wall Abscess: An unusual presentation of Carcinoma of the Colon
Published on: 18th October, 2019
OCLC Number/Unique Identifier: 8465489492
Background: Colorectal cancer progresses without any symptoms early on, or those clinical symptoms are very discrete and so are undetected for long periods of time. The case reported is an unusual presentation of colorectal cancer.
Case Report: A 60 year old man presented with right sided abdominal swelling. On examination, a well-defined, firm, tender swelling was noted. Computed tomography confirmed the presence of a mass arising from the right colon with infiltration of the right lateral abdominal wall and adjacent collection. An exploratory laparotomy with drainage of the subcutaneous abscess, resection of ascending colon, and ileotransverse colon anastomosis was performed.
Conclusion: A differential diagnosis of carcinoma colon should be considered when an elderly patient presents with abdominal wall abscess accompanied by altered bowel habits or per rectal bleeding, even if there are no other significant clinical symptoms and a thorough investigative work up is required to confirm the diagnosis, to avoid untimely delay in treatment, and reduce mortality.
Hot cholecystectomy
Published on: 20th November, 2019
OCLC Number/Unique Identifier: 8405164638
Acute cholecystitis is a common general surgery disease which may require hospital admission. Delayed or early cholecystectomy is the definitive treatment. Availability of theatre slots may postpone cholecystectomy for weeks. I am writing this letter to explain the importance of early cholecystectomy programme and the necessity of support such programme by hospital managers. I will rationalize the concept of such program and its clinical and economic benefits.
There are many strong evidences that early laparoscopic cholecystectomy (ELC) is a better option than delayed laparoscopic cholecystectomy (DLC) for management of acute cholecystitis. For example, a meta-analysis study showed ELC as safe and effective as DLC and it is associated with lower hospital costs, fewer work delay lost and greater patient satisfaction [1]. Furthermore, US Medicare database that include 29818 elderly patients with acute cholecystitis found a higher risk for mortality over the following two years in patients who were discharged without surgery compared with patients who underwent cholecystectomy in the initial hospitalization [2].
The risk of hospital re-admission after first attack of acute cholecystitis has been studied in a population –based analysis of the clinical course of 10304 patients with acute cholecystitis who discharged without cholecystectomy. Such analysis showed that the probability of a gall stone –related A&E visit or admission within 6 weeks, 12 weeks and 1 year was 14%, 19% and 29% respectively [3]. This will increase the gall stone disease burden and decrease patients’ satisfaction.
Per NICE guidelines we should offer ELC (to be carried out within 1 week of diagnosis) to patients with acute cholecystitis. Patients who had pancreatitis secondary to gallbladder stones should have laparoscopic cholecystectomy in the index admission [4]. NICE full health economy report showed that ELC burden is 2728.27 in compare to 3686.21 for DLC [5]. Furthermore, 2018/2019 NHS tariff for emergency laparoscopic cholecystectomy is between 6885 to 3872 pounds, while it is 3731 to 2080 pounds only for an elective case.
To sum up, ELC is as safe as DLC with potential lower mortality risk in elderly patients. In addition to eliminate the risk of re–admission after first attack of cholecystitis and decrease health care burden of gall bladder stones disease.
Precision and personalized vaccines needed to face COVID-19 pandemic
Published on: 28th April, 2021
OCLC Number/Unique Identifier: 9028054428
Among the abounding lessons we learned from the SARS-C0V-2 pandemic is the uttermost determinant that people are not equal before the severity of COVID-19. Indeed, the disease course differs with age, gender, ethnicity, underlying clinical conditions and virus variants. Other diseases modifying factors are associated with genetic traits such as those driving the immune response, the blood groups, the coagulation system and the ACE2 receptor variants [1-4].
Acute Appendicitis: Hispanics and the Hamburger Sign
Published on: 20th November, 2019
OCLC Number/Unique Identifier: 8405001290
Objective: To describe the presenting clinical findings of patients with acute appendicitis and compare them with those described in the medical literature. To corroborate a common medical myth among Hispanic physicians regarding the presentation of acute appendicitis.
Methods: This was a retrospective multicenter chart review of patients diagnosed post-operatively with appendicitis after presenting to five different Emergency Departments in Southern Puerto Rico (PR).
Results: A total of 1,540 patients with pathologically confirmed cases of appendicitis were enrolled in our study. Of the study population, 45% were female, and 55% were male, and 43% were over 21 years old. Reported symptoms in our study showed that 98% of the patients had abdominal pain, 47% had nausea, and only 17.6% presented with anorexia.
Conclusion: It was our main objective to compare the presenting signs and symptoms of patients with acute appendicitis in our Hispanic population in southern PR with those found in primary medical textbooks and literature. We gathered information regarding signs and symptoms, as well as laboratory and radiographic data of patients with positive pathologic exams for appendicitis. Of the 1,540 patients with confirmed appendicitis, only 17.6% presented with anorexia. Our findings demonstrate that the rate of anorexia in the studied population is significantly lower when compared to current literature. The absence of anorexia, once considered a hallmark of appendicitis, must not lead the physician to rule out this diagnosis in the Hispanic population.
Feasibility study on the evaluation of the effect of narrow-band CE-Chirp ASSR in the hearing field after hearing aid in hearing-impaired children
Published on: 12th July, 2019
OCLC Number/Unique Identifier: 8200911498
Objective Study: Whether the narrow-band CE-Chirp ASSR test in the sound field is an objective evaluation method for the hearing aid compensation effect, and whether there is a difference in children with different hearing loss levels.
Methods: 39 children (67 ears) wearing full digital hearing aids with good rehabilitation effect and ability to cooperate with behavioral audiometry were selected. The narrow-band CE-Chirp ASSR test group in the sound field was set as the experimental group, and the sound field behavioral audiometry after hearing aid was set as the control group. According to the degree of hearing loss, it was divided into moderate hearing loss group, severe hearing loss group and extremely severe hearing loss group. The difference between test results of experimental group and control group was compared.
Results: There were no significant differences between the experimental group and the control group in the moderate hearing loss group and the extremely severe hearing loss group at 0.5, 1, 2, and 4kHz (P > 0.05). The results of the experimental group and the control group in the severe hearing loss group, There was no significant difference at 0.5, 1, 2kHz (P > 0.05), there was a significant difference at 4kHz (P < 0.05), and the mean difference was - 6.4dB HL. When the degree of hearing loss was not grouped, there was no significant difference between the experimental group and the control group at 0.5, 1, 2kHz (P > 0.05), 4kHz was significantly different (P < 0.05), and the mean difference was -3.2dB HL.
Conclusion: It is clinically feasible to evaluate the hearing aid compensation effect of the narrow-band CE-Chirp ASSR in the hearing-impaired children. The grouping according to the degree of hearing loss can be more accurate in evaluating the hearing aid compensation effect. The narrow-band CE-Chirp in the sound field of children with moderate and very severe hearing loss ASSR results can be directly used to assess the hearing aid compensation effect, while children with severe hearing loss need to apply correction values at 4kHz.
Audit of the effect of non-nasal specific scoring on the Postoperative SNOT22 questionnaire
Published on: 23rd September, 2020
OCLC Number/Unique Identifier: 8796534426
The Sino-nasal outcome test (SNOT22) has been widely adopted in clinical practice and has been declared as the most suitable sinonasal outcome scoring system. It is simple disease specific encompassing 22 symptoms reflecting health burden of the rhino- logical patients.
Each item quantifies symptoms severity from 0(no problem) to 5 (worst symptom). The sum of each item results in a maximum score of 110. High score indicates poor outcome.
Laparoscopic-Assisted Transumbilical Extracorporeal Resection of Meckel’s Diverticulum in 10 years old boy with symptoms of gastrointestinal bleeding
Published on: 20th April, 2020
OCLC Number/Unique Identifier: 8587366913
The Meckel’s diverticulum (MD) is the most common anomaly of ductus omphaloentericus that surgeon encounters in clinical practice. The accurate incidence is unknown because most patients with the Meckel’s diverticulum are asymptomatic. Most studies report an incidence of about 2%. Approximately 4% of patients with the Meckel’s diverticulum become symptomatic.
A 10 years old boy, was sent from regional hospital. His symptoms started the day before he was hospitalized and represented as gastrointestinal bleeding, lower abdominal pain and four times vomiting, without fever. Ultrasound and X-ray of the abdomen were normal. Blood findings showed: RBC 3,19, hemoglobin 0,95, hematocrit 0,27. During a physical examination abdomen was palpatory soft, with no presence of the pain. Digital rectal examination showed blood. A scintigraphy pathologic scan showed a focal lesion of the right hemi abdomen consistent with the Meckel’s diverticulum.Patient was treated byLaparoscopic-Assisted Transumbilical Extracorporeal Resection of the Meckel’s Diverticulum.
Trichomonas Vaginalis-A Clinical Image
Published on: 21st July, 2017
OCLC Number/Unique Identifier: 7317592100
A 32-year-old G4P301LC3 woman presents to the office for a visit, with a 6-day history of vaginal discharge with an unpleasant odor. On speculum examination, the discharge was green in color and frothy in appearance. Is noticed vulvar erythema, edema, and pruritus, also is noted the characteristic erythematous, punctate epithelial papillae or “strawberry” appearance of the cervix. Vaginal pH was 6.2. Diagnosis of Trichomonas vaginalis is made via wet prep microscopic examination of vaginal swabs.But also, for diagnosis help even the exam with the speculum, concretely “strawberry” appearance of the cervix. The diagnosis is confirmed by culture.Trichomoniasis is a sexually transmitted infection [1,2], that caused by trichomonas vaginalis. Trichomonas vaginalis is a unicellular, anaerobic flagellated protozoan, that inhabits the lower genitourinary tracts of women and men, but that can cause vaginitis. Clinical findings of Trichomonas vaginalis include a profuse discharge with an unpleasant odor. The discharge may be yellow, gray, or green in color and may be frothy in appearance. Vaginal pH is in the 6 to 7.Vulvar erythema, edema, and pruritus can also be noted. The characteristic erythematous, punctate epithelial papillae or “strawberry” appearance of the cervix is apparent in only 10% of cases. Symptoms are usually worse immediately after menses because of the transient increase in vaginal pH at that time. Diagnosis of Trichomonas vaginalis is made via wet prep microscopic examination of vaginal swabs. Other, more sensitive tests are available, including nucleic acid probe study and immunochromatographic capillary flow dipstick technology. The diagnosis can be confirmed when necessary with culture, which is the most sensitive and specific study. Nucleic acid amplification tests (NAATs) have replaced culture as the gold standard. T vaginalis NAATs have been validated in asymptomatic and symptomatic women and are a highly sensitive test [3]. Because the Trichomonas vaginalis is a sexually transmitted infection, both partners should be treated to prevent reinfection. The mainstay of treatment for Trichomonas vaginalis infections is metronidazole. Treatment schemes can be:
Atypical Ductal Hyperplasia: Factors predicting upstaging to carcinoma
Published on: 6th July, 2020
OCLC Number/Unique Identifier: 8633817372
Aim: Percutaneous core needle biopsy (CNB) is considered the gold standard technique for initial histological diagnosis of suspicious breast lesions seen on screening mammogram, but it is less reliable for diagnosing atypical ductal hyperplasia (ADH) due to significant rates of diagnosis upstaging to malignant disease after excision biopsy. The purpose of this study was to identify factors that predict diagnosis upstage to carcinoma in patients diagnosed with ADH on core biopsy.
Methods: A retrospective database search identified 52 consecutive CNB of suspicious breast lesions revealing pure ADH. Inclusion criteria included asymptomatic women presenting for screening mammogram, who subsequently underwent surgical excision. Logistic regression analysis evaluated clinical, radiological, and histological factors.
Results: A total of 52 patients with ADH on CNB were identified who met our criteria. Twenty-six of 52 patients (50%) were upstaged to ductal carcinoma in situ or invasive carcinoma, based on histological interpretation of the surgically excised specimen. Lesion size was showed to be a statistically significant predictor on univariable logistic regression analysis. Multivariate logistic regression analysis revealed Asian ethnicity and lesion size as independent predictors of malignancy (p = 0.050 and 0.011, respectively). Conversely, women of Middle Eastern and European origin and lesions < 15 mm on mammography were negative predictors of malignancy.
Conclusion: Lesion size ≥ 15 mm on mammography and Asian ethnicity are independent risk factors for breast carcinoma in asymptomatic patients diagnosed with ADH on CNB.
Catamenial pneumothorax: Presentation of an uncommon Pathology
Published on: 20th December, 2017
OCLC Number/Unique Identifier: 7317596988
The catamenial pneumothorax is defined as the accumulation of air in the pleural cavity that appears in women infrequently and spontaneously with various clinical presentations. Actually, it is considered as an extremely rare entity with few cases described in the literature, that is the reason why the etiology is still discussed. However, a strong association with thoracic endometriosis syndrome has been found. We want to emphasize how the importance of conducting a diagnosis and having a timely management would improve the quality of life of the patient and give a better prognosis of the disease. Thus, a case report of a 38-year-old female patient who was receiving hormone therapy as a treatment for abdominal endometriosis and repetitive pneumothorax was presented. In the video-assisted thoracoscopy we saw diaphragmatic lesions and pneumothorax during the perioperative and postoperative period. Emphasize the importance of a detailed inspection of each intrathoracic organ during the surgical procedure, we also showed how the intraoperative pleurodesis, the placement of a mesh on the diaphragm and the continuity of the hormonal treatment, seems to be an effective therapy to prevent recurrences and have a better control of the disease.
Acute necrotising pancreatitis masquerading as psoas abscess: A report of two cases
Published on: 15th July, 2020
Acute pancreatitis is commonly diagnosed clinically, with its classical presentation of upper abdominal pain, backed by raised serum levels of enzymes amylase and lipase. However, unusual presentation of this common surgical emergency as a psoas abscess is a rare finding which can lead to missed diagnosis with a fatal outcome.
We present here two such cases of acute necrotising pancreatitis masquerading as psoas abscess, with no classical clinical symptoms and only mildly raised levels of serum amylase and lipase. The region of pancreas involved by necrosis influenced the site of presentation of the psoas abscess. In the first case, acute necrotising pancreatitis involving head and neck of pancreas presented as psoas abscess presenting in the right lumbar region, while the left side collection due to pancreatitis involving body and tail of pancreas manifested as an abscess in left flank.
While evaluating the aetiology of a psoas abscess, a differential diagnosis of necrotizing pancreatitis should be kept as a possibility.
A rare case: Congenital Megalourethra in prune belly syndrome
Published on: 30th January, 2018
OCLC Number/Unique Identifier: 7355941035
Introduction: Prune Belly syndrome is a disease characterized by abdominal muscle defect, bilateral cryptorchidsim and urinary system anomalies (reflux megaureter, hydronephrosis, etc.). Pulmonary, cardiac, and gastrointestinal anomalies may also be present. Management of these rare cases is very important. In this case, the clinical course of a patient with Prune Belly syndrome with megaurethra is presented.
Case: The patient from the first gestation and parturition with birth weight of 2500 g and 38 weeks was hospitalized because of the bilateral hydronephrosis. His physical examination revealed undescended testicles and a large penis. The abdominal muscles were not very atrophic. The size of the kidney was small, bilateral hydroureteronephrosis and wide posterior urethra on the ultrasound. Renal function tests were progressively disturbed and the patient underwent cystourethroscopy for diagnostic purposes in terms of posterior urethral valve. A large diverticulum was found in anterior urethra. Prune Belly Syndrome was thought because the orifices were in appearance of reflux. The vesicostomy was applied. After vesicostomy the renal function tests got better but he was hospitalized due to urosepsis two times. In cystoscopic examination, the diverticulum in the urethra was filled with urine and the drainage was very slow. Phimosis was opened with dorsal slit technique. Cutaneous urethrostomy was proximal to the anterior diverticulum.
Conclusion: Prune Belly syndrome should be considered in patients with megaurethra and postrenal or renal insufficiency although there are no obvious clinical findings. In Prune Belly cases, via a large penis with obstruction signs, anterior urethral diverticulum should be considered.
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