Secondary enuresis and urological manifestations in children with ataxia telangiectasia

BACKGROUND

Ataxia telangiectasia (AT) is a neurodegenerative cerebellar disorder, caused by mutations in the ATM gene, involved in DNA repair. Radiosensitivity, progressive ataxia, immune deficiency and malignancies, are well known symptoms, but urological manifestations are scarcely described.

OBJECTIVE

To characterize urologic manifestations in a large cohort of AT patients.

METHODS

Retrospective cross-sectional chart study comprising 52 AT patients followed at a National AT Center.

RESULTS

25% of the cohort (13 patients/8 males) had urologic symptoms, which presented at 11 ± 4.3 years. The most common symptom was secondary enuresis affecting 15% of the patients (8 children/4 males). Incontinence appeared at 8 ± 6.2 years of age, and resolved spontaneously within 15 ± 8.3 months in 6 patients. It preceded loss of ambulatory capacity by 1-2 years in 7 patients. Lumbosacral MRI were normal (4 children) and urine cultures (all) were negative. Urodynamic evaluation that was performed in only one patient revealed overactive bladder. Additional manifestations were macroscopic hematuria due to bladder telangiectasia in a 12-year-old, and renal cell carcinoma in a 22-year-old. Other manifestations unrelated to AT were neprolithiasis, vesico-ureteral reflux and scrotal pain, each in 1 patient.

DISCUSSION

Transient secondary enuresis is a frequent finding in AT patients, heralding loss of ambulatory capacity, tough it's pathophysiological mechanism is largely no understood.

24-h urine metabolic profile: is it necessary in all kidney stone formers?

PURPOSE

A 24-h urine metabolic profile (24-UMP) is an integral part of nephrolithiasis work-up. We aimed to explore whether it can be waived under certain circumstances.

MATERIALS AND METHODS

We reviewed our prospective registry database of patients seen at our outpatient clinic for nephrolithiasis between the years 2010 and 2017. Data included: gender, age at first stone, body mass index (BMI), self-reported comorbidities and family history of nephrolithiasis. A 24-UMP was obtained from each patient under random diet. The following were recorded: urine volume, urinary levels of sodium, calcium, uric acid, oxalate and citrate. Presence of at least one comorbidity (i.e., hypertension/diabetes/hyperlipidemia) was defined as "associated comorbidities" (AC). Their absence was defined as "no comorbidities" (NC). Subjects were divided into two subgroups: first-time and recurrent stone formers, which were further divided into two subgroups: 1st + AC; 1st + NC; recurrent + AC; recurrent + NC. 24-UMPs have been compared between the four groups.

RESULTS

Four hundred and fifty-seven patients were included in the study. In the AC groups, patients demonstrated higher BMI levels (p = 0.001), and were statistically significantly obese (BMI > 30, p = 0.001) and older at first stone event (p = 0.001). First formers, either with AC or NC were more likely to have low urine volume (LUV) compared with recurrent formers (72.5 vs. 59.5%, p = 0.005). In the remaining metabolic abnormalities, no such differences were observed.

CONCLUSIONS

First-time stone formers, either with or without AC are likely to demonstrate LUV as their primary metabolic abnormality in 24-UMP. Therefore, 24-UMP may be postponed until recurrent stone event.

Nephrolithiasis in Israel: Epidemiological Characteristics of Return Patients in a Tertiary Care Center

BACKGROUND

The prevalence and etiology of nephrolithiasis vary, depending on geography, gender and ethnicity.

OBJECTIVES

To analyze the demographic data of return nephrolithiasis patients in a tertiary care center.

METHODS

We retrospectively reviewed our prospective registry database of return patients seen at our outpatient clinic for nephrolithiasis. Data included gender, age at first visit, age at first stone event, body mass index (BMI), self-reported hypertension, diabetes mellitus (DM), and hyperlipidemia. All patients were seen at least twice and had undergone a metabolic workup.

RESULTS

A total of 260 return patients were seen during the period 2010-2015. The male:female ratio was 3.1:1. Mean age at the first stone event was 44.1 years. Median time elapsed since the first stone event to medical evaluation was 5 years (interquartile range 1-12 years). Hypertension was reported by 33.1% of the patients, DM by 23.5% and hyperlipidemia by 30.4%. All three diseases were reported by 11.5% of patients. The metabolic abnormalities detected were hypocitraturia (60%), low urine volume (LUV) (60%), hypercalciuria (40.8%), hyperoxaluria (24.2%), hyperuricosuria (16.5%) and hyperuricemia (13.5%). Stone compositions from most to least frequent were calcium-oxalate (81%), calcium-phosphate (11.9%) and uric acid (7.1%). We also found that 24.6% were obese (BMI ≥ 30 kg/m2) and showed higher rates of hypertension, DM, hyperlipidemia, hyperuricemia and hyperuricosuria compared with non-obese patients. Significantly higher rates of obesity and LUV were detected in females compared with males. Patients over age 45 had lower rates of hyperuricemia compared with patients ≥ 45 years old (P = 0.038).

CONCLUSIONS

Factors related to nephrolithiasis can potentially differ among populations and countries. Our findings emphasize the significance of individualized national health programs to address local issues.

The use of Haemostatic Agents does not impact the rate of hemorrhagic complications in patients undergoing partial nephrectomy for renal masses

Hemostatic agents(HAs) have gained increasing popularity as interventions to improve perioperative haemostasis and diminish the need for allogeneic red cell transfusion(PBT) despite a paucity of data supporting the practice. The aim of the current study is to examine the efficacy of HAs in reducing the rate of hemorrhagic complications during partial nephrectomy(PN). Data on 657 patients, who underwent elective PN between 2004–2013, were analyzed. The impact of HAs and SURGICEL was evaluated by comparing four sequential groups of patients: Group1 = Sutures alone, Group2 = sutures and HA, Group3 = sutures and SURGICEL, Group4 = both HA and SURGICEL. Complications included post-operative urinary leak(UL), PBT rate, delayed bleeding and post-operative renal failure. Results showed that the use of HAs did not engender a statistically significant difference in overall complications rate. Specifically, the addition of HAs did not reduce the rate of PBT, delayed bleeding or UL. Further analysis revealed that patients who received SURGICEL had significantly higher PBT rate and higher prevalence of UL cases. Addition of HAs to SURGICEL had no effect on the rate of these complications. In the current study, the use of HAs during open and laparoscopic PN did not reduce the rate of negative outcomes. Adequate suture renorrhaphy may be sufficient to prevent hemorrhagic complications.

Mesenteric Fibromatosis Mimicking Tumor Recurrence Following Radical Cystectomy and Bladder Replacement

We report an unusual case of benign tumor mimicking tumor recurrence following radical cystectomy and bladder replacement for high grade urothelial carcinoma.

Non-surgical treatment of latrogenic postoperatively diagnosed ureteral injuries

BACKGROUND

latrogenic ureteral injury may be seen following abdominopelvic surgeries. While ureteral injuries identified during surgery should be immediately and surgically repaired, those that are postoperatively diagnosed may be treated non-surgically by draining the ipsilateral kidney. Data regarding the outcome of this approach are still missing.

OBJECTIVES

To evaluate the success rates of non-surgical management of ureteral injuries diagnosed following abdominopelvic surgeries.

METHODS

We retrospectively reviewed the files of all patients treated for iatrogenic ureteral injuries diagnosed following abdominopelvic surgeries. Patients' ipsilateral kidney was percutaneously drained following diagnosis of injury by either nephrostomy tube (NT)/nephro-ureteral stent (NUS) or double-J stent (DJS) inserted retrogradely. The tube was left in place until a pyelogram confirmed healing or a conservative approach was abandoned due to failure.

RESULTS

Twenty-nine patients were identified as having ureteral injury following abdominopelvic surgery. Median time from injury to renal drainage was 9 days, interquartile range (IQR) 4-17 days. Seven cases (24%) had surgical repair. Among the other 22 patients, in 2 oncology patients the conservative approach was maintained although renal drainage failed to resolve the injury. In the remaining 20, median drainage length was 60 days (IQR 43.5-85). Calculated overall success rates following renal drainage was 69% (18/29), and with NUS approached 78.5%.

CONCLUSIONS

Ureteral injuries diagnosed following abdominopelvic surgeries can be treated conservatively. Ipsilateral renal drainage should be the first line of treatment before surgical repair, and NUS may be the preferred drainage to obtain spontaneous ureteral healing.

Long-term urinary bladder function following unilateral refluxing low loop cutaneous ureterostomy

Purpose

Unilateral low loop cutaneous ureterostomy (LLCU) has been offered as the preferred method of temporary urinary diversion in cases of massively dilated and refluxing ureters. We sought to explore whether LLCU is effective in preserving urinary bladder function in the long term.

Materials and Methods

The charts of all patients who had undergone temporary unilateral LLCU as newborns in the presence of massive vesico-ureteric reflux were retrospectively reviewed. Demographic data, follow-up length, and presence of incontinence were recorded. Patients were interviewed regarding lower urinary tract symptoms (LUTS), and their urination patterns were recorded by using uroflow and post-void residual (PVR) measurements.

Results

Between 1972 and 2003, a total of 24 patients underwent unilateral LLCU in the presence of massively refluxing ureters. Eight patients were included in the final analysis. The median age at diversion was 12 days, the median time to closure was 22.5 months, and the median follow-up was 12.5 years. Urinary bladders showed normal contour, normal capacities, and minimal PVRs in most cases. None of the patients required augmentation cystoplasty. One patient suffered from urinary leakage and few demonstrated minimal LUTS.

Conclusions

Unilateral refluxing LLCU is an effective method of urinary diversion that preserves urinary bladder function for the long term. Larger studies are required to confirm this finding.

Reduced radiation exposure with the use of an air retrograde pyelogram during fluoroscopic access for percutaneous nephrolithotomy

INTRODUCTION

Fluoroscopy with retrograde pyelogram is commonly used to obtain access for percutaneous nephrolithotomy (PNL). Our practice uses room air for retrograde identification of calyceal anatomy. Herein we explore whether an air pyelogram was associated with a decrease in radiation exposure compared with standard retrograde pyelogram.

METHODS

We retrospectively reviewed all PNL procedures performed at our institution over the past 2 years. Of the 260 PNL procedures performed during the study period, 96 had information on radiation dosage required for analysis. The effective dose (ED) was calculated using accepted conversion tables. Multivariable linear regression was used to determine the association between ED and the use of air pyelogram controlling for factors thought to affect radiation exposure.

RESULTS

Of the 96 PNL procedures included in the study, 60 (63%) were performed with an air retrograde pyelogram (AP) and 36 (37%) used contrast retrograde pyelogram (CP). Both groups were matched in terms of age, body mass index, stone burden, and number of access tracts. Multivariable linear regression showed significantly lower radiation exposure in the AP group than in the CP group (p = 0.001). There was no difference in fluoroscopy time between the two groups. Using an AP lowered the mean adjusted ED nearly twofold, from 7.67 (CI = 5.99-9.81) to 4.45 (CI = 3.68-5.38) mSv.

CONCLUSIONS

An air retrograde pyelogram is associated with decreased radiation exposure during PNL when compared with a contrast retrograde pyelogram.

The digital flexible ureteroscope: in vitro assessment of optical characteristics

INTRODUCTION

Recent advances in endoscope design have placed the charged coupled device chip on the tip of the endoscope. The image is instantly digitalized and converted into an electrical signal for transmission. Digital technology was first introduced into flexible cystoscopes/nephroscopes and subsequently into rigid and flexible ureteroscopes. Herein, we assess the image characteristics and advantages of a new generation of digital flexible ureteroscopes.

METHODS

The Olympus URF-V flexible digital ureteroscope and the Olympus URF-P3 fiberoptic ureteroscope were assessed in vitro for image resolution, distortion, color representation, grayscale imaging, field of view, and depth of field.

RESULTS

The digital ureteroscope had a higher resolution at 3, 5, 10, and 20 mm (25.2 lines/mm vs. 8.0, 14.1 vs. 5.0, 6.3 vs. 2.8, and 3.2 vs. 1.3), respectively. Distortion with the digital flexible ureteroscope was lower, though not statistically significant. Color representation was better with the digital ureteroscope, whereas contrast evaluation was comparable between both scopes. The digital flexlible ureteroscope produced a 5.3 times larger image size compared with the standard fiberoptic flexible uretersocpe with a narrower field of view. The depth of field was limited by light and not the optic or the camera for both ureteroscopes.

CONCLUSIONS

The development of digital flexible ureteroscopes represents a significant technological advance in urology. These devices offer significantly improved resolution and color reproduction as compared with traditional fiberoptic flexible ureteroscopes. Future clinical trials are warranted to ultimately determine the advantages of these innovative endoscopes.

Low dose computerized tomography for detection of urolithiasis--its effectiveness in the setting of the urology clinic

PURPOSE

Low dose noncontrast computerized tomography is becoming a common imaging tool to diagnose urolithiasis. We investigated its usefulness as a diagnostic tool in the outpatient setting.

MATERIALS AND METHODS

A total of 62 patients with suspected urolithiasis underwent standard renal stone protocol computerized tomography with a tube current of 160 mA. Images were modified by adding image noise to simulate tube currents of 70, 100 and 130 mA. Three urologists independently interpreted the original and simulated dose scans for stone number, location and associated signs of obstruction. In addition, the investigators rated the ease of interpreting the scans and their overall level of confidence.

RESULTS

There were no statistically significant differences in interobserver and intra-observer variability for stone detection or obstruction signs except significant interobserver variability in hydronephrosis and intra-observer variability in stranding categories. Each 1 mm increase in stone size increased the likelihood of a concordant response 3.55, 2.7 and 2-fold when reducing the tube current level by 19%, 38% and 56%, respectively (p=0.001, 0.008 and 0.021, respectively). Multiple stones or index stone location were not associated with agreement. The overall level of confidence decreased with lower simulated doses, particularly in the bony pelvis (p<0.02).

CONCLUSIONS

Low dose computerized tomography may serve as an effective tool in the setting of the urology clinic in patients with urolithiasis. This imaging tool can better assess urolithiasis and associated obstruction than plain abdominal radiographs, but it may be problematic with small stones (less than 2 mm) and evidence of distal ureteral obstruction. Its effectiveness as a long-term followup tool requires further prospective trials.

AKT1 E17 K pleckstrin homology domain mutation in urothelial carcinoma

The PI3K/AKT pathway is frequently activated in human cancer. Recently, a G to A point mutation (E17K) was found in the pleckstrin homology domain of AKT1. We aimed to explore this mutation in cases of urothelial carcinoma. Using chip-based matrix-assisted laser desorption-time-of-flight (MALDI-TOF) mass spectrometer, AKT1 E17K mutation was searched in 26 total RNA samples obtained from 26 patients known to have urothelial carcinoma. Mutation was found in one out of 26 (3.8%) patients - a 46 year old female with a low grade transitional cell carcinoma located to the lamina propria (Ta disease). Our finding is in line with previous studies showing AKT1 E17K mutation to be rare. Yet, further studies are required to determine whether this mutation is indeed related to less aggressive disease and carries better prognosis.