Simultaneous peritoneal and retroperitoneal splenosis mimics metastatic right adrenal mass

INTRODUCTION

Right retroperitoneal splenosis is rare with few reported cases. We report, here, the case of simultaneous peritoneal and retroperitoneal splenosis mimics metastatic right adrenal mass.

PRESENTATION OF CASE

A 28-year-old man who had previously undergone post traumatic splenectomy at childhood and subsequently presented with an large incidental non-functioning right adrenal mass with presence of extra-hepatic peritoneal focal lesion diagnosed as metastasis by magnetic resonance imaging (MRI). Adrenalectomy with metatstectomy was performed, and both masses were identified to be splenosis.

DISCUSSION

Adrenal incidentalomas (AIs) is defined as asymptomatic masses >1 cm. on cross-sectional imaging studies. AIs have significant malignant potential for masses > 6 cm. Splenosis are found most frequently in the left retroperitoneum in cases involving retroperitoneal splenosis. However, right retroperitoneal splenosis have been reported. Traditional imaging techniques cannot differentiate splenosis from malignancy.

CONCLUSION

Large right adrenal incidentalomas present with other abdominal, peritoneal masses could be splenosis in patient following post-traumatic splenectomy.

Acute kidney injury following radical cystectomy and urinary diversion: predictors and associated morbidity

Introduction:

Acute kidney injury (AKI) after major surgeries is associated with significant morbidity and mortality. We aim to report incidence, predictors and associated comorbidities of AKI after radical cystectomy in a large cohort of patients.

Materials and Methods:

We conducted a retrospective analysis of 1000 patients who underwent open radical cystectomy in a tertiary referral center. Perioperative serum creatinine measurements were used to define AKI according to the RIFLE criteria (as Risk, Injury and Failure). The predictors of AKI after surgery were determined using univariate and multivariate analyses.

Results:

Out of 988 evaluable patients, AKI developed in 46 (4.7%). According to RIFLE criteria; AKI-Risk, AKI-Injury and AKI-Failure occurred in 26 (2.6%), 9 (0.9%) and 11 (1.1%) patients, respectively. Multivariate analysis showed that performing nephroureterectomy with cystectomy (Odds ratio [OR]: 4.3; 95% Confidence interval [CI]: 1.3-13.6; p=0.01) and the development of high grade complications (OR: 3.8; 95% CI 1.9-7.2; p<0.0001) were independently associated with AKI.

Conclusions:

AKI is a significant morbidity after radical cystectomy and the term should be included during routine cystectomy morbidity assessment.

Long-term effects of anatrophic nephrolithotomy on selective renal function

To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

Muscle-invasive bladder and urethral cancer recurrence after surgical management of upper tract urothelial carcinoma: A review of 305 patients

OBJECTIVE

Bladder cancer recurrence after management of upper tract urothelial carcinoma (UTUC) is a common disease. Although the incidence and risk factors for the development of noninvasive bladder tumor have been reported in many series, rare studies have reported on muscle invasive bladder cancer (MIBC) and its urethral recurrence. We aimed to report the incidence, risk factors and survival rate for the development of MIBC and urethral tumors after surgical management of UTUC.

MATERIAL AND METHODS

We retrospectively reviewed patients who were surgically treated for UTUC from 1983 to 2013. The tumor was categorized according to the 1997 TNM staging and the 3-tiered WHO grading systems. The primary endpoint of this study was the occurrence of any post-treatment MIBC and its urethral recurrences. We studied the possible risk factors that may contribute to the development of such pathology as well as the prognosis of this pathology.

RESULTS

A total of 297 patients were eligible for analysis. Intravesical tumor recurrence was observed in 139 (46.8%) patients and radical cystectomy was warranted for 36 patients (MIBC or multicentric bladder recurrence). Twenty-seven patients were fit for surgery with ileal loop conduit was the urinary diversion for the majority, and others received radiotherapy. Ureteral tumor was the only statistically significant risk factor (p=0.001) and the incidence increased as the ureteral tumors became more distal (p=0.01). Occurrence of invasive or multicenteric bladder recurrence was a predictor for local, urethral recurrence and distant metastasis (p=0.016, 0.0001 and 0.01 respectively). Seven patients had urethral urothelial carcinoma; 5 were diagnosed at the time of cystectomy and 2 were discovered later (1 and 3 years after cystectomy).

CONCLUSION

MIBC is a relatively uncommon (6%) post UTUC, and ureteral tumors, especially distal in location, are the independent risk factor. Extended surveillance for those patients is needed. Urethral cancer recurrence is rare (2%); most cases are localized in the posterior urethra, they are noninvasive, and may develop even after cystectomy.

Contemporary Management of Renal Transplant Recipients With De Novo Urolithiasis: A Single Institution Experience and Review of the Literature

OBJECTIVES

We report on the long-term follow-up of managing allograft stones at a single tertiary referral institution and review the relevant literature.

MATERIALS AND METHODS

A retrospective analysis of renal allograft recipient charts was performed to identify patients who developed allograft lithiasis between 1974 and 2009. Patient and stone characteristics, diagnoses, treatments, and outcomes were described.

RESULTS

Sixteen patients developed 22 stones after a median follow-up of 170 months (range, 51-351 mo). The mean (standard deviation) and median diameter of the stones were 13.8 (8.5) mm and 11 mm. Among these, 3 stones were treated conservatively, 3 by shock-wave lithotripsy, and 7 by cystolitholapaxy. Seven patients underwent percutaneous treatment in the form of percutaneous nephrostomy tube fixation and spontaneous passage of stone (1 stone), shock-wave lithotripsy (1 stone), antegrade stenting (1 stone), and percutaneous nephrolithotomy (6 stones). All patients were stone free after treatment, except for 2 patients whose stones were stable and peripheral on long-term follow-up.

CONCLUSIONS

Allograft lithiasis requires a multimodal treatment tailored according to stone and graft characteristics. Protocols regarding spontaneous passage can be adopted if there is no harm to the graft and the patient is compliant. Careful attention to the anatomy during percutaneous nephrostomy tube placement is mandatory to avoid intestinal loop injury. A more attentive follow-up is required for early stone management.

Bioprocess enhancement of feather degradation using alkaliphilic microbial mixture

1. The main aim of this work is to develop a robust method to generate a microbial mixture which can successfully degrade poultry feathers to overcome environmental problems. 2. Four different alkaliphilic microbes were isolated and shown to degrade poultry feathers. 3. Two of the isolates were phylogenetically identified as Lysinibacillus and the others were identified as Nocardiopsis and Micrococcus. 4. The best microbial co-culture for white and black feather degradation was optimised for pH, temperature and relative population of the isolates to achieve almost 96% of degradation compared with a maximum of 31% when applying each isolate individually. 5. The maximum activity of keratinase was estimated to be 1.5 U/ml after 3 d for white feathers and 0.6 U/ml after 4 d for black feathers in a basal medium containing feather as the main carbon source. Additionally, non-denaturing polyacrylamide gel electrophoresis showed 4 and 3 protease activity bands for white and black feather, respectively. 6. This study provides a robust method to develop potential new mixtures of microorganisms that are able to degrade both white and black feathers by applying a Central Composite Design.

Non-transitional cell carcinoma of the upper urinary tract: A case series among 305 cases at a tertiary urology institute

Non-transitional cell carcinomas (non-TCC) of the upper urinary tract as squamous cell carcinoma (SCC), adenocarcinoma, and small cell carcinoma (SmCC) are rare with few case reports in the literature. We retrospectively reviewed our patients who surgically treated for upper tract urothelial carcinoma from 1983 to 2013 for non-TCC pathological cancer characteristics and survival. Among 305 patients, only 5 (1.6%) cases were found: One case of SmCC, another had adenocarcinoma, and 3 SCC cases. None of them had intravesical recurrence and the cancer-specific survival for non-TCC cohort is markedly decreased (log-rank = 0.01) compared to TCC patients.

A Method for Reconstruction of Severely Damaged Spinal Cord using Autologous Hematopoietic Stem Cells and Platelet-rich Protein as a Biological Scaffold

Introduction:

There have been attempts to alter the prognosis of severe spinal cord injury in different centers, but none of which have reliably altered the outcome. Some trials use stem cells (SCs) that produced widely differing results. We hereby add our experience in our center of a surgical reconstruction of the damaged spinal cord using a mixture of SCs and Platelet-Rich Protein (PRP) with fibrin coated as a biological scaffold.

Materials and Methods:

Four cases of severely damaged spinal cord have been operated for neurolysis and reconstruction of the spinal cord using SCs and platelet-rich protein (PRP) with fibrin coated harvested from the peripheral circulation of the patient. PRP serves to maintain the position of the SCs. One milliliter suspension contains an average of 2.8 × 10⁶ of autologous hematopoietic SCs. Patients were intraoperatively monitored by somatosensory evoked potential, motor evoked potentials, and delta wave. They are clinically followed postoperatively and electromyogram was repeated every 2 weeks. Magnetic resonance imaging (MRI) was repeated regularly. The patients are followed up for a period between 2 and 3 years.

Results:

One patient demonstrated motor and objective sensory improvement (P = 0.05), two other patients reported subjective sensory improvement, and the fourth one remained without any improvement (P = 0.1). None of these patients demonstrated any sign of deterioration or complication either on the surgery or on implanting of the SCs. MRI clearly proved that the inserted biological scaffold remained in place of reconstruction.

Conclusion:

SCs may play a role in restoring spinal cord functions. However, the unsolved problems of the use of SCs and related ethical issues should be addressed.

External stent versus double J drainage in patients with radical cystectomy and orthotopic urinary diversion: A randomized controlled trial

OBJECTIVES

To compare treatment-related outcomes of ureteral stenting with an external versus double J stent in patients with orthotopic reservoirs after radical cystectomy.

METHODS

Patients undergoing radical cystectomy and orthotopic neobladder were randomized into two groups; group I patients received external stents, whereas group II received double J stents. In both groups, preoperative parameters were recorded, and patients were assessed regarding urinary tract infection, urinary leakage, upper tract deterioration, readmission and hospital stay.

RESULTS

A total of 48 and 45 patients were randomized in the external stent group and double J group, respectively. Both groups were comparable in terms of age, sex, associated comorbidity and oncological status. Early urinary leak was observed in two patients (4.2%) in the external stent group, and in two patients (4.4%) in the double J group (P = 0.95). None of our patients developed ureteral strictures in the external stent group, and one patient did in the double J group (P = 0.3). Positive urine culture (58.3%, 51.1%) as well as febrile urinary tract infections (2.1%, 6.7%) were comparable between both groups, respectively (P = 0.43, 0.28). Wound complications (12.5%, 8.9%) and stent-related complications (2.1%, 0%) were comparable between both groups, respectively (P = 0.57, 0.33). The mean hospital stay was 17.5 days (range 14-32 days) and 14.6 days (range 10-42 days) in both groups, respectively (P = 0.001), with comparable re-admission rates (P = 0.95).

CONCLUSIONS

Incorporation of double J stents in orthotopic urinary diversion is a safe alternative to the routinely used external stenting.

Histopathologic Characteristics of Upper Tract Urothelial Carcinoma With an Emphasis on Their Effect on Cancer Survival: A Single-Institute Experience With 305 Patients With Long-Term Follow-Up

INTRODUCTION

Tumor stage and grade represent the best established predictors for the prognosis of upper tract urothelial carcinoma (UTUC). However, controversies still exist regarding the role of tumor necrosis, location, and multifocality in the prognosis of UTUC. We share our experience with 305 patients, reporting on the pathologic features in detail, cancer characteristics, and survival.

MATERIALS AND METHODS

We retrospectively reviewed the data from patients who had undergone surgery for UTUC from 1983 to 2013. The tumors were staged according to the 1997 TNM classification and the 3-tiered World Health Organization grading system. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method.

RESULTS

A total of 305 patients were eligible for analysis. The 5-year CSS for grade 1, 2, and 3 was 88%, 84%, and 60%, respectively. The CSS for stage pT1, T2, T3, and T4 was 82%, 70%, 62%, and 0%, respectively. On univariate analysis, tumor stage, tumor grade, positive lymph node status, and micropapillary invasion had adverse effects on survival (P = .006, P = .045, P = .01, and P = .005, respectively). On multivariate analysis, only stage and micropapillary variant maintained significance (P = .01). Multicentricity and tumor location affected CSS in the early follow-up period but did not in the late follow-up period. Neither carcinoma in situ nor adverse pathologic variants affected survival.

CONCLUSION

The tumor stage and presence of a micropapillary variant are of paramount prognostic significance for survival in patients with UTUC. The tumor grade and lymph node status are also good predictors. In our series, multifocality and tumor location affected early and mid-term survival with no significant effects on late survival.

Risk factors of hospital readmission after radical cystectomy and urinary diversion: analysis of a large contemporary series

OBJECTIVES

To determine the incidence, risk factors and causes of hospital readmission in a large series of patients who underwent radical cystectomy (RC) and urinary diversion.

PATIENTS AND METHODS

We retrospectively analysed the data of 1000 patients who underwent RC and urinary diversion between January 2004 and September 2009 in our tertiary referral centre. Patients stayed in hospital for 21 and 11 days for orthotopic and ileal conduit diversions, respectively. The primary outcome was the development of a complication requiring hospital readmission at ≤3 months (early) and >3 months (late). Causes of hospital readmissions were categorised according to frequency of readmissions. Predictors were determined using univariate and multivariate logistic regression models.

RESULTS

In all, 895 patients were analysed excluding 105 patients because of perioperative mortality and loss to follow-up. Early and late readmissions occurred in 8.6% and 11% patients, respectively. The commonest causes of first readmission were upper urinary tract obstruction (UUO, 13%) and pyelonephritis (12.4%) followed by intestinal obstruction (11.9%) and metabolic acidosis (11.3%). The development of postoperative high-grade complications (odds ratio [OR] 1.955; 95% confidence interval [CI] 1.254-3.046; P = 0.003) and orthotopic bladder substitution (OR 1.585; 95% CI 1.095-2.295; P = 0.015) were independent predictors for overall hospital readmission after RC. Postoperative high-grade complications (OR 2.488; 95% CI 1.391-4.450; P = 0.002), orthotopic bladder substitution (OR 2.492; 95% CI 1.423-4.364; P = 0.001) and prolonged hospital stay (OR 1.964; 95% CI:1.166-3.308; P = 0.011) were independent predictors for early readmission while hypertension (OR 1.670; 95% CI 1.007-2.769; P = 0.047) was an independent predictor for late readmission.

CONCLUSION

Hospital readmissions are a significant problem after RC. In the present study, UUO, pyelonephritis, metabolic acidosis and intestinal obstruction were the main causes of readmission. Orthotopic bladder substitution and development of postoperative high-grade complications were significant predictors for overall readmission.

Salvage of grafts with vascular thrombosis during live donor renal allotransplantation: a critical analysis of successful outcome

OBJECTIVES

To report a high-volume institution experience with salvage techniques for vascular accidents during live donor renal allotransplantation.

METHODS

Between March 1976 and January 2011, 2208 recipients underwent live donor renal allotransplantation. A retrospective review of recipients with vascular accidents - renal artery thrombosis and renal vein thrombosis - was carried out. Salvage procedures were recorded and their outcomes were assessed.

RESULTS

A total of 23 (1%) vascular accidents occurred, including renal artery thrombosis and renal vein thrombosis in 19 (0.8%) and four (0.18%) recipients, respectively. All renal artery thrombosis patients were treated by open revascularization and the graft was salvaged in 12 patients (63%). Two renal vein thrombosis events were resolved by percutaneous catheter-directed thrombolytic therapy. Of the other two allografts, one was salvaged by thrombectomy and revascularization, and the other was lost. On univariable analysis, older recipients (P = 0.003), pretransplant hypertension (P =  0.001), more human leukocyte antigen mismatches (≥3; P = 0.036), shorter ischemia time (≤45 min; P = 0.004) and longer time to diagnosis (>3.5 days; P = 0.013) were significantly associated with non-salvage of the graft after vascular accidents. Nevertheless, none of these variables were significant on the multivariable analysis. Over a median follow up of 35 months, the median (range) serum creatinine was 2 mg/dL (range 0.8-8.8 mg/dL), and 11 (79%) recipients were living with functioning grafts.

CONCLUSIONS

Despite the devastating complications, vascular accidents are salvageable and revascularization is crucial for graft salvage. Angiographic percutaneous techniques are viable alternatives for renal vein thrombosis.

The effect of three whitening oral rinses on enamel micro-hardness

The purpose of this study was to determine the effect on human enamel micro-hardness of three over-the-counter whitening oral rinses available in South Africa. Enamel fragments were gathered into three groups of 15 each. One group was exposed to Colgate Plax Whitening Blancheur, the second group to White Glo 2 in 1 and the third to Plus White, in each case for periods recommended by the respective manufacturers. Surface micro-hardness of all groups was measured before and after a 14 day treatment period. pH levels of the oral rinses were also determined with a combination pH electrode. Pre- and post- treatment data were analysed by the Wilcoxon Signed Rank Sum Test. According to the micro-hardness values no significant (p > 0.05) enamel damage was found as a result of treatment. However, it was observed that Colgate Pax and White Glo decreased the enamel hardness, an early sign of enamel damage, while Plus White showed a small increase in hardness. The three whitening oral rinses on the South African market do not damage the tooth enamel significantly when used as recommended by the manufacturers. However, extending the contact period and increasing the frequency of application might lead to damage of enamel.