Ureteroscopic management of chronic unilateral hematuria: a single-center experience over 22 years

Objective

To analyze the short and long term safety and efficacy of ureteroscopic evaluation and management of chronic unilateral hematuria.

Methods

We retrospectively reviewed patients with chronic unilateral hematuria from 1987 to 2008. The distal to middle ureter was evaluated with a semi-rigid ureteroscope without a guidewire. Subsequently, the flexible ureteroscope was advanced into the upper ureter to the renal pelvis using a low-pressure automated irrigant system (Uromat™). Lesions identified ureteroscopically were treated with diathermy fulguration.

Results

One hundred and four (56 male, 48 female) patients were identified, with a median age of 37 (14–80) years and median follow-up of 139 (34–277) months. The median preoperative duration of gross hematuria was 5 (1–144) months. Endoscopic findings included 61 (56%) minute venous rupture (MVR; a venous bleeding without clear abnormalities), 21 (20%) hemangioma (vascular tumor-like structure), 3 (3%) varix (tortuous vein), 1 (1%) calculus and 18 (17%) no lesions. The incidence of “no lesions” was less in the recent 12 years (9%) than the first 10 years (27%), while the incidence of MVR increased from 40 to 66% (p<0.05). All patients were treated endoscopically. Immediate success rate was 96% (100% in the recent 12 years). Long-term recurrent gross hematuria rate was 7%. Six resolved spontaneously and only 1 required ureteroscopy, revealing a different bleeding site.

Conclusion

Ureteroscopy and diathermy fulguration is highly useful for evaluation and treatment of chronic unilateral hematuria. Sophisticated technique and improved instrumentation contributes to a better outcome.

Histological changes due to intravesical instillation of mitomycin C

OBJECTIVE

Transurethral resection (TUR) is highly effective in the local control of superficial bladder cancer. However, the recurrence rate can reach 80% of the cases. Adjuvant intravesical chemotherapy may decrease significantly tumor recurrence. We describe a bladder adverse reaction to mitomycin C as adjuvant therapy for non-invasive bladder cancer

METHODS

Three patients with diagnosis of pTa G1 urothelial carcinoma were treated by TUR plus an instillation of 40 mg. of mitomicin C. A month later, the patients were attended for dysuria and hematuria. Cystoscopy and bladder biopsy were performed in all cases.

RESULTS

Multiple sessile lesions suspicious of tumor recurrence were found on cystoscopy. The histopathological diagnosis disclosed the existence of severe atypia of the urothelium and stromal changes similar to those observed after radiotherapy

CONCLUSIONS

Adjuvant intravesical chemotherapy with mitomycin C may cause local reactions with macroscopic patterns similar to tumoral recurrences.

Antopol-Goldman lesion: a rare clinical entity in the differential diagnosis of macroscopic hematuria

OBJECTIVE

To describe the case of a patient with gross hematuria. The pathological study revealed a subepithelial hematoma of the renal pelvis (Antopol-Goldman lesion).

METHODS/RESULTS

An 86 year-old woman presented with gross hematuria through the right ureteral orifice. A filling defect is visualized in the right renal pelvis on CT and right nephroureterectomy was carried out after the diagnosis of suspicious upper urinary tract tumor. The pathological study revealed the presence of a subepithelial hematoma without evidence of malignancy.

CONCLUSION

Antopol-Goldman lesion is a benign condition that one must have in mind in the work up of patients with hematuria and filling defects in the urinary tract who present a predisposing factor for pyelic hematoma.

Comparative analysis of two methodologies for the identification of urinary red blood cell casts

INTRODUCTION

Dysmorphic red blood cells (RBCs) in the urine are a strong indicator of a glomerular bleeding source. RBC casts, which while generally following RBC dysmorphism are not frequently seen on routine urinalysis, are also important indicators of glomerular hematuria.

OBJECTIVE

This study tested the superiority of a urine concentration technique (CT) over the standard method (SM) for RBC cast identification in a group of patients suspected of glomerular hematuria.

MATERIAL AND METHODS

Of a total of 4,227 routine urinary samples, 249 with dysmorphic hematuria were selected. The samples were processed according to two techniques: standard method (SM) and concentration technique (CT). The percentages of RBC cast identification according to each method were compared.

RESULTS

The CT showed a higher rate of RBC casts (52.6%) compared to the SM (8.4%) (p < 0.001).

DISCUSSION AND CONCLUSION

We suggest that the SM did not sufficiently concentrate the urine sample, the RBC casts remaining in the supernatant and being discarded. The CT increased the sensitivity of the RBC cast yield. The CT, associated with the presence of RBC dysmorphism, was useful to increase the agreement of the two parameters used for identification of glomerular-based bleeding and the diagnosis of glomerular diseases, important causes of chronic kidney disease.

Prostatic leiomyoma. Case report

OBJECTIVE

We try to show the relevance of this rare pathology and to set its importance in the differential diagnosis of prostate masses.

METHODS

We report a case and perform a search in the MEDLINE database of the series described up to the date.

RESULTS

Prostatic leiomyoma is a extremely rare anatomopathological finding, though the appearance of a glandular hyperplasia with small areas of leiomyomatous growth is more common. Up to date there are just a hundred cases described. They are benign mesenchymal tumors without evidence of disease recurrence after surgery. When they present symptomatology, they emulate benign hyperplasia with urinary tract infections. Although it has benign nature, surgical intervention is indicated when severe clinical symptoms appear.

CONCLUSIONS

The recognition of this benign entity and the distinction from other neoplasias has important therapeutic and prognostic implications. Imaging techniques and pathological analysis are crucial for this reason. When an unusual prostatic mass is detected, the leiomyoma must be included in the differential diagnosis.

[The clinical and pathologic features of vascular amyloid deposits of amyloid nephropathy in 6 patients]

OBJECTIVE

To analyze clinical and pathologic features of a rare vascular amyloid deposits of amyloid nephropathy (VADAN) in 6 patients, so as to improve its diagnosis and treatment.

METHODS

All patients received immunopathology, microscopy and electron microscopy examination, and amyloid types were analyzed.

RESULTS

There were 3 males and 3 females with ages ranging from 52 to 73 years. Two patients suffered from multiple myeloma. Majority patients had slight albuminuria and hematuria. One patient combined with minimal change glomerular disease presented nephrotic syndrome. One patient combined with IgA nephropathy had albuminuria and hematuria. And one patient had myeloma cast nephropathy with acute renal failure. Kidney biopsy proved amyloid deposits along interlobular arterial wall only in all 6 patients. Two cases secondary from multiple myeloma were κ amyloid, and the rests were λ amyloid.

CONCLUSIONS

VADAN is a rare type of amyloid nephropathy. Its clinical manifestation is different from common amyloid nephropathy. Kidney biopsy will benefit its differential diagnosis.

Retrograde flexible ureteroscopy: reshaping the upper urinary tract endourology

Introduction of retrograde flexible ureteroscopy represented a leap forward in upper urinary tract endourology. Nowadays, areas of the pyelocaliceal system accessible otherwise only by percutaneous or open surgery, can be approached in a retrograde fashion, using the anatomical pathways. The flexible ureteroscopes evolved from the limited deflectable first generation ones to the digital very maneuverable models. The ancillary instruments and the energy sources underwent a similar evolution. Flexible ureteroscopy is a very useful investigative method, especially in patients with equivocal data provided by the imaging. Introduction of this procedure decreased significantly the number of cases with so called "essential" hematuria. The conservatively treated upper urinary tract tumors can be also followed-up more efficiently, the recurrence being identified before becoming radiological obvious. Initially reserved only for diagnostic purposes, flexible ureteropyeloscopy may be used also in the treatment of various pathological conditions of the upper urinary tract such as lithiasis, stenosis, tumors, pyelocaliceal abnormalities etc. However, technical limitations regarding the visibility and access are still influencing the outcome of the method. The characteristics of the available flexible endoscope, and how they are influenced by the used energy sources and ancillary instruments is crucial for achieving the best performances. Also the particularities of the lesion and upper urinary tract anatomy have a significant impact over the flexible ureteroscopic approach. Despite the already achieved efficacy, the technological progress may still allow various improvements of the method, including robotic flexible ureteroscopy.

Assessment of hematuria

The most common causes of hematuria in adults include urinary tract infections, urolithiasis, benign prostatic enlargement, and urologic malignancy. Once hematuria is confirmed, its cause should be investigated through a comprehensive history, a focused physical examination, laboratory studies, an image-based assessment of the upper urinary tract, and a cystoscopic evaluation of the lower urinary system. Prompt evaluation and appropriate referral of patients with documented hematuria should be initiated in the primary care setting according to the proposed guidelines, and aimed at cost-effective and early detection of urologic abnormality.

[Case of Marfan syndrome with microscopic hematuria]

A 36-year-old man was admitted to our hospital for investigation of microscopic hematuria. He was very tall and presented arachnodactyly of the fingers and toes. Chest computed tomography and cardiac echography revealed annuloaortic ectasia and aortic regurgitation. Based on these findings, we suspected Marfan syndrome and performed gene analysis of the FBN1 gene, which encodes fibrillin-1. Mutational analysis showed the missence mutation, p. Ile 2585 Thr, present in exon 62 of the FBN1 gene. To investigate the genesis of microscopic and dismorphic hematuria, we performed a renal biopsy. Light microscopic analysis revealed the absence of any apparent histological changes in the glomerulus, small artery and arteriole. Electron microscopic analysis revealed the glomerular basement membrane to be irregularly thickened, however, there was neither any electron dense deposition nor fibrillar material. Marfan syndrome is an inherited disorder of connective tissue based on abnormality of the FBN1 gene. Fibfibrllin-1 acts not only as a component of microfibrils, but also as the regulator of transforming growth factor -beta signal transduction. From these points of view, we speculated that irregular formation of the glomerular basement membrane of our patient was induced by an imbalance in production of the extracellular matrix as the consequence of abnormal fibrillin-1--TGF-beta signaling.

Hepatitis C virus-related kidney disease: various histological patterns

BACKGROUND

Although hepatitis C virus (HCV) infection is known to be associated with Type 2 cryoglobulinemic glomerulopathy (CG), only a few reports about other types of nephropathy have been published.

METHODS

68 HCV antibody positive patients in whom renal biopsy had been performed for persistent proteinuria, hematuria, and/or renal dysfunction between 1992 and 2008 at our institute were included. The histological, clinical and laboratory characteristics including the age, gender, hypertension, diabetes mellitus, liver histology (chronic hepatitis or liver cirrhosis), HCV-RNA, HCV genotype, splenomegaly, gastroesophageal varices, serum creatinine, hemoglobin, platelet count, rheumatoid factor, cryoglobulin, IgG, IgA, IgM, CH50, C3, C4, creatinine clearance, 24-h protein excretion, and hematuria, between their nephropathy with and without immune deposition were compared.

RESULTS

Nephropathy was classified into two groups based on the detection of immune deposits by immunofluorescence microscopy: i.e., a positive group (n = 39) and a negative group (n = 29). The former group was further classified into three types of nephropathy: IgG dominant group (n = 10) (including membranous nephropathy (MN)), IgA dominant group (n = 20) (including IgA nephropathy (IgAN)), membranoproliferative glomerulonephritis (MPGN) (IgA type)), and IgM dominant group (n = 9) (MPGN apart from the IgA type). The latter group included diabetic nephropathy (n = 13), focal glomerular sclerosis (n = 4), and benign nephrosclerosis (n = 3), malignant nephrosclerosis (n = 1), tubulointerstitial nephritis (TIN) (n = 2), minimal change nephrotic syndrome (n = 1), cast nephropathy (n = 1), granulomatous TIN (n = 1), and others (n = 3). An increased serum IgM level, hypocomplementemia, splenomegaly, thrombocytopenia, liver cirrhosis, hematuria, and a high HCV RNA level were features of patients with MPGN of IgM dominant group (consistent with "CG").

CONCLUSIONS

Our results showed various histological patterns of HCV-related kidney disease and the specificity of CG, and revealed that a minority of HCV patients (n = 7) presented typical CG, while IgAN, MN, and diabetic nephropathy were more frequent.

[Liver damage in a patient treated with a vitamin K antagonist, a statin and an ACE inhibitor]

We report the case of a 71-year-old male patient who presented at the emergency room with episodes of epistaxis and jaundice. The patient was on therapy with phenprocoumon, atorvastatin and perindopril. Findings on admission included prominent elevation of transaminases and bilirubin and a high INR due to impaired liver function and oral anticoagulation. After exclusion of other causes like viral or autoimmune hepatitis and after having obtained a liver biopsy, a diagnosis of drug induced liver damage (DILI) was made. Epidemiology, pathophysiology and clinical signs of DILI are discussed with a special focus on coumarines, statins and ACE-inhibitors.

[Characteristic of cytopathological changes in urine after extracorporeal shock wave lithotripsy]

The aim of the study is to assess the damage to the urothelium caused by shock waves through cytological examination of the urinary sediment in patients who had ESWL. Study included 100 otherwise healthy first-time stone-formers aged 20 to 50, who underwent ESWL on Modulit SLK machine. Urinary samples were taken before and immediately after ESWL, in two days and on the fourth day after ESWL. Control group included 20 healthy individuals. The urine was centrifuged, smears fixed by conventional MGG method and stained by azure-eosine using Pappenheim's method. Cytogram data analysis was performed using morphometric methods, allowing for qualitative and quantitative cell characteristics be translated into digital form. Student t-criteria was used for statistical evaluation of the difference of derived figure parameters. The authors put the stress on destructives processes. In order to rule out biased assessment of the cytograms, morphometric examination of urinary sediment was performed. Averaged value of the total cell index was calculated with one of the forms of cytopathology and deduced heterogeneity of cytological indices within a particular group X(cell)/ Σep (X(cell) where is the average value of the total cell index with one of the forms of cytopathology within the whole sampling, Sep is the total number epithelial cells). The sum of absolute indices of cytological changes is considered as "destruction index" (DI), which reflects accumulated pathological changes in epithelial cells: DI=X(1)/Σep + X(2)/Σep Immediately after ESWL a statistically valid (p<0.01) significant increase in DI is registered. In two hours after the session DI is decreased, but remains rather high, and almost normalizes by the fourth day. We also explored the specificity particular for each term of examination, expressed by cytological changes. Examination of indices of heterogeneity within a group with moderately expressed destructive changes (X(1)/Σep) revealed that these digital values even in healthy men are slightly above zero (0.15 ± 0.03). Just after ESWL values rise to 0.6 ± 0.1, then slowly decrease to 0.4 ± 0.1 (2 hours after) and 0.25 ± 0.07 (four days after). As to parameters specific to deep cellular changes (X(2)/Σep), it is equal to zero healthy men, rises after ESWL, then decreases in two hours and almost normalizes by fourth day. Digital values for this parameter are several orders lower than for parameters of cells with moderate changes. Study results indicate that epithelial lining of the upper urinary tract undergoes cytopatho-logical changes of different degrees, still they are of transitory and reversible nature, which is proven by urinary sediment cytogram performed on the fourth postprocedure day.

[Clinical significance of urine sediment spectrum analyses in crescentic glomerulonephritis]

OBJECTIVE

To explore whether the analyses of urine sediment spectrum contribute to the diagnosis of crescentic nephritis and whether special cells in urine could be a biomarker for the early stage crescentic nephritis.

METHODS

Thirty-five patients diagnosed as crescentic nephritis with renal biopsy were recruited. The phase-contrast microscope was used to observe the early morning urine and offer comprehensive descriptions of urine sediment spectrum. And podocalyxin antibody was utilized to detect podocytes in urine and renal specimens by immunohistochemistry.

RESULTS

Marked hematuria and casts were present in the urine of crescentic nephritis and "special cells" appeared in over 50% subjects. The detection rates of "special cells" were 75%, 41% and 0 respectively in early, middle and later stages of crescentic nephritis. Podocytes were identified in the urine of 8/9 subjects.

CONCLUSIONS

The urine sediment spectrum contributes to the diagnosis of crescentic nephritis. And special cells in urine are helpful to gauge the stage of crescentic nephritis.

[Isolated microhematuria: biopsy, yes or no?]

Isolated asymptomatic hematuria is frequently encountered in clinical practice but there are no established recommendations for its evaluation and management. There is controversy regarding which tests are necessary and whether renal biopsy is indicated. In the pediatric population, renal biopsy should be considered if there is evidence of progressive renal disease or when parents are worried about their child's diagnosis or prognosis. In adults, examinations for isolated microhematuria should include exclusion of pharmacological causes, journeys to endemic areas for S. haematobium or tuberculosis, sickle-cell disease, endometriosis and, in patients older than 40 years, kidney, ureteral or bladder cancer. Examination of urinary sediment may help in identifying the origin of microhematuria. If it is decided to perform a renal biopsy, the patient should be carefully informed of the possible complications of renal biopsy, including the possibility of finding normal renal tissue.

Impact of primary hypertension on hematuria of the patients with benign prostatic hyperplasia

BACKGROUND

Both benign prostatic hyperplasia (BPH) and primary hypertension are common in the elderly men. The purpose of this study was to investigate the possible effect of primary hypertension on the hematuria in patients with BPH.

METHODS

All patients who underwent transurethral resection of prostate or opening operation had confirmed diagnoses of BPH histologically. comparative analysis of packet was used to analyze the incidence of hematuria in 423 BPH patients with or without hypertension. Immunostaining of CD34 and vascular endothelial growth factor (VEGF) was carried out in tissues of 50 cases of simple BPH and 50 cases of BPH accompanied with hypertension.

RESULTS

The incidence of hematuria in the BPH with hypertension was significantly higher than that in the simple BPH (P < 0.01). Furthermore, the incidence of hematuria in patients who had hypertension for more than 10 years was clearly higher than that in the patients who had hypertension for less than 10 years (P < 0.01). Both microvessel density (MVD) based on CD34 immunostaining and VEGF expression were significantly higher in the BPH tissues of patients with hypertension than that in the simple BPH (P < 0.01, P < 0.05).

CONCLUSIONS

Long-term hypertension may significantly increase the incidence of hematuria in patients with both BPH and hypertension. Increased MVD level and VEGF expression may account for the higher incidence of hematuria in these patients.

Urinary cytologic features of primary large cell neuroendocrine carcinoma of the urinary bladder: a case report

BACKGROUND

Little is known about urine cytology of large cell neuroendocrine carcinoma (LCNEC) of the bladder. We report a case of primary LCNEC of the bladder, focusing on urinary cytology.

CASE

A 76-year-old woman who had a history of transurethral resection for urothelial carcinoma of the bladder visited our hospital because of intermittent gross hematuria. Urinary cytology on this visit identified atypical cells, interpreted initially as urothelial carcinoma. Cystoscopy detected a tumor apart from the previous bladder urothelial carcinoma. The diagnosis of LCNEC was pathologically confirmed after the transurethral resection; subsequently radical cystectomy and bilateral pelvic lymphadenectomy were performed. Based on the review of urine cytology for this tumor, neoplastic cells possessed rosette and nuclear molding arrangements with finely or coarsely granular, hyperchromatic nuclei. The average nuclear size of the neoplastic cells was 10.3 microm, whereas the average cell size was 14.9 microm. These cells were immunocytochemically positive for synaptophysin, consistent with LCNEC. The operative course for this patient was uneventful, and LCNEC had not recurred in the 48 months since cystectomy.

CONCLUSION

Our observations suggest that urinary cytology in combination with morphometry and immunocytochemistry may be a potentially useful method for the detection of LCNEC of the bladder.

[Contribution of bladder biopsy to the study of urogynaecological patient]

BACKGROUND

One of the characteristics of urinary symptoms in women is their lack of specificity. Patients with stress incontinence or urgency, local irritation, infection, distal stenosis or a neoplastic process have very similar symptoms.

OBJECTIVE

Determine the frequency of bladder structural lesions detected by urethrocistoscopy in which we performed bladder biopsies.

MATERIAL AND METHOD

Descriptive, retrospective, analytical study of files and videos of 331 patients treated in Urodifem de Occidente (private Urogynecology Center). Thirty-five biopsies were taken. The statistical analysis was expressed as means standard deviations, ranges, percentages and Fishers test.

RESULTS

Patients ages range 30-90 years average 60+13.76. Predominant symptoms were: irritative vesical syndrome 62.8%; pelvic pain 45.71%; urge incontinence 31.4%; hematuria 31.4%; vesical voiding dysfunction 11.4%. Principal endoscopic findings: Urethrotrigonitis; glomerular lesions or Hunner ulcers; vesical trabeculations; tumor or suspect lesions. Histopathologic findings were: Interstitial Cystitis 42.9%; chronic Cystitis 11.4%; Cystitis glandularis 8.6%; Cystitis follicular 11.4%; bladder cancer 5.7%; Vesical Papilloma 5.7%.

CONCLUSIONS

This study supports the practice of vesical biopsy when lesions other than those from chronic infection are observes in the presence of tumors or suspect lesions.

Hereditary spherocytosis with immunoglobulin A nephropathy

Hereditary spherocytosis is a familial hemolytic anemia. Immunoglobulin A (IgA) nephropathy associated with hereditary spherocytosis has not been reported in children. Here, we report a case of a 17-year-old boy with IgA nephropathy and hereditary spherocytosis. The patient was diagnosed with hereditary spherocytosis at the age of 12 years and splenectomy was done at the age of 15 years. Later, the patient presented with macroscopic hematuria and proteinuria. Kidney biopsy of the boy was consistent with IgA nephropathy. Treatment with angiotensin-converting enzyme inhibitor was started. The patient became free of proteinuria after the 6th month of therapy.

Natural history and renal pathology in patients with isolated microscopic hematuria

BACKGROUND/AIMS

No definite conclusions have been reached about the natural history of patients with isolated microscopic hematuria (IMH). In this study, we observed the natural history of patients with IMH and examined factors related to a pathologic diagnosis and subsequent prognosis.

METHODS

We retrospectively evaluated 156 subjects with IMH who had a renal biopsy performed. Of the 156 subjects, 33.3% were diagnosed with IgA nephropathy, 23.7% with mesangial proliferative glomerulonephritis, 15.4% with glomerular minor lesion, and 12.8% with thin basement membrane nephropathy; 6.4% had normal biopsies.

RESULTS

We followed up with 100 subjects for about 31 months. During this follow-up period, two subjects who had received a pathologic diagnosis of IgA nephropathy developed chronic kidney disease. During the course of the study, one of these subjects presented with proteinuria and hypertension and the other with proteinuria. The overall incidences of proteinuria and hypertension were 6% and 5% respectively.

CONCLUSIONS

The prognosis for patients with IMH was relatively favorable, but patients developing proteinuria and/or hypertension require careful observation and management during the follow-up period.