Presence of transient hydronephrosis immediately after surgery has a limited influence on renal function 1 year after ileal neobladder construction

Othotopic ileal neobladder “Belgrade pouch” in females

Background/Aim. Orthotopic continent neobladder pro-vides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency. Standard surgical techniques require the usage of an ileal segment in the length of 50?65 cm for neobladder creation with favorable results. However, the usage of a long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications. The aim of this study was to analyze clinical outcomes of the ?Belgrade pouch? orthotopic bladder replacement in female patients and to promote the usage of shorter ileal segment for neobladder creation. Methods. A prospective study conducted in our institution from 2009 to 2019 included 37 female patients who underwent orthotopic bladder replacement ac-cording to ?Belgrade pouch? technique with the usage of shorter ileal segment whose average length for neobladder creation was 28 cm. Inclusion criteria were: female continent patients older than 18, organ-confined muscle-invasive bladder carcinoma and, the American Society of Anestesiologists (ASA) score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonary diseases, systemic illnesses and metabolic diseases which may have some influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, histopathological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two-year periods of follow-up. Results. Average age of patients was 58 (32?67) years. Average time of surgical procedures was 199 (155?320) min. Blood transfusion was intraoperatively applied in 32.43% of the patients in average volume of 385 (300?640) mL. A total of 29.47% patients had anemia preoperatively. In the early postoperative period we reported one patient with paralytic ileus which was resolved conservatively and one patient with urinary fistula appearance; 56.75% of the patients were in pT2 stage. Two years following the surgery, day-time continence was achieved in 91.89% of the patients, neobladder capacity was 459 (345?592 ) mL, post-void residual urine volume was 27 (0?40) mL, 24 h voiding frequency 6, metabolic acidosis appeared in 2.7% of the patients. Survival rate in 2-year period was 86.48%. Conclusion. Orthotropic ileal neobladder created from the shorter ileal segment (?Belgrade pouch?) in females provides a high level of continence without a significant increase of voiding frequency, with adequate capacity, without urinary tract retention and with decrease of metabolic complications.

A gravity-assisted approach to the management of urinary diversion: 99mTc-MAG3 diuresis renography with F + 10(sp) method

OBJECTIVE

Radical cystectomy with permanent urinary diversion is the gold standard treatment for invasive muscle bladder cancer. Hydronephrosis is common in these patients, but Ultrasound (US) or Computed Tomography Urography (CTU) scan are unable to discriminate obstructive from non-obstructive hydronephrosis. We used Diuresis Renography (DR) with F + 10 in seated position (sp) method in the identification of patients with a Uretero-ileal Anastomosis Stricture (UAS) who would benefit from surgical therapy.

METHODS

We studied 39 asymptomatic patients, who underwent radical cystectomy and urinary diversion. Based on radiological findings (US, CTU) 44 kidneys were hydronephrotic. All patients underwent a 99mTc-MAG3 DR with F + 10(sp) method. We acquired a DR for 20 min with the patient in a seated position. Patient drank 400-500 mL of water at 5 min after tracer injection and received a 20 mg bolus of Furosemide at 10 min during dynamic acquisition. The indices Time to peak, diuretic half time, and 20 min/peak ratio have been evaluated. Retrograde pyelography confirmed UAS in all patients with DR obstructive findings. We repeated DR as follow-up in two subgroups of patients.

RESULTS

DR with F + 10(sp) method showed obstructive findings in 36 out of 44 hydronephrotic kidneys. 6 patients showed non-obstructive findings. 32 patients showed obstructive findings (20 out of 32 developed UAS within 12 months after surgery). Fifteen pts underwent a surgical treatment of UAS. In 1 patient with equivocal findings, we observed an ileo-ureteral reflux.

CONCLUSIONS

The DR with F + 10(sp) method in the seated position has a lower uncertain diagnostic rate, compared to the radiological findings of US or CTU, in management of bladder cancer patients with urinary diversion. The semiquantitative indices diuretic half time and 20 min/peak ratio evaluated in a condition of favorable gravity reduce uncertain responses improving interobserver concordance.

Advantages of gravity-assisted diuretic renogram: F + 10 (seated position) method

INTRODUCTION

In 1978, O'Reilly introduced the diuretic renogram using the F + 20 method. Initially, the patient was examined in the seated position. A dose of 40 mg furosemide was injected intravenously 20 min following tracer injection and dynamic acquisition was prolonged for 15-20 min. In 1992, the guidelines suggested to study patients in the supine position to avoid risk of diuretic-induced hypotension and reduce patient movement. Unfortunately, equivocal findings were reported in 15-30% of cases. Side effects such as bladder fullness and disruption because of voiding were reported. Several methods had been proposed in the supine position, such as the well-tempered diuretic renogram F + 20, F - 15, F0 and F + 2, with different time in minute of diuretic administration in relation to tracer injection. However, as confirmed by many studies, there was no clear evidence suggesting superiority among these methods. We suggest using the diuretic renogram with the F ± 10(sp) method for the diagnosis of obstruction in adult patients with hydronephrosis and for the follow-up in patients who underwent a surgical treatment of the urinary tract.

METHODS

We searched all international guidelines and articles of most influential authors published from 1978 to October 2020 on diuretic renogram.

RESULTS

We selected 60 articles.

DISCUSSION

F + 10(sp) method improves patient compliance avoiding bladder fullness-related problems, without need of catheterization. It allows for a more reliable quantification of the renal output, thanks to outflow indices that are favored by gravity effects.

Renal function outcomes in the early and intermediate phases after radical cystectomy by ileal conduit

Introduction and Objectives: An ileal conduit (IC) is an established option for urinary diversion, despite the fact that early renal impairment (RI) sometimes occurs after surgery. The aim of this study was to investigate the incidence and risk factors of early RI.

Materials and Methods: Thirty-one patients diagnosed with muscle-invasive bladder cancer who underwent RC with IC were analyzed in this study. Early RI was defined as a greater than 25% decrease in estimated glomerular filtration rate (eGFR) over the course of one year after surgery. The incidence and risk factors of early RI were evaluated.

Results: The mean preoperative eGFR of the patients was 69.6 mL/min/1.73 m². Early RI was observed in 7 (22.5%) patients. Multivariate analyses demonstrated that postoperative hydronephrosis was an independent risk factor for early RI (P=0.018). The mean intermediate-term eGFR change was −5.1 mL/min/1.73 m² in patients with early RI and was greater than that (−2.9) in patients without early RI, although neither were statistically significantly different.

Conclusion: Renal function after RC with IC decreased immediately over the course of one year, and postoperative hydronephrosis was an independent risk factor for early RI. Renal function had decreased slightly at intermediate-term follow-up with or without early RI.

Atezolizumab in patients with renal insufficiency and mixed variant histology: analyses from an expanded access program in platinum-treated locally advanced or metastatic urothelial carcinoma

Background

Atezolizumab is a treatment for locally advanced/metastatic urothelial carcinoma (mUC). However, its use in patients with renal insufficiency or UC with mixed variant histology (MVH) is not well characterized.

Objective

To report efficacy and safety of atezolizumab in these special subpopulations from an expanded access program (EAP).

Design, setting, and participants

A total of 218 patients were enrolled at 36 US study sites (November 2015–August 2016), and the trial ended following the approval of atezolizumab by the US Food and Drug Administration. This post hoc analysis investigated outcomes in specific study subgroups.

Intervention

Atezolizumab 1200 mg was administered intravenously every 3 weeks until loss of clinical benefit, unacceptable toxicity, death, consent withdrawal, decision to discontinue, commercial availability, or study closure.

Outcome measurements and statistical analysis

Response Evaluation Criteria in Solid Tumors V.1.1 responses and safety were evaluated by baseline renal function and histology.

Results and limitations

Objective responses occurred in 0/6 (0%), 4/19 (21%), 1/27 (3.7%), and 12/62 (19%) of evaluable patients with creatinine clearance (CrCl) <30, 30–45, 45–60, and ≥60 mL/min, respectively, and stable disease was seen in three patients with CrCl <30 mL/min. Objective responses were seen in 13/102 patients (13%) with urothelial carcinoma (UC) histology only and in 4/12 patients (33%) with UC with MVH. Treatment-related adverse event frequencies ranged from 35% to 54% across the earlier indicated CrCl subgroups and they were also similar in patients with pure UC or UC with MVH (46%).

Conclusions

In this EAP mUC subgroup analysis, clinical benefit of atezolizumab occurred in patients with compromised renal function or MVH UC tumors. Safety was comparable across subgroups.

Patient summary

We examined the efficacy and safety of atezolizumab for UC in certain patients participating in an EAP. We found that responses to atezolizumab occurred, and safety was similar, in most patient subgroups with varying levels of kidney functioning or less common types of tumor tissue histology.

Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic

Background

Point-of-care ultrasound (PoCUS) by emergency physicians for renal colic has been proposed as an alternative to computed tomography (CT) to avoid ionizing radiation exposure and shorten emergency department length of stay. Previous studies have employed experienced or credentialed ultrasonographers or required advanced ultrasound skills. We sought to measure the diagnostic accuracy of PoCUS by physicians with varied experience using a simplified binary outcome of presence or absence of hydronephrosis. Secondary outcomes include assessment as to whether the presence of hydronephrosis on PoCUS is predictive of complications, and to evaluate possible causes for the reduced diagnostic accuracy such as body mass index (BMI) and time between PoCUS and formal imaging, and scanner experience.

Results

413 patients were enrolled in the study. PoCUS showed a specificity of 71.8% [95% CI 65.0, 77.9] and sensitivity of 77.1% [95% CI 70.9, 82.6]. Hydronephrosis on PoCUS was predictive of complications (relative risk 3.13; [95% CI 1.30, 7.53]). The time interval between PoCUS and formal imaging, BMI, and scanner experience did not influence the accuracy of PoCUS.

Conclusions

PoCUS for hydronephrosis in suspected renal colic has moderate accuracy when performed by providers with varied experience for the binary outcome of presence or absence of hydronephrosis. Hydronephrosis on PoCUS is associated with increased rates of complications. PoCUS for hydronephrosis is limited in its utility as a stand-alone test, however this inexpensive, readily available test may be useful in conjunction with clinical course to determine which patients would benefit from formal imaging or urologic consultation.

ClinicalTrials.gov Identifier NCT01323842

Whole body ultrasound in the operating room and intensive care unit

Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.