Anatomy and anatomical variations of adrenal veins and its application to adrenal venous sampling

PURPOSE

Our aim was to study the anatomy of the left and right main adrenal veins (LAV and RAV) and to identify their anatomical variations in order to see the practical application of these findings to adrenal venous sampling (AVS).

METHODS

Our work is based on dissection of 80 adrenal glands from fresh corpses in the forensic medicine department. We studied the number, the drainage, the direction and the level of termination of the main adrenal veins.

RESULTS

The average length of the LAV was 21 mm. It ended in 100% of cases at the upper edge of the left renal vein with a mean connection angle of 70° and after an anastomosis with the lower phrenic vein in 36 cases(90%). The average length of the RAV was 9 mm. It ended in 100% of cases at the level of the retro hepatic inferior vena cava (IVC) mainly on its posterior face in 21 cases (53%) and on its right lateral border in 18 cases (45%). The mean angle of the RAV in relation to the vertical axis of the IVC was 40°, with extremes ranging from 15° to 90°.

CONCLUSIONS

AVS seems to be easier on the left than on the right side because of the greater length of the adrenal vein (21 mm vs. 9 mm) and a greater angle of connection (70° with the left renal vein vs. 40° with the IVC), which explains the lower success rate of cannulation and the more frequent occurrence of blood sample contamination on the right side.

Antimicrobial prophylaxis protocol based on rectal swab culture before prostate biopsy to prevent infectious complications: a prospective randomized comparative study

PURPOSE

To evaluate the benefit of targeted antibiotic prophylaxis (TAP) based on rectal swab culture in comparison with standard empiric antimicrobial prophylaxis in patients undergoing transrectal ultrasound-guided needle biopsy of the prostate (TRUS-BP), as well as to assess rate of fecal carriage of Fluoroquinolone-resistant Enterobacterales FQRE.

PATIENTS AND METHODS

We prospectively analyzed data that randomized 157 patients within two groups: (G1) TAP according to rectal swab performed 10 days before PB; (G2): empirical antibiotic prophylaxis with ciprofloxacin. Prevalence of FQRE digestive carriage and risk factors were investigated. Incidence of infectious complications after (TRUS-BP) in each group was compared.

RESULTS

G2 included 80 patients versus 77 in G1. There was no difference between the two groups regarding age, diabetes, prostate volume, PSA, number of biopsy cores, and risk factors for FQRE. In G2, the prevalence of FQRE digestive carriage was 56.3% all related to E. coli species. In the case of digestive carriage of FQRE, TAP according to the rectal swab culture with third-generation cephalosporins was performed in 73.3%. Patients with FQRE had history of FQ use within the last 6 months in 17.8% (p = 0.03). Rate of febrile urinary tract infection after PB was 13% in G1 and 3.8% in G2 (p = 0.02).

CONCLUSIONS

Incidence of FQ resistance in the intestinal flora of our local population was prevalent. Risk factor for resistance was the use of FQ within the last 6 months. TAP adapted to rectal swab, mainly with third-generation cephalosporins, significantly reduced the rate of infectious complications after (TRUS-BP).

Prostatic condyloma acuminata: An uncommon endoscopic discovery in an asymptomatic 68-year-old male

Prostatic condyloma acuminata is a rarely encountered clinical manifestation primarily linked to low-risk subtypes of human papillomavirus (HPV), such as HPV-6 and HPV-11. Unlike the more common anogenital presentation, prostatic condyloma acuminata remains an infrequent phenomenon, necessitating a nuanced approach to diagnosis and management. We present a case report involving a 68-year-old patient with an intricate medical history, where the discovery of prostatic condyloma acuminata presented diagnostic challenges and clinical intricacies.

A cadaveric anatomical study of the adrenals: vascular relationship

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

Risk factors for sepsis and mortality in patients with emphysematous pyelonephritis : a series of 68 cases (case series)

Background

Emphysematous pyelonephritis (EPN) is a rare and severe necrotizing infection of the kidney with a high rate of complications and mortality. Our aim was to investigate risk factors of urosepsis and mortality in case of EPN.

Materials and methods

Between January 2010 and December 2022 the charts of patients diagnosed with EPN were retrospectively reviewed. Patients medical records were collected and data including demographics, BMI, EPN type, the organism causing the infection and biochemical variables were registered. The authors performed an univariate and multivariate logistic regression analysis for sepsis, septic shock, and mortality. Statistical significance was defined as a P-value of <0.05.

Results

Our study included 68 patients (63% females, mean age 58.6 years old). Forty-eight patients (70.6%) had diabetes. Half of the patients (50%) presented with sepsis and 11 patients (16.2%) developed a septic shock. The following factors were associated with sepsis by univariate analysis: diabetes (P=0.01), higher blood sugar on admission (P=0.01), higher leukocytic count (P<0.001), higher lymphocytic count (P<0.001), and lower platelet to leukocytes ratio (P<0.001). Multivariate regression analysis revealed that the main risk factors of urosepsis were the leukocytic (OR: 85.7; 95% CI: 9.177-800.486; P<0.001) and lymphocytic count (OR: 6.65; 95% CI: 1.228-36.050; P=0.028). Neither of the variables was significantly associated with a higher risk of mortality.

Conclusion

Leukocytic and lymphocytic count on admission are independent simple predictors for sepsis in patients with EPN.

Isolated ureteral injury from multiple stab wounds: A case report

This is a case report about a 44-year-old woman who sustained multiple stab wounds, resulting in an isolated right ureteral injury. Despite a precise diagnosis from an urgent CT scan showing contrast material extravasation, the patient's stable vital signs allowed for a thorough surgical exploration, leading to an accurate diagnosis. Immediate surgical repair of the right ureter using an end-to-end anastomosis following precise surgical principles achieved complete restoration of the initial injuries. The case highlights the accuracy of CT scan assessment, the unreliability of hematuria in diagnosing ureteral injuries, and the need for a high index of suspicion during surgical exploration to avoid overlooking such cases.

Squamous and glandular metaplasia related to a renal pelvis stone leading to secondary pyeloureteral junction syndrome

Keratinizing squamous metaplasia of the renal pelvis is a rare lesion of the upper urinary tract that can occur in the context of chronic aggression to the urothelium, potentially leading to a secondary pyeloureteral junction syndrome. We report the case of a 43-year-old patient discovered intraoperatively in relation to a renal pelvis stone causing a pyeloureteral junction syndrome. The extemporaneous histological examination ruled out a malignant process, and we performed a pyeloplasty according to KUSS-ANDERSON technique. This pathology should be recognized by the urologist for appropriate management. Treatment is conservative, with extended follow-up to detect recurrences or carcinomatous degenerations.

Validation of the Aldosteronoma Resolution Score as a Predictive Resolution Score of Hypertension After Unilateral Adrenalectomy for Primary Aldosteronism in a North-African Population

BACKGROUND

Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. Aldosteronoma Resolution Score (ARS) is a four-item predictive score for the cure of hypertension after adrenalectomy for UPA and has been demonstrated to be valid in different populations. We aimed in this study to validate the accuracy of this score in a North-African population.

METHODS

Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Postoperative outcomes were assessed using the primary aldosteronism surgical outcome (PASO) criterion. The accuracy of the ARS was determined retrospectively by receiver operating characteristic curve and area under the curve.

RESULTS

Thirty-four patients (48%) had complete clinical success according to the PASO criteria. Multivariate regression analysis revealed that the main determinants of complete clinical success were the absence of diabetes (OR: 5.205), a BMI <30 (OR: 4.930), a number of antihypertensive medications ≤2 (OR: 8.667), a plasma ARR >332 (OR: 4.554) and an ARS score ≥3 (OR: 2.056). Cure rates were, respectively, 21.1, 51.6, and 66.6% for patients with a score ARS 0-1, 2-3, and 4-5. The AUC of the ARS was 0.837.

CONCLUSION

The ARS is a sufficiently predictive score in our North-African population. It may be used preoperatively to predict the outcome after adrenalectomy in these populations.

Retroperitoneal ganglioneuroma: A five-case series from a single Tunisian center

INTRODUCTION AND IMPORTANCE

Retroperitoneal ganglioneuroma is an infrequent, benign tumor originating from the sympathetic nervous system. The diagnosis predominantly relies on histological assessment, often as an incidental discovery. Surgical removal stands as the primary treatment modality, and the overall prognosis tends to be favorable.

CASE PRESENTATION

Objective: In order to comprehensively examine the diagnostic, therapeutic, and progressive aspects of retroperitoneal ganglioneuroma, this study aims to analyze five cases of retroperitoneal ganglioneuroma that were surgically managed between 1993 and 2013.

PATIENTS AND METHODS

We present a series of five cases involving retroperitoneal ganglioneuromas that underwent surgical intervention in the urology department of Charles Nicolle Teaching Hospital of Tunis between the years 1993 and 2013. The study cohort comprised three females and two males, with an average age of 36.4 years (ranging from 10 to 88 years). Among these cases, four instances showcased incidental tumor detection, while one case manifested with cruralgia due to nerve compression. Complete tumor excision was achieved in all cases, with a single instance necessitating concurrent nephrectomy. Accurate diagnosis was ascertained through meticulous histological examination.

CLINICAL DISCUSSION

Results: The case series encompassed three women and two men, with an average age of 36.4 years (ranging from 10 to 88 years). The majority of cases (four out of five) unveiled tumors incidentally, whereas one case presented with cruralgia. Surgical removal resulted in complete resection of all tumors, although nephrectomy was necessary in one instance. Postoperative complications were minimal, and effective anticoagulant treatment addressed one thrombotic event. While recurrence was noted in a solitary case, subsequent imaging confirmed its stability. The average follow-up duration extended to 23.2 months (ranging from 6 to 72 months).

CONCLUSION

Retroperitoneal ganglioneuroma, being a rare and benign neoplasm, mandates meticulous pathological assessment and precise imaging for precise localization. Unquestionably, complete surgical resection remains paramount to forestall recurrence and mitigate the likelihood of malignant transformation. Overall, the prognosis associated with retroperitoneal ganglioneuroma tends to be favorable.

Leiomyosarcoma of the bladder: A review and a report of four further cases

INTRODUCTION AND IMPORTANCE

Our study aims to expose the experience of our department in dealing with bladder leiomyosarcomas and illustrate the management tools of this rare pathology.

CASE PRESENTATION

We present a retrospective study of 4 cases of bladder leiomyosarcoma, gathered in the Department of Urology during the period of 1996-2022. All our patients were exclusively male and aged between 35 and 73 years. No history of pelvic irradiation nor chemotherapy was found in our patients. Three patients had high-grade leiomyosarcoma and pT2 stage whereas only one had a low-grade tumour. Three patients underwent radical treatment by cystoprostatectomy with extensive bilateral pelvic lymph node dissection and one patient was treated by endoscopic re-resection and endoscopic monitoring. We noticed 2 lymph nodes and liver metastasis recurrences in 2 patients treated by radical surgery while 2 patients didn't present recurrences at two years of follow-up.

CLINICAL DISCUSSION

To date, there is no clear and precise therapeutic approach for the treatment of bladder leiomyosarcoma. Little is known about the long term survival associated with these tumours. All studies agree that the prognosis for bladder leiomyosarcoma is poor, if not diagnosed early, especially those presenting with an undifferentiated tumour grade, distant metastatis and treated without surgical therapy.

CONCLUSION

Bladder leiomyosarcoma is a rare and highly aggressive tumour. The anatomopathological examination provides diagnosis and prognosis assessment. Radical surgery remains the most suitable therapeutic approach.

A juxtaglomerular cell tumor revealed by a hemorrhagic stroke. A case report

With about 110 cases reported in literature, juxtaglomerular cell tumors are rare. We report a 25 years old patient who was admitted in neurology for a hemorrhagic stroke secondary to a cerebral aneurysm rupture due to high blood pressure. Etiological investigations showed a solid mass of the left kidney. A radical nephrectomy was realized and pathological examination and immunohistochemical profile concluded to juxtaglomerular cell tumor. The originality of this observation is based on the mode of presentation of a rare renal tumor by a malignant high blood pressure.

Inflammatory suppurated tumor of urachus mimicking a malignant urachus adenocarcinoma

This is a case report about a patient presenting with a urachal mass mimicking a urachus adenocarcinoma. Cystoscopy showed a vesicourachal patent diverticulum. Histological findings after the removal of the umbilicus, urachus, urachal tumor, as well as a bladder cuff, consisted of a nonspecific polymorphous suppurative inflammatory infiltrate. Urachal adenocarcinoma is an aggressive tumor with poor prognosis if not treated while it is still localized. Surgical excision is the only recommended treatment that offers the best chances of survival. As no preoperative procedure has been proven accurate enough to rule out the diagnosis of adenocarcinoma, surgery appears to be inevitable.

Can radiological scores predict difficulties in removal of encrusted ureteral stents?

In the present study, we aimed to report our single-center experience in encrusted ureteral stent management and to compare the utility of two different scoring systems in patient management. This is a retrospective study of patients who underwent various surgical procedures to remove encrusted ureteral stent. Encrusted stent grading was performed using KUB and FECal grading sytems. FECal grading system scored from Grade 1 to Grade 5 according to stone size, location, and degree of stent incrustation and the KUB score is the sum of the stone burden scores of three different parts of an encrusted stent within the kidney, ureter, and bladder determined using a scale from 1 to 5 according to the maximal diameter of encrustation. We compared these two classifications for the prediction of perioperative outcomes. Fifty patients were included in the study (52% female, mean age 48 years). The mean time from ureteral stent insertion until diagnosis of encrustation was 11.4 ± 13.6 months. High-grade incrustations (FECal Grade 3, 4, and 5) accounted for 62% of cases. The mean KUB score was 9.8 ± 2.7. The average number of procedures required to remove the stent was 1.71 ± 1.38. Multimodal surgery was required to remove 42% of the stents. Both, a total KUB score ≥ 9 and high-grade FECal classification were found to be significant predictors of longer operative time (> 100 min), need for multiple surgeries, and need for invasive surgery. While high-grade FECal classification showed a significant association with need for multimodal surgery (OR 6.92, p = 0.008), a total KUB score  ≥  9 showed no association (OR 2.91, p = 0.086). These two scores seem to be good indicators in predicting difficulties for surgical management of encrusted ureteral stent with a clear advantage of the FECal score in terms of prediction of multimodal surgery.

Predictors of successful outcome after adrenalectomy for unilateral primary aldosteronism

Introduction

Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. The cause of resistant hypertension after surgery is still a matter of debate. Our aim was to investigate cure rates after surgery and to evaluate preoperative factors that might influence the surgical outcome.

Methods

Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Preoperative medical records were collected and follow-up data (1-158 months) were registered. Antihypertensive medication doses were calculated using defined daily doses (DDD) and postoperative outcomes were assessed using the Primary Aldosteronism Surgical Outcome (PASO) criterion.

Results

Of 91 enrolled patients, 71 (59% women, mean age 46 years, median length of follow-up 21 months) were suitable for evaluation. Thirty-four patients (48%) had complete clinical success according to the PASO criteria. The most relevant factors associated with complete clinical success on univariate analysis were: absence of diabetes (p= 0.007), low body mass index (BMI) (p= 0.001), lower preoperative DDD (p= 0.01), preoperatively controlled blood pressure (p= 0.024), higher plasma aldosterone to renin ratio (ARR) (p= 0.001), adenoma subtyping (p <0.001) and aldosteronoma resolution score (ARS) (p= 0.002). Multivariate regression analysis showed that the major predictors of complete clinical success were absence of diabetes (OR: 5.205), a BMI < 30 (OR: 4.930), a plasma ARR > 332 (OR: 4.554) and an ARS ≥ 3 (OR: 2.056).

Conclusion

Complete and partial clinical response rates were achieved in respectively 48 and 43% of cases. The main predictors of complete resolution of hypertension were absence of diabetes, low BMI, high plasma ARR and high ARS. Taking these factors into account may help identify patients at risk of persistent postoperative hypertension who may require long-term surveillance and medication.

Management of blunt renal trauma on pre-existing diseased kidneys: a cross-sectional study

Pathological kidney trauma is a special entity. Congenital or acquired lesions may interfere with clinical presentation, radiological imaging, and the therapeutic approach.

Objective

Our objective was to determine the clinical, radiological, and therapeutic features of this entity.

Materials and methods

The medical records of 37 observations were retrospectively collected from January 1992 to February 2022. All cases were explored by a kidney ultrasound and/or a computed tomography scan, and classified according to the American Association of Surgery of Trauma. Pre-existing renal abnormalities were found in 37 patients among 203 (18.2%). The most common underlying lesion were urolithiasis (37.8%) followed by pyelo-ureteral junction syndrome (32.4%). Surgical abstention was decided in 11 cases, four nephrectomies were performed as a matter of urgency, and seven nephrectomies were performed remotely. The cure of uropathy was performed after an average delay of 3 months.

Conclusion

Kidneys with underlying pathology are habitually more susceptible to trauma. Contusions are often benign contrasting with a high nephrectomy rate.

Coexistence of multiple clear cell papillary renal cell carcinoma with renal oncocytoma: a case report

Clear cell papillary renal cell carcinoma (CCPRCC) is a new entity, previously known as unclassified renal cell carcinoma, and initiallly identified in patients suffering of end-stage kidney failure. It is extremely rare to see this new entity associated with others renal malignant lesions.

Case presentation

The authors report a case of a female 65-year-old suffering from end-stage kidney failure for 10 years, who presented with a double left renal tumor, composed by an oncocytoma associated to multiple CCPRCC, a very rare entity. A radical left nephrectomy was realized by lumbotomy, with an uneventful postoperative course. Histological examination was challenging. Immunohistological examination showed diffuse positivity of cytokertain 7. No local recurrence nor metastatic progression were found during the 12 months of follow-up.

Clinical discussion

CCPRCC, is a new entity, previously known as the unclassified rena cell carcinoma, is a malignant renal tumor, initially reported in patients at end-stage kidney failure. Oncocytoma is a well-known rare benign renal tumor. The association of both is rare, and should be kept in mind, especially when scanoguided diagnosis biopsy is realized. Histopathological confirmation may be challenging, given the recent identification of CCPRCC. The nuclei disposal toward the luminal surface is a characteristic pathological landmark of CCPRCC. Immunohistopathological examination is of great help, showing a distinctive profile: diffuse staining for cytokertain 7 and carbonic anhydrase IX.

Conclusion

CCPRCC is a new malignant pathological entity in renal tumors. It can be associated with other benign renal lesions. This should be taken into consideration while histopathological examination, mainly of scanoguided biopsy cores.

Giant retroperitoneal leiomyosarcoma: a case report

Retroperitoneal leiomyosarcomas are rare tumors, mostly malignant. They are silent slow growing, and at the time of diagnosis, they are often of a considerable size. Management necessitates en bloc resection of the mass with adjacent organs, which is often challenging due to large size of the tumor. Herein, we present a case of 59-year-old male patient presenting for surgical management of 190 × 150 × 140 mm retroperitoneal leiomyosarcoma.

Retrovesical hydatid cyst: an unusual location of hydatid disease about a case series

Hydatid disease is an endemic zoonosis in regions with temperate climates where pastoral farming is common. Retrovesical localization is rare. Given the rarity of this entity, the lack of personal clinical experience, and the difficulty with detecting early symptoms, the diagnosis remains elusive for years.

Methods

This is a 30-year retrospective, descriptive and analytic study of seven patients who were hospitalized and operated on in the Department of Urology during 30 years (1990-2019).

Outcomes

The average patient age was 54 years (range: 28-76). Signs of bladder irritation were the predominant presenting complaint. No cases of hydaturia were noted. Preoperative diagnosis was based on ultrasonography and serology tests. Hydatid serology was positive for three patients. In three cases, a hydatid cyst of the liver was associated. A partial cystopericystectomy was performed for five patients, it was total for one patient. The resection of the prominent dome was realized once. No cystovesical fistula was found. The mean postoperative stay was 16 days. The postoperative course was uneventful for five patients. Urinary fistula occurred in one patient. One case of infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation.

Conclusion

The preoperative diagnosis of retrovesical hydatid cysts is based mainly on ultrasonography. Open surgery is the treatment of choice. Different approaches are possible. Given the rarity of this entity, management should be guided by experienced experts.

Oncocytoma with a vascular extension, associated with a papillary carcinoma: A case report

This is a case report about a patient which presents with two right renal tumors, one of them being an oncocytoma with typical histopathological features and renal vein extension. Recent studies show that despite renal vein thrombus being a histological sign of malignancy; when associated with renal oncocytoma, it should not alter the benign prognosis of oncocytoma, and a simple follow-up may be carried. Further explorations should be done when easily available, and when the histopathologic diagnosis of oncocytoma is uncertain, to rule out the differential diagnosis of a chromophobe renal cell carcinoma, oncocytic variant.

Paratesticular leiomyoma: A case report of a rare entity

Paratesticular leiomyoma is an extremely rare benign tumour. It is often asymptomatic. It is sometimes difficult to distinguish leiomyomas from malignant testicular tumours, which leads to radical orchidectomy, despite its benign nature. Magnetic resonance imaging can be helpful to make conservative management of this lesion.

Air gun accident: A case report of a penile injury

Air rifle, although considered as a toy, can cause injuries ranging from trivial to very grievous. The severity of injuries depends on the type of air rifle, the distance of firing, and the anatomic site at which the bullet hits. We present a case involving a young boy, who was accidently hit by an air rifle while playing. The Bullet penetrated the penis through the glans to be lodged in between the distal extremities of the corpus cavernosum behind the urethra. The surgical treatment was performed and the results were good.

Prostate adenocarcinoma metastasis to the testis: A new case report

Prostate cancer (PCa) in the second most common cancer in men worldwide. It commonly metastasizes to the bone, lymph nodes, liver and lungs. Synchronous or metachronous testicular metastasis is a rare finding, generally diagnosed incidentally after bilateral orchidectomy for hormonal management in patients with advanced PCa, or at autopsy. We report a case of a 55-year-old male, presenting a PCa and who developed a single testicular metastasis treated by radical orchidectomy, while he was under hormonotherapy.

Two brothers with congenital bulbar urethral stricture: case report of a very rare condition

Congenital urethral stricture is rare. It has been reported in only four sets of brothers. We report the fifth set of brothers. Cases of two brothers aged 23 and 18 years old diagnosed with low urinary tract symptoms are presented. We diagnosed an apparently congenital urethral stricture in both brothers. Internal urethrotomy was performed in both cases. Both are asymptomatic after 24 and 20 months of follow-up. Congenital urethral strictures are probably more frequent than we think. We suggest that a congenital origin should be considered if there is no history of infections or trauma.

An insight into the diagnostic and prognostic value of HOX A13 ’s expression in non‐muscle invasive bladder cancer

Background

Several studies have interrogated the molecular pathways and their interacting genes underlying bladder cancer (BCa) tumorigenesis, yet, the role of homeobox genes is still poorly understood. Specifically, HOXA13, which plays an important role as a major actor in the urogenital tract's development.

Methods

Immunohistochemical (IHC) staining was performed to inspect the differential expression of HOXA13 protein in non‐muscle‐invasive bladder cancer (NMIBC) and non‐tumoral tissues. A semiquantitative scoring system was adopted to evaluate the IHC labeling. Correlation to clinical parameters was performed by descriptive statistics. Overall survival was estimated by the Kaplan–Meier method and Cox regression model. The functional HOX A13 protein association networks (PPI) were obtained using String 11.0 database.

Results

HOX A13 exhibited cytoplasmic and nuclear staining. Its expression levels were lower in high‐grade NMIBC (HG NMIBC) compared to low‐grade ones (LG NMIBC). The expression of HOX A13 was correlated to tumor grade (LG/HG) (p = 0.036) and stage (TA/T1) (p = 0.036). Nevertheless, its expression was not correlated to clinical parameters and was not able to predict the overall survival of patients with HG NMIBC. Finally, PPI analysis revealed that HOX A13 seems to be a part of a molecular network holding mainly PBX1, MEIS, ALDH1A2, HOX A10, and HOX A11.

Conclusion

The deregulation of HOX A13 is not associated with the prognosis of BCa. It seems to be rather implicated in the early initiation of urothelial tumorigenesis and thus may serve as a diagnostic marker in patients with NMIBC. Further experimentations on larger validation sets are mandatory.

Upper urinary tract urothelial carcinoma diagnosis by biopsy of a vaginal metastasis

Upper tract urothelial carcinoma presents 5% of urothelial cancers. The most frequent revealing symptom gross haematuria. Vaginal metastasis is rare revealing condition. The combination on these two symptoms should recall the diagnosis of this neoplasm. Biopsy of the vaginal mass can make the histologic diagnosis easily.

Impact de la COVID-19 sur la formation des résidents en Maladies Infectieuses

Introduction

Les résidents en Maladies Infectieuses sont depuis 2020 parmi les médecins de première ligne dans la prise en charge des patients présentant une infection par le SARS-CoV-2. Toutefois, aucune étude ne s'est intéressée à l'impact de la pandémie sur leur formation.

Matériels et méthodes

Il s'agissait d'une étude transversale menée dans le service des Maladies Infectieuses durant la période (1^er Novembre-31 décembre 2021). Un questionnaire était envoyé aux résidents via Google forms comportant des questions sur la formation en Maladies Infectieuses durant la pandémie de la COVID-19. Les questionnaires étaient envoyés par e-mail.

Résultats

Quarante-cinq questionnaires étaient envoyés durant la période de l'étude et 34 résidents (75,5 %) avaient répondu. L'âge moyen était 29,7 ans ± 2,7 ans (26-36 ans) et le sex ratio (H/F) était à 0,13. Durant l'année 2020, l'effectif comptait 30 résidents participants et durant l'année 2021, 34 résidents. Le contact avec les patients ayant la COVID-19 était jugé fréquent chez 12 résidents (40 %) au cours du 1^er semestre de l'année 2020 et 21 résidents (61,7 %) au cours du 2^ème semestre de la même année. Vingt-huit participants avaient répondu que le premier semestre de l'année 2020 comme étant le plus stressant (n=28, 93,3 %). L'activité clinique habituelle était jugée diminuée pour 24 résidents (80 %) durant le 1^er semestre de l'année 2020 et pour 18 résidents (53 %) durant le 1^er semestre de l'année 2021.La formation des résidents dans les services hospitaliers (Staffs, visites au lits des malades) était jugée diminuée durant toute l'année 2020. La formation extra-hospitalière (DIU, congrès, cours de collège et l'auto-apprentissage) avait diminuée durant les quatre semestres. En effet, la participation aux cours de collège avait diminuée, au cours du 1^er semestre de 2020, pour 19 résidents (63,3 %) et arrêtée pour 8 (26,6 %). Cette activité était touchée au cours du 1^er semestre de l'année 2021 avec une diminution de la participation pour 17 résidents (50 %). Cependant, elle était arrêtée uniquement pour un seul résident (2.9 %). Le recours à la formation virtuelle était plus important pour les DIU durant le 2^ème semestre de l'année 2020 (53,3 %) et le 1^er semestre de l'année 2021 (44,1 %). Les obstacles à la formation chez les résidents étaient essentiellement : l'impact psychologique de la pandémie (n=26, 76,5 %) et la suspension des activités habituelles (n=23, 67,6 %). Pour améliorer leur formation, les participants avaient proposé de partager l'activité COVID-19 avec les autres spécialités (n=23, 67,6 %) et de renforcer la formation en ligne (18, 52,9 %).

Conclusion

L'impact de la pandémie sur la formation des résidents en Maladies Infectieuses était important. Nous devons tirer des leçons de cette pandémie et améliorer les conditions du travail des résidents pour garantir une formation équitable et suffisante. L'élaboration d'un portfolio pour les résidents en Maladies Infectieuses devient une urgence afin de rattraper le retard et de parfaire rapidement leur formation.

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MO967: Lymphocele After Renal Transplantation: Management, Risk Factors and Impact on Transplant Survival

BACKGROUND AND AIMS

Lymphocele after renal transplantation remains a common complication, despite all the technical precautions taken, in particular the ligation of lymphatic vessels. Its incidence varies according to the series, depending on the diagnostic methodology, and whether or not it is systematically screened.

This study aims to investigate the risk factors for lymphocele and its impact on transplant survival.

METHOD

We performed a retrospective longitudinal descriptive study including all patients who had a kidney transplant in a Urology department from 1986 to 2017. Clinical presentation and management of lymphocele were studied. Then, the characteristics of patients who presented a lymphocele were compared with those of the rest of the population including characteristics related to the recipient, the donor, the transplant and the procedure to identify risk factors. The impact of lymphocele on patient and transplant survival was then studied.

RESULTS

A total of 720 patients were included with a mean age of 32.7 years. The transplant was from a living donor in 79% and a brain-dead donor in 21%. Lymphocele occurred in 51 patients (7.1%). The lymphocele was asymptomatic in 80%, and clinical manifestations were related to the compression of the transplant or its important size, requiring active treatment, most often percutaneous (13.7%). The lymphocele did not require treatment in 42 cases (82.4%) with disappearance in 90.5%. Revision surgery for a lymphocele was necessary in two cases.

The risk factors for lymphocele were a cadaveric donor (P = 0.003) and an advanced age of the recipient (P  &lt; 0.001). No predictive factors related to the transplant (vascular anatomy), or procedure (location and type of anastomoses, ischemia time) were identified.

Transplant survival was 77.9% at 5 years, with a median survival of 15.9 years. The occurrence of a lymphocele did not influence the survival of the transplant (P = 0.25) (Figure 1).

CONCLUSION

Our study showed that lymphocele is usually asymptomatic, not requiring a specific treatment in most cases with a high rate of spontaneous disappearance with no impact on transplant survival. Risk factors were a cadaveric donor which may reflect the absence of careful ligation of the transplant's lymphatic vessels in the context of urgent, sometimes multi-organ, cadaveric procurement and advanced recipient age.

MO968: Vascular Complications of Renal Transplantation: Risk Factors and Impact on Graft Survival

BACKGROUND AND AIMS

Despite the progress made in renal transplantation, vascular complications can occur, jeopardizing the prognosis of the transplant.

This study aims to investigate the risk factors of vascular complications and their impact on transplant survival.

METHOD

We performed a retrospective longitudinal descriptive study including all patients who had a kidney transplant in a Urology department from 1986 to 2017. Transplant Vascular complications included: Arterial thrombosis (AT), Venous thrombosis (VT), hemorrhagic complications (hemorrhage and hematoma) and arterial stenosis (AS). The potential risk factors for vascular complications that were investigated included characteristics related to the recipient, the donor, the transplant and the procedure. The impact of vascular complications on transplant survival was then studied.

RESULTS

A total of 720 patients were included with a mean age of 32.7 years. The transplant was from a living donor in 79% and a brain-dead donor in 21%.

AT occurred in 15 patients (2.1%) and VT occurred in 10 patients (1.4%). Risk factors for vascular thrombosis were recipient age &gt;35 years (P = 0.001; OR = 10.78), recipient smoking (P = 0.005; OR = 1.8), multiple arteries (P  &lt; 0.001; OR = 1.45) and prolonged warm ischemia (P = 0.02). Perirenal hematoma occurred in 11 patients (1.5%) and hemorrhage occurred in six patients (0.8%). The risk factors for bleeding complications were a prolonged pre-transplantation dialysis time (P = 0.03; OR = 1.35), and prolonged warm ischemia (P = 0.02; OR = 1.26). AS was the most frequent vascular complication, occurring in 20 cases (2.8%) and no risk factors were identified.

Transplant survival was 77.9% at 5 years, with a median survival of 15.9 years. Vascular thrombosis led to the loss of the transplant in all cases, and externalized hemorrhage significantly reduced transplant survival (P  &lt; 0.001). Perirenal hematoma (P = 0.42) and transplant artery stenosis (P = 0.25) had no impact on transplant survival (Figure 1).

CONCLUSION

Our study showed that the vascular complications impacted the survival of the transplant and that they were related to factors related to the recipient, the transplant and the procedure insisting on a multidisciplinary and personalized management for each case.

Ejaculatory duct reflux revealed by chronic scrotal swelling in an adult

Ejaculatory duct reflux is rare and few investigations have focused on this entity, which is usually described in children. This study reports a new case of unilateral ejaculatory reflux in a 32-year-old patient, with a history of urethroplasty at the age of 5 for hypospadias, who presented for right chronic scrotal swelling. Urethrocystscopy showed an anterior urethral stricture and a gaping opening of the right ejaculatory duct. CT scan with opacification through the right ejaculatory duct, showed a dilated right seminal vesicle, associated to a reflux in the right deferent vas and epididymis, which was dilated explaining the scrotal swelling.

A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein

PURPOSE

Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations.

METHODS

Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV).

RESULTS

The average length of the LAV was 21 mm its mean width was 5 mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8 mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found.

CONCLUSIONS

The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks.

Management and prognosis of liposarcomas of the spermatic cord: an experience with six cases

Liposarcoma of the spermatic cord (LSC) is a rare tumor with no consensus on therapeutic management. This study reports six new cases of LSC. The patients’ age ranged from 56 to 80 years. All patients presented with a scrotal mass, and it was ultrasound that oriented the diagnosis. The initial treatment consisted of an inguinal orchiectomy. Anatomopathological study coupled with immunohistochemistry using the anti-MDM2 antibody confirmed that the tumors were well-differentiated LSC in four cases and dedifferentiated LSC in the other two cases. Adjuvant radiotherapy was performed in two patients. No recurrence was noted in these two patients at 14 and 34 months of follow-up. The only recurrence we had was local and occurred at 44 months of follow-up in a patient who had a dedifferentiated form ofLSC.

Association of a common genetic variant (insertion/deletion) in ACE gene with prostate cancer susceptibility in a Tunisian population

Background

Angiotensin‐converting enzyme (ACE) plays a pivotal role in several pathologies including cancers. The association of insertion/deletion (I/D) polymorphism of the ACE gene with prostate cancer (PC) risk remains controversial. We aimed to investigate for the first time, to our Knowledge, in North Africa the potential relationship between ACE I/D polymorphism with PC susceptibility and clinical outcomes of PC patients.

Methods

This case‐control study included 143 healthy individuals and 124 patients diagnosed with PC. Using genomic DNA, the samples were genotyped for ACE I/D polymorphism by polymerase chain reaction (PCR).

Results

We found that The D allele is significantly associated with an increased risk of PC and D/D + D/I genotypes were at 3 times increased risk of PC ([p = 0.005], OR = 2.95, IC 95% = 1.26–7.09) compared with I/I genotype (p = 0.003, OR = 0.3, IC 95% = 0.12–0.74). We observed an association between D/D and D/I genotypes with advanced age (≥70 years) (p = 0.014; r² = 0.22). Furthermore, there is a significant prediction of advanced Gleason score ≥8 based on epidemiological parameters and ACE genotype (p = 0.000; R² = 0.349), although no significant association was observed with stage and metastasis.

Conclusion

The ACE I/D polymorphism is likely to predispose to PC and could play a role in PC progression and aggressiveness.

[A longitudinal study about post-traumatic stress disorder after delivery in Tunisian primiparous]

OBJECTIVES

The aims of this study were to estimate the incidence of the post-partum post-traumatic stress disorder (PP-PTSD) in primiparous women, and to determine the profile of women at risk of developing this disorder.

METHODS

We conducted a descriptive, prospective and longitudinal study carried out at the maternity department of the Hedi Chaker Hospital, Sfax-Tunisia over a period of 15 months. At the first stage of the study, the Saint-Antoine pain questionnaire, the peri-traumatic dissociative experiences questionnaire and the peri-traumatic distress inventory were used respectively to assess the pain of delivery, the peri-traumatic dissociation and distress. At the second stage of the study, the questionnaires, perinatal post-traumatic stress disorder (PPQ), hospital anxiety and depression scale and the Edinburgh postnatal depression scale were used respectively for the PP-PTSD screening and the assessment of the post-partum anxious and depressive symptomatology.

RESULTS

The study population consisted of 183 parturients at the first stage of the study and 150 parturients at the second stage of the study. The incidence of the PP-PTSD was 9.3 %. In the multivariate study, some factors studied were significantly associated with the development of PTSD-PP, including a history of therapeutic termination of pregnancy, a history of miscarriage, exposure to a stressful event during pregnancy, prenatal hospitalization of the mother, instrumental delivery, pain intensity especially in the affective component, peri-traumatic dissociation and avoidance of sexual intercourse for fear of a new pregnancy. However the skin to skin contact with the new-born immediately after delivery was a significant protective factor.

CONCLUSION

The psychological consequences associated with the first birth, particularly the PP-PTSD, are common. The Identification of women at risk and a systematic screening of postpartum post-traumatic stress symptoms are desirable.

Particularités de l’infection à coronavirus chez les patients diabétiques

Objectif

Décrire les caractéristiques épidémio-cliniques, radiologiques et thérapeutiques de l’infection au SARS-COV2 chez les diabétiques.

Matériels et méthodes

Étude rétrospective portant sur les malades diabétiques hospitalisés au service des maladies infectieuses pour une infection à coronavirus durant la période (2020–2021).

Résultats

On a colligé 95 malades diabétiques parmi les 224 malades hospitalisés pour une infection SARS-cov2 (42,4 %). Ils étaient âgés en moyenne de 64 ans (32 ans–86 ans) avec une prédominance masculine (sex-ratio = 1,26). Quatre-vingt-douze malades (96,8 %) avaient un diabète de type 2 dont 18 étaient insulinonécessitants.

Les manifestations cliniques étaient dominées par les arthromyalgies (n = 82, 86,3 %), la toux sèche (n = 55, 57,9 %) et la fièvre (n = 41, 43,1 %). Deux patients (2,1 %) présentaient une douleur thoracique secondaire à une embolie pulmonaire et un syndrome coronarien aigu. La dyspnée était le maître symptôme observé dans 94,7 % des cas, apparue dans un délai moyen de 8,6 jours. Une tomodensitométrie thoracique réalisée chez 52 malades (54,7 %), montrait une atteinte minime (< 10 %) dans 3,85 % des cas, modérée (10–25 %) et étendue (25–50 %) dans 25 % chacune, sévère (50–75 %) dans 36,5 % et critique (> 75 %) dans 9,6 % des cas. Tous les malades bénéficiaient d’une anticoagulation et 92 malades (96,8 %) d’une oxygénothérapie associée à la corticothérapie dans 91,6 % des cas. L’évolution était favorable dans 87,4 % des cas. Douze malades (12,6 %) étaient transférés à l’unité des soins intensifs.

Discussion

Dans notre étude, la moitié des malades diabétiques ont présenté une atteinte pulmonaire de plus de 50 %. Une prise en charge précoce et adaptée serait essentielle pour améliorer le pronostic.

Maladie à Coronavirus (COVID-19) : connaissance, attitude et pratiques du personnel de santé

Introduction

La pandémie de la maladie à coronavirus (COVID-19) a provoqué une crise sanitaire majeure. Le personnel de santé est en première ligne de la gestion de cette pandémie. L’étude vise à déterminer les connaissances, les attitudes et les pratiques du personnel de santé (PS).

Matériels et méthodes

Une étude transversale a été entreprise parmi le PS de février à mars 2021. L’étude a évalué les connaissances, l’attitude et les pratiques à l’aide d’un questionnaire auto-administré en ligne (Google formulaire) par e-mail et sur des plateformes de réseaux sociaux.

Résultats

Un total de 100 PS avaient participé à l’étude dont 84 % d’entre eux avaient un âge entre 18 et 29 ans et 79 % étaient des femmes. La majorité d’entre eux étaient des médecins ou des médecins en formations (79 %). Cinquante-cinq participants déclaraient ne pas avoir participé à des formations sur la prévention et le contrôle des infections par le SRAS-CoV-2. Les participants disposaient de connaissances satisfaisantes sur la COVID-19 avec 72 % de taux de réponses correctes sur : l’agent causal, le mode de transmission, la période d’incubation, les signes cliniques, la confirmation diagnostique et les mesures de prévention. Quatre-vingt-cinq participants avaient de bonnes pratiques contre l’infection par le SRAS-CoV-2. Une grande majorité des professionnels de la santé prenaient les mesures de précaution adéquates telles que l’utilisation d’un désinfectant pour les mains (78 %), le port des équipements de protection individuelle (94 %), les enlever soigneusement et les jeter au bon endroit (77 %) et procéder à l’isolement des patients suspects ou confirmés (92 %).

Conclusion

Cette étude a montré que le personnel de santé avait des connaissances suffisantes et une attitude positive envers la COVID-19. La diffusion continue d’informations sur la prévention de la propagation de la COVID-19 à tous le personnel de santé renforcera sa lutte contre ce virus. Les autorités sanitaires et les décideurs doivent fournir les ressources nécessaires pour le permettre de travailler dans un environnement sûr.

Isolated bladder metastasis from lung adenocarcinoma: a case report

Cancers of extra bladder origin represent between 2 and 12% of bladder neoplasms and are most often secondary to contiguous bladder invasion. Metastasis from distant organs is exceptional, especially from pulmonary adenocarcinoma with <10 cases identified over the last 20 years. We report here a new case of a 55-year-old patient with a recently diagnosed pulmonary adenocarcinoma referred to the urology department for macroscopic hematuria. Computed tomography scan showed, in addition to the lung mass of the right lower lobe with a right mediastinal adenopathy, a thickening of the right lateral bladder wall. Cystoscopy showed inflammatory lesions on the bladder mucosa, which biopsy with immunohistochemical examination revealed to be tumoral proliferation in the lamina propria realizing the same immunohistochemical profile of the primary lung tumor (CK7+/TTF1+/CK20-/PSA-). The patient was treated with palliative platinum-based chemotherapy and unfortunately died 5 months after diagnosis.

Partial open tumorectomy for a renal tumor in a horseshoe kidney with a close contact with the vena cava: A case report

Introduction and importance

Horseshoe kidney has unique anatomical features, such as a complex blood supply. We report a patient with renal tumor in a horseshoe kidney in close contact with the vena cava, who underwent open tumorectomy.

Case presentation

A 72-year-old woman was referred to our hospital with a 4-cm enhancing mid-pole mass in the right moiety of a horseshoe kidney. Open tumorectomy was performed with parenchymal clamping. The warm ischemia time was 18 min. Pathologic examination confirmed a diagnosis of pT1a clear cell renal cell carcinoma with negative surgical margins. At 3 months postoperatively, computed tomography showed no local recurrence or metastasis and renal function was intact.

Clinical discussion

Horseshoe kidney is a rare congenital abnormality. Renal cell carcinoma is the most frequent tumor in adults having this anomaly and treatment in localised tumors if usually tumorectomy. Surgery may be challenging in some cases because of its difficulty.

Conclusion

Open surgery remains the standard treatment for horseshoe kidney tumors because of anatomic complexity and especially in cases where the tumor is difficult to extirpate.

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Renal cell carcinoma tumors in horseshoe kidneys are a very rare entity.

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Management of localised tumors in horseshoe kidney is surgical and surgery is challenging due to anatomical difficulties.

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Open surgery is usually the best option for tumors having a posterior development in the horseshoe kidney.