The headache of the post transurethral prostate surgery pyuria: Pursuit for evidence

• Objective To prospectively assess early post-TUPS (transurethral prostate surgery) urinalysis changes and bacteriuria with its clinical relevance. • Methods Patients with BPO enrolled for TUPS were prospectively assessed. Patients were assessed at 2, 4, 8, 12, and 24-weeks postoperatively by DVAS (dysuria-visual-analogue-scale), IPSS-QOL, uroflow, and PVR. Routine urinalysis was performed before discharge and at all visits. MSUC (midstream urine culture) was performed before discharge, 4 and 12-weeks postoperatively. • Results At final analysis 152 patients were evaluable. Significant pyuria was reported in 52%, 96.1%, 94.1%, 71.7%, 78.9% and 52.5% in before discharge, 2-, 4-, 8-, 12-, and 24-weeks urinalysis postoperative respectively. The mean time to non-significant-pyuria (95%CI) was 19.1(17.5-20.7), 20.1(17.3-22.9), 15.8(12.8-18.8) and 14(10.3-17.8) weeks after prostate resection, vaporization, enucleation, and incision respectively, (P0.03). Regardless of the TUPS technique, half of the patients had significant pyuria at 24-weeks postoperative. MSUC was positive in 37/152(24.3%), 3/152(2%), 23/152(15.1%), and 5/152(3.3%) preoperatively, before discharge, 4 and 12-weeks postoperative respectively. Only positive preoperative urine leucocyte esterase independently predicted positive 4-weeks MSUC (OR3.8, 95%CI1.3-11.1, P0.013). No significant correlation was found between IPSS or DVAS and positive MSUC nor between IPSS and postoperative pyuria at different follow-up points (P>0.05). However, the degree of postoperative dysuria was significantly correlated with postoperative pyuria count by urinalysis at 2-Weeks (r0.69, P0.03), 8-Weeks (r0.26, P0.001) and 12-Weeks (r0.23, P0.004). • Conclusion There is a persistent but gradually declining pyuria and microhematuria following TUPS up to 6 months postoperative. An earlier resolution was noted following prostate incision and enucleation. While routine urine analyses screening in these months would be of no clear clinical value, a routine urine culture would be of a reasonable significance at 1 month post-operatively.

Ureteral wall thickness as a predictor for non-invasive treatment success for steinstrasse. Can we save time?

PURPOSE

We aimed to define factors affecting the non-invasive overall treatment success (medical expulsive therapy (MET) ± shock wave lithotripsy (SWL)) for uncomplicated ureteral steinstrasse (SS) clearance.

METHODS

We retrospectively evaluated consecutive patients who underwent SWL for renal stones between 2017 and 2021. Patients with uncomplicated SS were included. All patient's demographic and radiological data, e.g., age, gender, pre-SWL stenting, SS site, type, leading stone size in widest diameter (< 10 mm and ≥ 10 mm), ureteral wall thickness (UWT) in mm against the leading stone were collected. If SS was diagnosed, medical treatment was given for 4 weeks. In case of MET failure, either SWL for the leading stones + MET or direct URS was done. Non-invasive treatment success (SFR) was considered if complete clearance of SS occurred with no complications or the need for invasive intervention.

RESULTS

A total of 145 patients were included with mean age of 45.9 ± 12.4 years. SFR in case of MET only occurred in 27.9%. Complications happened in 26 patients (17.9%). Non-invasive treatment SFR was achieved in 78 patients (53.8%) totally where SS type I, leading stone size ≤ 10 mm type and decreased UWT around the leading stone increased treatment success.

CONCLUSION

Ureteral wall thickness is an important factor predicting SS management success. Besides the decreased UWT, non-invasive management should be offered for type I SS with leading stone ≤ 10 mm.

Randomized trial to assess the potential role of ascorbic acid and statin for post-contrast acute kidney injury prevention

PURPOSE

To evaluate the effect of using statins and ascorbic acid for the prevention of post-contrast acute kidney injury (PC-AKI) in patients undergoing urologic diagnostic elective contrast-enhanced computed tomography (CECT).

METHODS

This registered trial (NCT03391830) was for statin naïve patients underwent elective CECT. Patients were randomized allocated to two groups: the first group received atorvastatin 80-mg the day before the study and atorvastatin 40-mg two hours before the CECT and for continue on atorvastatin 40-mg two days after CECT; plus ascorbic acid 500 mg with atorvastatin. The other group received two tablets of placebo once/daily before the procedure and for another 3 days. The primary outcome was to assess the incidence PC-AKI.

RESULTS

The baseline parameters were comparable between both groups. The final median (interquartile range "IQR") serum creatinine were 0.80 (0.60, 1.00) and 0.80 (0.60, 1.00), respectively, with insignificant p-value (p = 0.8). The median (IQR) final estimated GFR were 95.2 (72.8, 108.1) and 88.6 (71.9, 111.0) mL/min in placebo and statin plus ascorbic acid groups, respectively (p = 0.48). The eGFR difference median (IQR) were - 6.46 (- 11.72, - 4.18) and - 6.57 (- 13.38, - 3.82) ml/min in placebo and statin plus ascorbic acid groups, respectively (p = 0.58). PC-AKI occurred in 11 patients (9.8%) in placebo group and in 3 patients (3%) in statin plus ascorbic acid group (p = 0.04).

CONCLUSIONS

Statin and ascorbic acid did not statistically improve neither serum creatinine nor eGFR values in patient underwent CECT. However, it can decrease the incidence of the clinically insignificant PC-AKI.

The efficacy of the new Bosniak classification v.2019 in benign lesions prediction within the higher Bosniak cysts classes

INTRODUCTION

Identification of benign lesions among higher classes of renal Bosniak cysts who are vulnerable to active surveillance instead of surgical approach is still questionable. We aimed in this study to delineate the efficacy of the new Bosniak v2019 classification in benign lesions identification among those cases with higher Bosniak classes in comparison with the final histopathology.

MATERIALS

In a retrospective review between 2010 and 2021 for patients diagnosed as higher classes Bosniak renal masses was done. Patients' demographics and radiological data i.e.,: age, gender, and final Bosniak v2019 categorization for class III: (1) Enhancing thick wall/septa >4 mm (III-WS) and (2) Enhancing irregular wall/septa or convex protrusion with obtuse margins <3 mm (III-OP) and for class IV as: (1) Enhancing nodule or convex protrusion with obtuse margins >4 mm (IV-OP) and (2) Enhancing nodule or convex protrusion with acute margins of any size (IV-AP).

RESULTS

A total of 137 patients were included. Bosniak III was identified in 56 patients. Malignancy was detected in 74.5% of resected masses. Among resected Bosniak III cyst, 46.4% were benign histopathologically. Male gender and Bosniak III-OP were independent risks for malignancy among the resected Bosniak III cysts. Conversely, in resected Bosniak IV renal cysts, only 9 of resected masses were benign. In univariate analysis, male gender, absence of multilocular cyst and endophytic masses were predictors for malignancy in resected Bosniak IV cyst. None of the previous predictors was significant in multivariate analysis.

CONCLUSION

The Bosniak subclassification v.2019 can define benign lesions. Bosniak III-OP was an independent risk for malignancy detection among the resected Bosniak III cysts.

Bladder perforation as a complication of transurethral resection of bladder tumors: the predictors, management, and its impact in a series of 1570 at a tertiary urology institute

OBJECTIVES

To report the incidence, predictors, the impact of bladder perforation (BP), and our protocol of management in patients who underwent trans-urethral resection of bladder tumor (TURBT).

METHODS

This is a retrospective study, between 2006 and 2020, on patients who underwent TURBT for non-muscle-invasive bladder cancer (NMIBC). Bladder perforation was defined as any full thickness resection of the bladder wall. Bladder perforations were managed based on their severity and type. Small BP with no or mild symptoms were managed with prolongation of urethral catheters. Those with significant extraperitoneal extravasations were managed by insertion of a tube drain (TD). Abdominal exploration was done for extensive BP and all intraperitoneal extravasations.

RESULTS

Our study included 1,570 patients, the mean age was 58 ± 11 years and 86% were males. Bladder perforation was recorded in 10% (n = 158) of the patients. The perforation was extraperitoneal in 95%, and in 86%, the perforation was associated with no symptoms, mild symptoms, or mild fluid extravasation that required only prolongation of the urethral catheter. On the other hand, active intervention was required for the 21 remaining patients (14%) with TD being the most frequent management. History of previous TURBT (p = 0.001) and obturator jerk (p = 0.0001) were the only predictors for BP.

CONCLUSIONS

The overall incidence of bladder perforation is 10%; however, 86% required only prolongation of urethral catheter. Bladder perforation did not affect the probability for tumor recurrence, tumor progression nor radical cystectomy.

Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer

Purpose

Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC.

Methods

Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology.

Results

In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively).

Conclusions

During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.

Utility of Pre-Transplant Bladder Cycling for Patients With a Defunctionalized Bladder. A Randomized Controlled Trial

OBJECTIVE

To study the necessity of pre-transplant programmed bladder cycling (PBC) in patients with defunctionalized bladder (DB).

METHOD

This RCT included renal transplant (RT) candidates with DB. Eligible patients were assigned to 2 groups, group I underwent PBC before RT and group II underwent direct RT into the DB. The primary outcome was to assess the efficacy of PBC in improving post- RT bladder capacity. Secondly, to compare its impact on early urological complications and 3-month voiding function and 1-year graft function and survival. Graft function was evaluated using serum creatinine and eGFR using MDRD equation.

RESULTS

Groups I included 23 patients and group II included 20 patients. The mean ±SD of bladder capacity was 88.7±11.7mL and 90.6 ±9.8mL in both groups, respectively (P = .5). In group I, PBC increased bladder capacity to 194.7 ±21.2 mL (P < .001). Targeted bladder capacity was achieved in 19 (82.6 %) patients and 2 patients developed UTI. At 3-months, bladder capacity, compliance and bladder contractility index improved significantly in both groups with a significant reduction in maximum detrusor pressure with no significant difference between both groups (P = .3,0.4, 0.2 and 0.8, respectively). Urinary leakage occurred in one (4.3%) and 3 patients (15%) in group 1 and 2, respectively (P = .2). At 1-year, no statistically significant differences in the median (IQR) serum creatinine (P = .05) and eGFR (P = .07) between both groups were noted.

CONCLUSION

Pre-transplant PBC for DB-patients provided no clinical advantage concerning post-operative urological complication, urodynamic criteria and graft function and survival.

Bilateral orbital myositis in a patient with rheumatoid arthritis on treatment with tofacitinib: a report and review of literature

Orbital myositis is a rare inflammatory condition affecting the extraocular muscles of the eyes. It has also been linked to systemic autoimmune diseases. We present a case of orbital myositis in a 57-year-old male undergoing treatment for rheumatoid arthritis (RA) with tofacitinib, a Janus kinase inhibitor (JAK). Prompt administration of intravenous steroids led to rapid symptom improvement. To date, only six published cases have documented the association between RA and orbital myositis. This is the first description of orbital myositis occurring during treatment with the anti-inflammatory drug tofacitinib, an increasingly used disease-modifying anti-rheumatic drug (DMARD). We review the literature and emphasize the importance of ongoing vigilance regarding adverse events linked to tofacitinib.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

A case of bowel perforation secondary to burn conversion

SUMMARY

Burn conversion is a process by which superficial partial-thickness burns spontaneously progress into deep partialthickness or full-thickness wounds. Factors that influence this process centre around poor perfusion which can be related to either too much or too little fluid resuscitation, infection, free radical damage, and metabolic or nutritional derangements. Therein lies the role of preventative strategies, i.e., adequate fluid resuscitation, prompt identification and management of sepsis, correction of electrolyte derangements and early institution of feeds. Prevention of burn conversion could prevent the need for surgical intervention and improve the morbidity and mortality of burns patients.

Delayed management of paediatric burn sepsis resulting in limb loss

SUMMARY

Primary health care centres, community health centres and district hospitals often have medical staff that have minimal exposure to paediatric patients. This may contribute to the challenge of recognising a critically ill paediatric patient. It is already a difficult task as many clinicians are not comfortable or well equipped to manage burn patients, even in regional or tertiary facilities. Identification of the systemic inflammatory response syndrome (SIRS) versus sepsis is difficult in burns owing to the clinical presentation. Identifying the clinical signs determines the need for immediate treatment (i.e., fluid resuscitation) no matter the cause. Investigations will follow to determine the cause, further management and response to treatment. These two cases illustrate the deficit in skill and knowledge in the identification of the sick burninjured child. Although telemedicine has made large advances in allowing access to expert advice in remote locations, its usefulness is dependent on the clinical signs being identified and adequately portrayed to the expert. The way forward is better undergraduate and postgraduate training in this area with an emphasis on clinical acumen.

Amputations secondary to burn injuries in a resource-limited setting

INTRODUCTION

Amputations are a devastating consequence of severe burns. Amputations in a resource-limited setting are challenging as rehabilitation services available to these patients are inconsistent and often fragmented. Epileptic patients are a particularly vulnerable group when it comes to burn-injuries and often sustain deeper burns. The aim of this study is to analyse amputations secondary to burn injuries. We seek to identify vulnerable groups as a means for advocacy efforts to reduce the devastation of an amputation secondary to a burn injury. This paper highlights the burden of these injuries on the healthcare system and emphasizes the need for additional trained therapists for the rehabilitation of these patients.

METHODS

A retrospective database review was conducted. All burns admissions who underwent an amputation between 1 February 2016 and 31 January 2019 were considered.

RESULTS

A total of 1575 patients were admitted during the study period. Fifty-four percent of the admissions were paediatric patients. The amputation rate in the paediatric population was 1.5% (13/850) while in the adult population it was 4.8% (35/724) . Most paediatric amputations were as a result of electrical injuries. Flame burns were most likely to result in amputations in the adult group and convulsions were the leading circumstance leading to the injury. There was no significant difference in sepsis or length of stay between the groups. There were no mortalities in the paediatric group but there was an 11% mortality rate in the adult group.

CONCLUSION

The incidence of amputations in burns is low, however, it remains a devastating morbidity. Epileptics are a vulnerable group and these patients account for the most amputations among adult burns patients. Education interventions are needed regarding their diagnosis, administration of their medication and the importance of compliance. Advocacy efforts to ensure constant supply of anti-epileptic drugs at the clinics and other district level health facilities is also essential. Electrical injuries in children are not as common as hot water scalds, however, they are more likely to result in amputation. Communities need to be informed of the risk associated with illegal electrical connections and initiatives need to drive the safe provision of affordable electricity to these under-privileged, vulnerable communities.

The effect of renal transplantation on female sexual function: An age-matched pair analysis

OBJECTIVES

To evaluate female sexual function (FSF) after renal transplantation (RT) and compare it to an age-matched normal females (control).

MATERIAL AND METHODS

The study included 100 sexually active RT women in child-bearing period. Sexual function was evaluated with Female Sexual Function Index (FSFI). We compared the mean scores of all domains of FSFI to an age-matched sexually active normal women. Also, we compared the current FSFI to the pre-transplant status in 54 married women before RT. Factors affecting the FSF after RT were assessed.

RESULTS

In comparison to control group, RT had statistically significant lower sexual desire (p <0.001) with no significant differences as regard arousal, lubrication, orgasm, satisfaction, pain and total FSFI score (P>0.05). Among RT, 83 % had normal sexual function and 83.7% of the control had normal sexual function (p=0.8). After RT, the FSFI score increased significantly from 20.7±5.4 to 27.8±3.1 (P<0.001) and 85.2% had normal sexual function compared to 22.2% before RT (P<0.001) with statistically significant improvement in all domains (p<0.001) except for pain score (p=0.8). Female circumcision was the only identified factor associated with FSD (P=0.02).

CONCLUSION

Successful RT significantly improves female sexual function of ESRD patients. The sexual function after RT is comparable to healthy control except for lower sexual desire.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

INTRODUCTION

The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN).

METHODS

We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm3 were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality.

RESULTS

Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm3 and lower PLR ≤18.4 increased the risk of drainage failure (p = 0.009 and 0.001, respectively).

CONCLUSION

Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

The accuracy of computed tomography in the diagnosis of upper urinary tract urothelial carcinoma in correlation with the final histopathology: A retrospective study in 275 patients at a Tertiary Urology Institute

Introduction:

Because the reports in the literature of radiologic investigations for upper tract urothelial cancer (UTUC) are limited by the number of patients, and included patients with different pathologies, we aimed to study the overall accuracy of computed tomography (CT) in the diagnosis of UTUC and their accuracy on predicting tumor location.

Methods:

A retrospective review from 1990 to 2017 included patients who were treated for UTUC. Unenhanced CT scan was obtained first using Multi-Detector Computed Tomography (MDCT, Philips Medical Systems), then nonionic contrast medium, containing 350 mg iodine/ml was injected at 4 mL/s. Analysis was performed using SPSS^®.

Results:

Of 275 patients, complete data on CT was available on 270 (98%) patients. CT reported only two false positive and six false negative results and the overall accuracy was 96-97%. In comparison to the final pathological reports, CT/CTU detected 85% of the tumor location of in the renal pelvic and 50% of the calyceal tumors. In ureteric tumors, they detected distal (66/71= 93%) more than proximal ureteric tumors (60%).

Conclusion:

In our cohort, CT/ CTU has a high overall accuracy (97%) in diagnosing UTUC, capability to well visualize tumors of distal ureter and renal pelvis, but could miss calyceal tumors. The matter to rely only on CT without ureteroscopic biopsy in the diagnosis of UTUC especially if radical surgery is planned needs further prospective studies.

Optimization of shockwave lithotripsy use for single medium sized hard renal stone with stone density ≥ 1000 HU. A prospective study

PURPOSE

To identify shock wave lithotripsy (SWL) success predictors in hard renal stones (average stone density ≥ 1000 HU).

MATERIALS

We prospectively evaluated patients who underwent SWL for hard renal stones between April 2018 and December 2020. Radiological parameters were identified, e.g., stone site, size, the average density in addition to stone core and shell mean density, and renal cortical thickness (RKT). SWL sessions were performed using Doli-S lithotripter till a maximum of 3-4 sessions with 2-4 weeks interval. Initial response to SWL included stone fragmentation and decreased stone size after the first SWL. Treatment success was considered if complete clearance of renal stones occurred or in case of clinically insignificant residual fragments ≤ 4 mm after 12 weeks follow up by NCCT.

RESULTS

Out of 1878 patients who underwent SWL, the study included 157 patients with hard renal stones. Treatment overall success was found in 92 patients (58.6%) where 69 patients (43.9%) had complete stone clearance. On multivariate analysis, stone shell density < 901 HU, maximum stone size < 1 cm, RKT > 1.95 cm and initial treatment response were associated with increased the success rate after SWL for hard renal stones (P = 0.0001, 0.009, < 0.0001 and < 0.0001, respectively).

CONCLUSION

In hard renal stones, treatment overall success was found in 58.6% where complete stone clearance was found in 43.9%. Stone outer shell fragility, lower stone size, increased RKT and initial response to SWL were associated with a higher success rate at 12-week follow-up.

Functional multigenic variations associated with hodgkin lymphoma

INTRODUCTION

The current study aimed to describe genotypes associated with Hodgkin lymphoma (HL) in a cohort of Saudi and non-Saudi patients and discuss their possible susceptibility to HL.

METHODS

We studied clinical, histopathological, and laboratory findings of HL patients admitted over 12 years duration, at King Fahd University Hospital, KSA. The genomic DNAs of HL patients (n = 61) and normal control subjects (n = 36) were extracted, and genotyping was performed using the Illumina human exome bead chip. Set of HL patients and set of normal controls were included in this study.

RESULTS

A total of 35 DNA variants were found to be highly significant with the P-value <9.90 × 10^-11 among 243 345 exonic biomarkers and obeying the Hardy-Weinberg equilibrium. Nine, MEGF11-rs150945752 (P-value 1.20 × 10^-12 ), CACNA1I- s58055559 (P-value 1.93 × 10^-12 ), DECR2-rs146760080 (P-value 2.19 × 10^-12 ), STAB1-rs143894786 (P-value 2.45 × 10^-12 ), ZNF526-rs144433879 (P-value 2.76 × 10^-12 ), CPLANE1-rs200612080 (P-value 3.77 × 10^-12 ), DLK1-rs1058009 (P-value 5.95 × 10^-12 ), RTN4RL2-rs61745214 (P-value 7.71 × 10^-12 ), and PGRMC1-rs145582672 (P-value 8.56 × 10^-12 ), exonic variants on chromosomes 15, 22, and 16 were highly associated with HL cases. THE HIGHLY SIGNIFICANT HAPLOTYPES AT CHROMOSOME 3: rs143894786G; rs149982219G with P-value = 3.43 × 10^-14 was found to be the risk haplotype for the HL patients. The opposite alleles at chromosome 3: rs143894786A; rs149982219G is protective with P-value = 2.46 × 10^-12 . Maximum number of SNPs at the chromosome 19: rs144433879C; rs181265966G; rs201144421C; rs145591797G; rs200560875G; rs77270337G (risk P-value = 2.24 × 10^-12 ) and its opposite allele rs144433879A; rs181265966A; rs201144421T; rs145591797A; rs200560875A; rs77270337A (protective P-value = 2.60 × 10^-9 ) were found to be associated haplotype with the HL and controls, respectively, in Saudi population.

CONCLUSION

Our study concludes that the HL is genetically heterogeneous with multigene causation.

Initial radiological findings associated with active bleeding control necessity and long term functional outcomes after isolated high grade blunt renal trauma

INTRODUCTION

To assess the predictors for conservative management failure and long term outcomes after isolated blunt high grade renal trauma (HGRT).

METHODS

 A retrospective analysis of patients with isolated blunt HGRT (renal trauma grade ≥ IV) was conducted. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of conservative treatment failure (need for active bleeding control e.g.: transarterial angioembolization (TAE) and/or surgical exploration). The secondary outcome was to assess the renal parenchymal volume (RPV) changes post HGRT in correlation with the different lines of management using CT-measured RPV. The difference in RPV ≥ 5% at follow up was considered significant.

RESULTS

The study included 63 patients, mean (SD) age was 35.1 (16.6) years. Conservative management was successful in 39 patients (62%), while the need for active bleeding control was required in 16 and 8 patients who underwent TAE and surgical exploration, respectively. Increased hematoma rim distance (HRD), laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of vascular contrast extravasation (VCE) were predictors for conservative treatment failure (P= 0.006, 0.02, 0.045 and 0.002, respectively). After a mean of 19 months follow up, patients were subclassified into 2 groups: patients with preserved RPV (28 patients) and patients with decreased RPV (29 patients). Renal parenchymal devascularization ≥ 25% was found a predictor for ipsilateral RPV decrease (P = 0.02).

CONCLUSION

Increased HRD, laceration numbers > 3, parenchymal devascularization ≥ 25%, and presence of VCE are findings that reflect the necessity for active bleeding interventions after isolated blunt HGRT. Parenchymal devascularization ≥ 25% is an independent factor for RPV deterioration. Neither the grade of renal trauma nor the type of treatment is a predictor for such deterioration.

De novo chromophobe renal cell carcinoma in the graft three decades after renal transplantation in a patient with a history of three renal transplants

De novo renal allograft tumors were reported sporadically. Most of them were small, low-grade, and papillary renal cell carcinoma (RCC) type. A 46-year-old male presented with hematuria three decades after the first transplant. The patient had a history of three renal transplants. A tumor (12 cm × 13 cm) was diagnosed in the nonfunctioning first transplanted kidney. Radical nephrectomy of the graft harboring the tumor with preservation of the adjacent functioning graft was done and identified to be chromophobe RCC. After two-year follow-up, the patients had a perfect graft function with no evidence of oncological failure. We suggest that allograft tumor be considered in patient evaluation for hematuria. Regular follow-up imaging of transplanted kidney is mandatory even after graft failure for early detection of graft tumors.

5-Year Long-Term Outcome of Live-Donor Renal Transplant Recipients With Enterocystoplasty and Ureterocystoplasty: An Age- and Sex-Matched Pair Analysis

OBJECTIVE

To assess surgical complications, febrile UTI, graft function and 5-year graft survival after renal transplantation (RT) in patients with augmentation cytsoplasty (AC) and to compare them to RT patients with normal lower urinary tract.

MATERIALS AND METHODS

A case-control study of 34 RT patients with AC including 23 patients with enterocystoplasty (EC) and 11 patients with ureterocystoplasty (UC) was performed. The primary outcome was to determine the difference between both groups regarding postoperative surgical complications and febrile UTI episodes. Graft function was compared at 1, 3, and 5 years and 5-year graft survival was determined. The secondary outcome was to compare them to an age- and gender-matched control group (122 patients) with normal lower urinary tract.

RESULTS

There was no significant difference regarding surgical complications or rates of hospital readmission between AC groups. Seventeen (73.9%) and 5 (45.5%) patients developed 33 and 14 episodes of febrile UTI in EC and UC groups, respectively (P= .5). Control group had shown lower incidence surgical complications (P = .001) and febrile UTIs (P = .02) compared to AC groups. At 3 and 5 years, UC had higher median eGFR than EC (P = .08, 0.008, respectively). The 5-year graft survival was 32 (94.1%) with no statistically significant difference between EC (95.7%) and UC (90.9%) (P = .5) or between AC and control (85.2%, P = .3).

CONCLUSION

Although RT after AC was associated with higher surgical complications and UTI episodes, they had comparable 5-year graft survival to their control. When indicated, UC should be the preferred choice of AC whenever possible.

Development and validation of a simple stone score to estimate the probability of residual stones prior to percutaneous nephrolithotomy

BACKGROUND

The aim of the present study was to develop and internally validate a simple stone score (SSS) to estimate the probability of clinically significant residual fragments (CSRF) prior to percutaneous nephrolithotomy (PNL).

METHODS

The files of 1170 PNL procedures between January and December 2015 were evaluated. CT-derived stone characteristics were examined. Caliceal stone distribution (CSD) was assigned three grades based on the number of calices involved regardless of the renal pelvis (I = no or single calix; II = more than one calix; and III = more than 2 calices or complete staghorn stones). CSRF was defined as any residuals >4 mm in postoperative CT. A logistic regression model to predict the CSRF was fitted, and coefficients were used to develop the SSS. The SSS was validated by discrimination, calibration, and decision curve analysis (DCA).

RESULTS

Patients' data were split into training (936, 80%) and validating (234, 20%) datasets. In the training partition, independent predictors of CSRF were CSD-grade II (OR: 4.2; 95%CI: 2.5-7; P<0.001), grade III (OR: 7.8; 95%CI: 4.2-14.4; P<0.001) and largest stone diameter (LSD) (OR:1.3; 95%CI: 1.1-1.6; P<0.001). Score points 0, 1, 2, and 0, 3, 9 were given to LSD<30, 30-40, >40 mm, and CSD grades I, II, III, respectively. Discrimination of the SSS was 0.79 and after 10-fold cross-validation and internal validation was 0.86. The calibration plot and DCA highlighted the validity and clinical significance of the SSS.

CONCLUSIONS

The novel SSS could be used to describe the risk of CSRF prior to PNL. Further studies are invited for external validation.

Development and validation of a simple stone score to estimate the probability of residual stones prior to percutaneous nephrolithotomy

BACKGROUND

The aim of the present study was to develop and internally validate a simple stone score (SSS) to estimate the probability of clinically significant residual fragments (CSRF) prior to percutaneous nephrolithotomy (PNL).

METHODS

The files of 1170 PNL procedures between January and December 2015 were evaluated. CT-derived stone characteristics were examined. Caliceal stone distribution (CSD) was assigned three grades based on the number of calices involved regardless of the renal pelvis (I = no or single calix; II = more than one calix; and III = more than 2 calices or complete staghorn stones). CSRF was defined as any residuals >4 mm in postoperative CT. A logistic regression model to predict the CSRF was fitted, and coefficients were used to develop the SSS. The SSS was validated by discrimination, calibration, and decision curve analysis (DCA).

RESULTS

Patients' data were split into training (936, 80%) and validating (234, 20%) datasets. In the training partition, independent predictors of CSRF were CSD-grade II (OR: 4.2; 95%CI: 2.5-7; P<0.001), grade III (OR: 7.8; 95%CI: 4.2-14.4; P<0.001) and largest stone diameter (LSD) (OR:1.3; 95%CI: 1.1-1.6; P<0.001). Score points 0, 1, 2, and 0, 3, 9 were given to LSD<30, 30-40, >40 mm, and CSD grades I, II, III, respectively. Discrimination of the SSS was 0.79 and after 10-fold cross-validation and internal validation was 0.86. The calibration plot and DCA highlighted the validity and clinical significance of the SSS.

CONCLUSIONS

The novel SSS could be used to describe the risk of CSRF prior to PNL. Further studies are invited for external validation.

Enhanced recovery after surgery (ERAS) following radical cystectomy: is it worth implementing for all patients?

PURPOSE

To report the overall effect of ERAS protocol implementation in patients undergoing radical cystectomy and its impact on the length of hospital stay (LOS) and surgical outcomes considering their comorbid conditions.

METHODS

Retrospective cohort study including 296 patients (146 non-ERAS patients vs. 150 ERAS patients) undergoing radical cystectomy and urinary diversion from 2010 to 2018. Age-adjusted Charlson Comorbidity Index (ACCI) score eight was set as cut off value between low-risk and high-risk patients. The primary outcome was LOS. Secondary outcomes were time to bowel movements, tolerance of regular diet, the incidence of postoperative ileus, postoperative complications, and 30- and 90-day readmission rates.

RESULTS

A higher comorbidity burden was identified in the ERAS group compared to non-ERAS patients (p = 0.04). Median (IQR) LOS for non-ERAS was group 8(4) and 8(5) for ERAS group (p = 0.07). ERAS group demonstrated shorter time to resume bowel movements as well as time to tolerance of regular diet (p = 0.007, p = 0.023, respectively). Low-risk patients managed by the ERAS protocol demonstrated a significantly shortened gastrointestinal (GIT) recovery time (p = 0.001) as well as a reduction of LOS (p = 0.04). No significant reduction of LOS was identified for patients with higher comorbidity when placed on the ERAS protocol (p = 0.65). There were no significant differences in postoperative complications or readmission rates between groups.

CONCLUSION

ERAS protocol implementation following radical cystectomy showed significant improvements in GIT recovery, nevertheless, it did not result in a decrease in LOS or readmission rates. Low-risk patients appeared to derive more benefit from ERAS protocol implementation than high-risk patients.

Long-term outcomes after pyeloplasty for pelvi-ureteric junction obstruction in adults associated with renal congenital anomalies: Age, sex and renal function matched analysis

Objective: To assess the long-term outcomes after pyeloplasty for pelvi-ureteric junction obstruction (PUJO) associated with renal anomalies.

Patients and methods: Data were collected for patients after pyeloplasty for PUJO associated with renal anomalies and analysed retrospectively. Long-term functional success was evaluated by comparing the renographic split renal function (SRF) and glomerular filtration rate (GFR) at last follow-up with baseline values. A change of 5% in SRF was considered significant. Factors affecting functional outcome were assessed. The outcomes were compared to an age, sex and renal function matched group with PUJO in otherwise normal kidneys (Group 2) to evaluate the pattern of difference in functional recoverability in both groups. This was assessed using repeated-measures analysis of variance.

Results: The study initially included 70 adult patients, with a mean age of 31.8 years. At a median of 44 months, 55 patients completed follow-up (Group 1) and no statistically significant changes in GFR (P = 0.7) and SRF (P = 0.06) were found. In all, 17, four and 34 patients showed a decrease, increase and static SRF (functional success rate was 69%). Higher preoperative SRF (P = 0.02) and Anderson–Hynes (A–H) pyeloplasty (P = 0.003) were associated with functional preservation. In the comparison with the other matched group (Group 2), the patients in Group 2 had better functional recoverability after pyeloplasty than patients with associated anomalies [GFR (P = 0.001), SRF (P = 0.002) and functional success (P = 0.001)].

Conclusion: Functional preservation after pyeloplasty in associated renal anomalies could be achieved in 69% of patients, which was significantly lower than those with otherwise normal kidneys. A–H pyeloplasty and higher preoperative SRF were associated with better functional outcomes.

Abbreviations: A–H: Anderson–Hynes; HSK: horseshoe kidneys; OR: odds ratio; PUJO: PUJ obstruction; SRF: split renal function; T_1/2, half-time

Supranormal differential renal function in adults with ureteropelvic junction obstruction: Does it really exist?

Introduction

Some patients with ureteropelvic junction obstruction (UPJO) have supranormal differential renal function (snDRF). We aimed to study the outcomes of pyeloplasty in adult patients with UPJO and either snDRF or normal differential renal function (nDRF) and to identify preoperative factors responsible for the snDRF phenomenon.

Materials and Methods

We retrospectively retrieved data for all patients who underwent pyeloplasty and had snDRF (differential renal function [DRF] ≥55%) and nDRF (DRF between 45 and 55%) preoperatively. Preoperative radiological data using computed tomography or magnetic resonance imaging were correlated with the presence of snDRF phenomenon. In addition, scintigraphic findings pre- and post-operatively were also assessed to evaluate the functional outcomes.

Results

Of a total of 856 patients, 31 had snDRF (group 1) and 42 had nDRF (group 2). After a mean of 37 months' follow-up in Group 1, 22 patients developed DRF reduction with non-obstructive pattern. Mean DRF % decreased from 59 ± 2.8 to 48 ± 13 (P < 0.0001). However, in Group 2, five patients had DRF decrease. Four patients developed snDRF phenomenon postoperatively. Increased renal pelvis volume ≥50 mm³ and increased anteroposterior pelvic diameter (APD) ≥37 mm were found to predict snDRF phenomenon. The same findings, in addition to preoperative snDRF, correlated with postoperative DRF decrease.

Conclusion

SnDRF function could be expected in patients with increased renal pelvis volume and APD. The absolute value or changes in DRF are not reliable to judge treatment failure.

Report of two rare cases of adrenal incidentalomas with different origins: revisiting pathological and radiological findings with a short review of the literature

BACKGROUND

Adrenal tumors can be detected incidentally in 4 to 8% of patients radiologically. Adenomas, pheochromocytomas, and adrenocortical carcinomas represent the most common tumors of the adrenal glands. Rare histopathological findings are uncommon. We aimed to report two rare primary adrenal tumors diagnosed initially as incidentalomas to identify clinical characteristics, management, and clinical outcomes after treatment.

CASE PRESENTATION

The first case was a 52-year-old man presented with an incidentally discovered locally advanced primary adrenal angiosarcoma. The patient was managed surgically with no adjuvant therapy. The patient was followed up for 3 years without evidence of local recurrence. The second case was a 63-year-old woman, presented with an incidentally discovered primary diffuse B-cell lymphoma of the left adrenal gland. She was treated by adrenalectomy. Later on, adjuvant six cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy were given. After 6 months follow-up, the patient was alive and disease-free.

CONCLUSION

The diagnosis of adrenal tumors increased nowadays because of the widespread use of imaging studies, though rare pathologies should be taken into consideration.

Prophylaxis against renal ischemia-reperfusion injury in canine model: Stem cell approach

Introduction

Stem cell therapy at the time of ischemia/reperfusion (I/R) injury has been hypothesized to attenuate the severity of acute kidney injury and to accelerate the regeneration process in lower animal models. Data in higher animal models is limited and discordant. We aimed to explore the reno-protective effects of stem cells on I/R related renal injury in a canine model.

Materials and Methods

Twenty-seven dogs that were treated with bone marrow-derived mesenchymal stem cells (BM-MSCs) were compared with another 27 dogs treated with adipose tissue-derived MSCs (AT-MSCs) following 90 min of warm ischemia to assess IR injury. Each group was divided into three subgroups (nine dogs each), according to the stem cell dose (5, 10, 15 × 10⁶ in 500 μl volume) injected directly into the renal cortex after reperfusion. All dogs were re-evaluated by renogram, histopathology, and pro-inflammatory markers at 2 weeks, 2, and 3 months.

Results

In Group I, there was a mean reduction of creatinine clearance by 78%, 64%, and 74% at the three used doses, respectively, at 2 weeks. At 3 months, these kidneys regained a mean of 84%, 92%, and 72%, respectively, of its basal function. In Group II, the reduction of clearance was much more modest with mean of 14%, 6%, and 24% respectively at 2 weeks with more intense recovery of renal function by mean of 90%, 100%, and 76%, respectively, at 3 months. Group I had significantly more tubular necrosis and delayed regeneration compared with the Group II. Expressions of pro-inflammatory markers were upregulated in both the groups with a higher and more sustained expression in Group I.

Conclusion

Stem cells protected against ischemic reperfusion injury in a canine model. AT-MSCs provided better protection than BM-MSCs.

Single Versus Maintenance Intravesical Chemotherapy for the Prevention of Bladder Recurrence after Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Randomized Clinical Trial

INTRODUCTION

The objective of this study was to determine the efficiency of 1-year maintenance intravesical chemotherapy (MIC) in reducing bladder recurrence (BR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma compared with single intravesical instillation (SIC).

PATIENTS AND METHODS

Between January 2015 and May 2017, patients who underwent RNU were randomized to receive SIC (epirubicin 50 mg) or MIC (once weekly for 6 weeks plus once monthly for 1 year). The primary outcome was the rate of histologically proven BR. The secondary outcomes included chemotherapy-related toxicities and disease-specific survival (DSS). Thirty-five patients in each arm were required to achieve a power of 80%.

RESULTS

A total of 38 (SIC) and 36 (MIC) patients were analyzed. In SIC, BR developed in 5 (13.2%) over a median follow-up of 3 months (range, 3-6 months) compared with 9 (25%) patients over 12 months (range, 3-28 months) in MIC (P = .08). The 6- and 12-month BR-free survivals were the same (86.8%) in SIC versus 88.9% and 83.3% in MIC, respectively (P = .2). Lymphovascular invasion was significantly associated with BR (P = .04). Post-RNU intravesical chemotherapy regimens did not alter DSS. Blood transfusion and advanced tumor stage were independent predictors for DSS. No significant medication toxicity was reported.

CONCLUSIONS

Following RNU, MIC did not change the natural course of BR beyond a single instillation apart from potentially delaying its occurrence. Lymphovascular invasion and blood transfusion were associated with worse BR and DSS outcomes, respectively.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE

In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification.

METHODS

A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS^®.

RESULTS

Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality.

CONCLUSION

Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Outcome of Live-Donor Renal Transplants With Incidentally Diagnosed Renal Angiomyolipoma in the Donor

INTRODUCTION

Accepting donors with renal lesion amenable for pre-transplant management with no suspected long-term harm seems to expand the live-donor pool. We aimed to assess the long-term outcome of live-donor renal transplantation with incidentally discovered renal angiomyolipoma (AML) during routine evaluation of donors.

PATIENTS AND METHODS

A retrospective evaluation of incidentally discovered AML, during live-related-donor evaluation, was performed. The tumor criteria were retrieved. In cases with exophytic tumor, a back-table, partial nephrectomy was done with frozen section to exclude malignancy. Endophytic lesions were kept in situ and transplanted. Both donor and recipient were followed up by periodic imaging.

RESULTS

Among 2925 cases, 6 AML with a median volume of 0.96 (range, 0.5-2) cm² were identified. The median recipients' age was 21 (range, 10-38) years and the median donors' age was 48 (range, 45-50). Two AML were exophytic and back-table partial nephrectomy was performed, while 4 were endophytic and kept in situ, and the kidney was transplanted. After a median follow-up of 82 (range, 25-150) months, 4 patients were alive with functioning grafts and 2 resumed hemodialysis 5 and 7 years after transplantation. There was no evidence of increase in the AML size or newly developed AML in the grafts. All donors were alive with normal renal function (mean ± standard deviation, serum creatinine was 0.9 ± 0.2 mg/dL) and none developed new AML in the remaining kidney.

CONCLUSION

Incidentally discovered AML during live-donor evaluation is not a contraindication of donation after proper counseling of the couples and regular, periodic follow-up.

Long-term outcomes of upper tract urothelial carcinoma: A retrospective evaluation of single-center experience in 275 patients

OBJECTIVE

We aimed to report our 25-year experience on upper tract urothelial carcinoma (UTUC) on a larger number of patients with long-term follow-up at a single tertiary urology institute.

MATERIAL AND METHODS

A retrospective study was conducted on 275 patients from 1990 to 2015. Basic patient demographic data with the laboratory and radiologic investigations were collected. We used 1997 TNM classification and the three-tiered WHO grading system. Data were collected using an SPSS^® version 21 spreadsheet.

RESULTS

The mean age was 59±11 years, and 88% of all the patients were male. Previous and concurrent bladder tumors were found in 16% and 26%, respectively. Computed tomography gave an overall accuracy of 96%. Open nephroureterectomy and bladder cuff excision was performed for 85%, and the remaining by laparoscopy and nephron-sparing surgeries. Tumor was pelvicalyceal, ureteric, and both in 40%, 40%, and 20% respectively. In 97% of the patients, the tumor was transitional cell carcinoma. Nearly two-thirds of the patients were of low grade and non-invasive in stage. Nearly half of the patients (46%) had bladder tumor recurrence after NU. Bladder, urethral, and contralateral recurrence, distant, local metastasis occurred in 46%, 2%, 1%, 7.5%, and 6%, respectively.

CONCLUSION

UTUC is a unique disease with synchronous and metachronous urothelial tumor recurrence that requires long-term surveillance. The majority (two-thirds) of the patients are non-invasive in stage of grade II. Tumor stage is of paramount prognostic significance for survival; the five-year survival rate of T1 and T4 is 80% and 0%, respectively.

Coincidental Bladder Cuff Transitional Cell Carcinoma in Nephroureterectomy Specimens: Risk Factors, Prognosis and Clinical Implementation

PURPOSE

There is a lack of reporting of the bladder cuff pathology in the literature and ongoing debate regarding the role of bladder cuff excision (BCE) in the prognosis in patients with upper tract urothelial carcinoma (UTUC). We aimed to know the risk factors, the survival, and the clinical course of such pathology.

MATERIALS AND METHODS

The study was retrospective, from 1983-2013 on 305 patients who had diagnosed with UTUC. Patients were managed by radical open/ laparoscopic nephroureterectomy with bladder cuff excision. The tumor was staged using 1997 TNM classification and the 3-tiered WHO grading system was used for grading. Patients who found to have a malignant bladder cuff on the final pathology were further analyzed for the risk factors for such disease and its effect on survivaltheir outcomes.

RESULTS

13/ 281 (4.6%) cases were found to have malignant bladder cuff. Regarding tumor stage; one case was diagnosed with Tis, eight had T1 and four cases had T2 malignant bladder cuff. All cases were with pure ureteric or multifocalcentric tumors, and none had pure pelvicalyceal tumors (p = .001).Local recurrence at the surgical site and distant metastasis were significantly higher among patients with malignant bladder cuff (p = .001 and .002 respectively), and the last sustained its significance in multivariate analysis. Those patients had a poor prognosis when compared to non-malignant bladder cuff cases (Log Rank test, p = .001)Conclusion: Ureteric tumor is the only independent risk factor for malignant bladder cuff at the final pathology and is associated with increased risks for invasive bladder tumor, distant metastasis and poor survival in comparison with non-malignant bladder cuff. In a clinical implementation, BCE is considered as a mandatory step in management of ureteric tumors, while it could be omitted in pure and low grade renal pelvis tumors.