Renal medullary carcinoma: the zebra amongst the horses

A 13-year old Latino male who presented with recurrent gross hematuria, 5-cm right sided poorly defined heterogeneous mass, enlarged retrocaval lymph nodes and 1.2 cm paratracheal lymph node. Given the need for multiple blood transfusions, robot-assisted radical nephrectomy with lymph node dissection was performed. Pathology revealed pT3a high-grade tumor, clear margins, and positive lymph node. Additionally, with multiple sickled RBCs and loss of staining of SMARCB1 in tumor specimen, and hemoglobin electrophoresis suggesting sickle cell trait, diagnosis of metastatic renal medullary carcinoma was confirmed. The patient was enrolled into COG AREN 03B2 trial, and has completed 10 cycles of carboplatin/gemcitabine/bortezomib alternating with cisplatin/gemcitabine/paclitaxel, with no evidence of recurrent disease 9 months post-surgery.

A Rare Case of Urinary Bladder Hamartoma Clinically Mimicking an Urothelial Carcinoma: A Case Report and Review of the Literature

Urinary bladder hamartoma is a rare benign proliferation with only 14 cases reported in the literature at present. Urinary bladder hamartoma is composed of a disorderly admixture of normal urinary bladder components, essentially represented by glands lined by transitional epithelium and a variable percentage of fibrous stroma, smooth muscle bundles, and adipose tissue. Urinary bladder hamartomas do not exhibit cytological or architectural abnormalities and show no necrosis or increase in mitotic activity. Clinical manifestations are usually represented by lower urinary tract symptoms, more or less frequently paired with gross hematuria. Several pediatric cases of urinary bladder hamartoma have been reported, sometimes with syndromic associations. Transurethral resection has been curative in all cases reported, with no evidence of recurrence. Here we report an additional rare urinary bladder hamartoma, clinically mimicking urothelial carcinoma, providing a review of the literature regarding this unusual entity.

Diagnostic Challenges and Management of Acquired Hemophilia A Presenting as Gross Hematuria: A Case Report

Acquired hemophilia A (AHA) is a rare autoimmune disorder marked by autoantibodies against coagulation factor VIII, leading to bleeding complications. This case report explores a unique presentation of AHA, initially manifested as gross hematuria, a symptom often encountered in healthcare settings with a broad range of differential diagnoses. The background of this study highlights the rarity of AHA and its diverse clinical presentations. The case involves a 62-year-old man with no history of bleeding disorders, presenting with gross hematuria and later developing severe anemia and ecchymoses. Methods employed in the evaluation included urological assessments such as cystoscopy and computed tomography, alongside hematological investigations, which later revealed a prolonged activated partial thromboplastin time (aPTT) and a critically low factor VIII level, indicative of AHA. Results showed a lack of early recognition of coagulation abnormalities, underscoring the need for comprehensive initial assessments in cases of unexplained hematuria. The patient's management at a specialized Hemophilia Center involved inhibitor eradication therapy and management of acute bleeding episodes, resulting in significant clinical improvement. The conclusions drawn from this case emphasize the importance of considering rare conditions like AHA in the differential diagnosis of hematuria and the necessity for a broad diagnostic approach. It advocates for heightened awareness and early coagulation studies in unexplained cases of hematuria to prevent delayed diagnoses and improve patient outcomes. This case contributes to the understanding of AHA's clinical variability and the critical nature of early and comprehensive diagnostic approaches in hematuria evaluation.

Corrigendum: Urethral discharge as an early manifestation of urinary tract infection in children ≤24 months old

[This corrects the article DOI: 10.3389/fped.2023.1149218.].

An Autonomous Continuous Bladder Irrigation System

Introduction and Objective: Continuous bladder irrigation (CBI) is used in a variety of clinical settings, including post-transurethral surgery and the emergency department. Currently, CBI administration relies on nurses to diligently monitor and switch irrigation bags, as well as titrate the inflow rate based on effluent color. Inappropriate administration can result in discomfort to patients, clot urinary retention, repeat injury to the pathologic or surgical site, extended hospital stays, and even operative management. Our objective was to create an autonomous CBI system that decreases the incidence of disrupted irrigation flow and monitors the outflow to alert clinicians of critical events. Methods: 3D printing and off-the-shelf microcontrollers were used to design a device to fit the needs identified by stakeholders at our institution. An in vitro model of the bladder was created to test our design. The mechanical, electrical, and software subsystems were adjusted accordingly to meet our design requirements. Results: Our in vitro CBI model was able to simulate routine CBI administration with sudden bleeding. Bovine blood was used to simulate the bleeding events. A device was created that met identified stakeholder needs. Accurate detection of critical bleeding events, catheter blockage, and empty irrigation bags were achieved. The device responds to bleeding appropriately by increasing the irrigation rate. When the catheter is blocked, it stops the irrigation and alerts the nurse. Our system accurately titrated the irrigation rate to match a set outflow blood level parameter, conserving irrigation and minimizing nursing workload. Continuous monitoring of CBI effluent was recorded. Conclusions: We anticipate our device will decrease the cognitive load on nurses in busy clinical settings and improve workflow. Moreover, the detection of critical events will likely decrease patient morbidity. Continuous monitoring of the CBI outflow may prove to be a new clinical decision-making tool for ongoing hematuria. Clinical trial is pending.

Successful Conservative Management of Emphysematous Cystitis With Pneumoperitoneum: A Case Report and Literature Review

Emphysematous cystitis is a rare type of urinary tract infection that is characterized by the accumulation of gas within the walls and lumen of the urinary bladder. In rarer instances, pneumoperitoneum may accompany emphysematous cystitis. When pneumoperitoneum is suspected through imaging studies in patients with emphysematous cystitis, surgical abdominal exploration is frequently performed considering the possibility of bladder perforation or coexistence of intestinal perforation. We successfully managed a case of emphysematous cystitis accompanied with pneumoperitoneum conservatively. A 90-year-old woman hospitalized with a gastric ulcer developed abrupt lower abdominal pain and hematuria. Contrast-enhanced CT revealed gas within the bladder wall, which was consistent with emphysematous cystitis, and pneumoperitoneum. No obvious bowel or bladder perforation was observed in the CT scan. Regarding her high surgical risk and clinical stability, surgical abdominal exploration was not performed, and she was managed conservatively with urethral catheter placement and antibiotics. She recovered with the treatment, and CT imaging obtained on day 18 demonstrated resolution of the bladder wall emphysema and no signs of pneumoperitoneum. We performed a literature review using MEDLINE and Japana Centra Revuo Medicina Web and confirmed 13 previously reported cases of emphysematous cystitis and pneumoperitoneum. Based on the review of these 13 cases and our case, it is difficult to predict the presence of bladder perforation solely based on peritoneal signs in physical findings or ascites on CT scans. Therefore, it would be preferable to perform surgical abdominal exploration to make a definite diagnosis and select an appropriate treatment. However, the fact that at least eight out of the 10 cases managed conservatively survived suggests that there is a specific clinical entity among patients who present with emphysematous cystitis and pneumoperitoneum that can be safely managed conservatively. Further accumulation of cases and research is necessary to determine which cases can be treated conservatively.

A Rare Complication of Henoch-Schönlein Purpura/IgA Vasculitis in an Adult Woman After COVID-19 Infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can affect multiple organs due to activation of an inflammatory response. One of the key components of this response is the activation of immunoglobulin A (IgA), thus causing endothelial injury and inflammation. Henoch-Schönlein purpura (HSP) has been rarely reported in adult patients as a complication of the coronavirus disease 2019 (COVID-19) infection. In this report, we present a case of HSP occurring one week after the diagnosis of COVID-19 in a 23-year-old woman. Her symptoms included nausea, vomiting, diffused abdominal pain, joint pain, hematuria, and palpable purpura of the lower extremities. She was treated with intravenous methylprednisolone sodium succinate, followed by oral prednisone therapy, which resulted in clinical improvement, including resolution of abdominal and joint pain as well as skin rashes, without remaining renal complication.

An Atypical Case of Bladder Lipoma Presenting as Gross Hematuria: A Case Report

While conventional lipomas represent the most commonly seen benign mesenchymal tumor in adults, their occurrence in the bladder wall is exceptionally rare. This report details a rare case of a bladder lipoma, a benign tumor primarily composed of mature adipocytes, presenting as gross hematuria in a 68-year-old male. Despite the patient's previous history of left nephrectomy, no significant pathological findings were initially observed. The bladder lipoma was detected via cystoscopy as a polypoid mass on the posterior bladder wall and confirmed through transurethral resection of the bladder tumor (TUR-BT). Histopathological analysis verified the mass as a bladder lipoma composed of mature adipocytes. Following a specific postoperative follow-up period, no recurrence of the tumor was observed, suggesting successful treatment. This case underscores the clinical significance of considering bladder lipoma in differential diagnoses of bladder tumors, especially in patients presenting with gross hematuria, given its exceptional rarity.

Urethral discharge as an early manifestation of urinary tract infection in children ≤24 months old

Background

Children with febrile urinary tract infections (UTIs) are prone to kidney scarring if they are not treated promptly; however, ambiguous symptoms before fever onset makes the early detection of UTIs difficult. Our study aimed to identify urethral discharge as an early manifestation in children with UTI.

Methods

This study enrolled 678 children younger than 24 months with paired urinalysis and culture performed between 2015 and 2021; 544 children were diagnosed with UTIs. Clinical symptoms, urinalysis, and paired urine culture results were compared.

Results

Urethral discharge was observed in 5.1% of children with UTI and yielded a specificity of 92.5% for diagnosing UTI. Children with urethral discharge had a less severe UTI course, furthermore, nine of them received antibiotics before fever occurred and seven of them were free of fever during UTI course. Urethral discharge was associated with alkalotic urine and Klebsiella pneumonia infection.

Conclusions

Urethral discharge is an early symptom in children with UTI; it may present before fever onset and help ensure prompt antibiotic intervention.

New-onset crescent IgA nephropathy following the CoronaVac vaccine: A case report

RATIONALE

Although coronavirus disease 2019 (COVID-19) remains a global threat, administering effective and safe vaccines is currently the most promising strategy to curb the ongoing pandemic and decrease the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. However, there remains some uncertainty regarding the safety of vaccines for patients with kidney disease.

PATIENT CONCERNS

A 58-year-old man presented at our institution with gross hematuria 48 hours after receiving his first dose of the CoronaVac (Sinovac) vaccine.

DIAGNOSES

Analysis of a renal biopsy sample led to the diagnosis of crescentic immunoglobulin A nephropathy (IgAN), which we considered an adverse event of receiving the CoronaVac vaccine in China.

INTERVENTIONS

The patient's serum creatinine and albumin levels were 1.20 mg/dL and 31.3 g/L, respectively; as such, he was administered a diuretic. His serum creatinine level had risen to 7.45 mg/dL 1 month later, and he developed high blood pressure. The patient then received conventional doses of hormone therapy but developed recurrent fever, which led to the suspicion of active tuberculosis (which he had a history of) and suspension of the hormone therapy.

OUTCOMES

The patient's renal function deteriorated further, and he ultimately underwent dialysis.

LESSONS

The patient's course of events of apparent IgAN exacerbation should prompt nephrologists to closely follow patients with glomerular disease after they receive a COVID-19 vaccine, especially if persistent gross hematuria occurs.

IgA Nephropathy with Gross Hematuria Following COVID-19 mRNA Vaccination

A 28-year-old woman experienced gross hematuria after the administration of the second dose of an messenger ribonucleic acid (mRNA) vaccine (BNT162b2). She was diagnosed with Immunogloblin A nephropathy (IgAN) by a renal biopsy two weeks after vaccination, which revealed a mild increase in mesangial cells and a matrix with co-depositions of galactose-deficient IgA1 and C3 in the mesangial region. The gross hematuria and proteinuria gradually improved without any medication, suggesting that immune activation by the mRNA vaccine may not elicit continuous disease progression of IgAN. Thus, further studies investigating the relationship between mRNA vaccines against COVID-19 and the progression of IgAN should be conducted.

Case Report: A case of recurrent thrombosis in pediatric antiphospholipid syndrome associated with pediatric onset systemic lupus

Systemic lupus erythematosus (SLE) is an autoimmune disease with multi-system involvement as the main manifestation, and has complex and diverse clinical features. Studies on large samples have revealed that SLE patients have a significantly increased risk of thrombotic events, which are also one of the important causes of morbidity and mortality in SLE patients. Antiphospholipid syndrome (APS) is a rare autoimmune disorder characterized by recurrent arterial and venous thrombosis, pregnancy-related complications, and the persistence of antiphospholipid antibodies at a 12-week interval. There are few reports about SLE coexisting with APS in children. This paper reported a school-age patient who started the disease with gross hematuria after bumping into the waist. The initial diagnosis of renal contusion was then confirmed by color Doppler ultrasound as renal vein and inferior vena cava embolism. She suddenly developed severe chest pain and dyspnea 3 days after hospitalization. And imaging supported pulmonary embolism with massive proteinuria, hypoalbuminemia, and hypercholesterolemia. The initial diagnosis was nephrotic syndrome (NS) with arteriovenous embolization, and popliteal vein embolism occurred again 5 years later, and she was thus diagnosed with SLE coexisting with APS. Afterwards, we discussed the possible mechanism and therapeutic strategies of SLE&APS that started with nephrotic syndrome, in order to achieve early identification and treatment of the disease and improve the prognosis of children.

Recurrent urinary retention due to clots caused by a congenital renal arteriovenous malformation that forms a complex vascular network: Report of two cases

INTRODUCTION

Repeated urinary retention due to clots caused by congenital renal arteriovenous malformation is rare.

CASE PRESENTATION

A 40-year-old woman (case 1) and a 66-year-old man (case 2) experienced recurrent urinary retention due to clots. Neither patient had a history of renal trauma nor was taking any medications. Contrast-enhanced abdominal computed tomography revealed a large hematoma in the renal pelvis and ureter with no masses, stones, or vascular lesions and only dilated blood vessels in the arterial phase in case 1. Angiography of the kidney in both patients revealed an arteriovenous malformation, and embolization of the arteries feeding the arteriovenous malformation was performed. Soon after embolization, hematuria disappeared completely with no recurrence for 5 years in case 1 and 2 years in case 2.

CONCLUSION

Congenital renal arteriovenous malformation should be considered as a cause of recurrent clot retention, and angiographic embolization of the feeding arteries can be an effective treatment.

Pancreatic cancer diagnosed by the detection of gross hematuria due to urinary bladder metastasis: A case report

Pancreatic cancer is not easy to detect at its early stages due to difficulties in identifying symptoms at these stages. As it progresses, abdominal pain, loss of appetite, abdominal distension, jaundice and pain in the back, especially the lower back, might develop. Moreover, sudden onset or worsening of diabetes mellitus may be seen, which often prompts screening for the detection of pancreatic cancer. Since it rapidly spreads to surrounding tissues and organs, pancreatic cancer has a poor prognosis. However, metastasis to the bladder is rare, with few cases diagnosed on the basis of detecting gross hematuria. The current study presents a case of gross hematuria and exacerbated diabetes in a 90-year-old woman. Cystoscopy revealed a non-papillary tumor in the posterior bladder wall. Pathological examination of bladder tumor specimens obtained via transurethral resection revealed adenocarcinoma. Subsequent systemic examinations revealed primary pancreatic cancer that had metastasized to the bladder. To the best of our knowledge, this is the second reported case of pancreatic cancer diagnosed based on the detection of gross hematuria due to bladder metastasis, since 1992.

Something Out of Nothing: A Rare Case of Pulmonary Renal Syndrome With Pauci-Immune Glomerulonephritis and Diffuse Alveolar Hemorrhage With Negative Serologies

Background: Pauci-immune crescentic glomerulonephritis (CrGN) is one of the most common etiologies of rapidly progressive glomerulonephritis. This condition presents with crescentic glomerulonephritis with little or no immunoglobulin staining and negative serological workup aside from a positive antineutrophil cytoplasmic autoantibody (ANCA). Typically, patients with pauci-immune CrGN have an underlying systemic small vessel vasculitis, but in rare cases, it presents without any known vasculitis or ANCA. Pauci-immune ANCA negative CrGN is often strictly isolated to the kidneys. In this case, we present a patient with ANCA negative, pauci-immune CrGN with severe diffuse alveolar hemorrhage.

Case Presentation: A 66-year-old Hispanic woman with a past medical history of controlled hypertension presented with fatigue and dysphagia. On admission, her vital signs were significant for hypoxia on room air, and her physical exam was remarkable for crackles bilaterally. The initial laboratory results revealed anemia (hemoglobin 5.2 g/dL), hyperkalemia (6.3 mmol/L), elevated creatinine (4.50 mg/dL, with a baseline of 0.9mg/dL). Urinalysis showed moderate blood and urine protein (200 mg/dL). Urine microscopic examination showed 25-50 RBCs seen/high power field.

The patient was admitted to ICU due to hypoxia, a computed tomography scan of the chest/abdomen/pelvis was obtained and revealed multifocal pulmonary consolidations. A blood transfusion was ordered. The patient began to have hemoptysis and subsequent bronchoscopy showed diffuse alveolar hemorrhage. ICU team proceeded to intubate her as the hemorrhage continued to worsen. Further workup revealed a positive anti-nuclear antibodies (ANA) of 1:40, but otherwise negative serologies including myeloperoxidase (MPO)-ANCA, glomerular basement membrane antibody, and anti-double stranded DNA. Kidney biopsy showed necrotizing glomerulonephritis with crescents and negative immunofluorescence. She was diagnosed with pauci-immune ANCA-negative vasculitis with associated diffuse alveolar hemorrhage and nephritis based on these results and was started on pulse-dose steroids. The patient was started on intravenous (IV) high-dose cyclophosphamide, which helped improved the overall clinical condition significantly. After creatinine began trending down and urine output improved, the patient was discharged on a regimen of daily oral cyclophosphamide and steroid taper. Patient oxygen requirements decreased and she was sent home with supplemental oxygen while requiring 3L/min of oxygen.

Conclusion: Pauci-immune and ANCA-negative glomerulonephritis with concurrent diffuse alveolar hemorrhage is exceptionally rare. In this situation, medical management relied on clinical evidence from similar populations in the use of steroids and cyclophosphamide. This case report aims to shed more light on the clinical progression and management of this condition. Here we present a case of pulmonary-renal syndrome with biopsy-proven glomerulonephritis but without ANCA positive serologies.

[Relevance of an accurate microscopic examination of urinary sediment in a patient after mitral valve surgery]

Hemoglobinuria, clinically revealing as gross hematuria associated with anemia, increased hemolysis indices, acute kidney injury (AKI), can all be caused by mechanical intravascular hemolysis following mitral valve surgery. It can result from factors related to the surgical procedure or acquired later, such as paravalvular leak (PL), whose definite diagnosis is based on transesophageal echocardiography. We report the case of a patient who experienced macrohematuria and AKI, initially attributed to acute glomerulonephritis, two months after mitral valve surgery. Careful microscopic examination of the urinary sediment was a diriment diagnostic tool to differentiate acute renal failure caused by hemoglobinuria from hematuria in the course of acute glomerulonephritis, directing clinicians to investigate post-operative valvular dysfunction. From the literature review we can deduce that, notwithstanding new technologies in cardiac surgery, this rare form of AKI from intravascular hemolysis requires immediate nephrological attention and that the use of microscopic urinary sediment is decisive.

Hyperuricosuria, hematuria, and novel bladder images with IgA nephropathy

Episodic (recurrent) macroscopic hematuria in patients with IgA nephropathy is usually associated with a benign prognosis, although some patients experience a transient fall in glomerular filtration rate during the episodes. We present a 15-year-old girl with mild IgA nephropathy who had multiple episodes of macroscopic hematuria associated with severe but transient decreases in estimated glomerular filtration rate, low levels of serum uric acid, and marked increases in fractional excretion of uric acid. Ultrasound studies showed marked inflammatory changes in the bladder, especially involving the trigone. Cystoscopic findings were consistent with these changes. We hypothesize that the macroscopic hematuria may have resulted, at least in part, from hyperuricosuria causing acute irritation of the bladder mucosa in the trigone area.

The real cause of right lower abdominal pain: an analysis of ultrasonographic findings

A pelvic accessory spleen is uncommon and most patients with this condition are asymptomatic. Ureteral calculus is a common disease and can cause acute abdominal pain. We report a 51-year-old male patient who presented at our hospital with acute right lower abdominal pain and gross hematuria. A large mass on the right side of the pelvis was detected on an ultrasound examination, as well as a calculus in the lower segment of the right ureter. Computed tomography angiography showed the presence of a long vascular pedicle with an artery originating from the splenic artery and a vein that joined with the splenic vein. Laparoscopy was carried out and it showed a solid mass covered with omentum on the right lower abdomen. The mass was then removed surgically. Histopathological examination of the resected specimens confirmed splenic tissue. We speculate that the accessory spleen and ureteral calculus caused right lower abdominal pain in our case. However, the ureteral calculus might have played a much more important role in causing acute right lower abdominal pain than the accessory spleen.

Propafenone-associated Gross Hematuria: A Case Report and Review of the Literature

PURPOSE

Propafenone hydrochloride has been widely used for the treatment of supraventricular and ventricular arrhythmias. We present a case report of an 81-year-old patient with propafenone-associated gross hematuria.

METHODS

The Naranjo Adverse Drug Reaction Probability Scale was used to assess causality. We also performed a literature search to find publications that report propafenone-associated gross hematuria.

FINDINGS

The Naranjo scale generated a score of 6, suggesting a probable association between gross hematuria and propafenone therapy. Thirteen publications that reported an association between gross hematuria and propafenone administration were found.

IMPLICATIONS

A probable association exists between gross hematuria and propafenone.

Epidemiology of IgA Nephropathy: A Global Perspective

IgA nephropathy (IgAN), or Berger's disease, is the most common primary glomerular disease worldwide, but varies largely in its geographic distribution. A systematic review of 1,619 publications from the five continental regions of the world was performed to assess the prevalence of IgAN in different worldwide regions and analyze factors responsible for geographic differences. All observational studies that described the prevalence and incidence data on glomerulonephritis were considered. IgAN is more frequent in Asian populations (45 cases per million population/y in Japan) than in Caucasians (31 cases per million population/y in France). These differences are owing to some relevant aspects: (1) systematic mass screening of urine in populations, as occurring in some Asian countries (Hong Kong, Japan, Korea, and Singapore), is not common in Western countries; (2) general practitioners and health care professionals in Western countries underestimate persistent microscopic hematuria and/or mild proteinuria in apparently healthy individuals causing late referral to a nephrologist; and (3) nephrologists adopt different indications for kidney biopsy in individuals with persistent urinary abnormalities. In addition, differences also are owing to the source of data, because the frequency of IgAN observed in a nephrology center with a high incidence of kidney biopsies is higher than in a regional renal biopsy registry that receives data from many centers. In conclusion, greater efforts should be made to diagnose IgAN earlier in individuals who manifest persistent microhematuria and/or mild proteinuria and to introduce less stringent indications for kidney biopsies. This preventive approach, followed by early therapy, may reduce the global burden of end-stage kidney disease caused by IgAN.

Ectopic adrenal adenoma causing gross hematuria: Steroidogenic enzyme profiling and literature review

Introduction

Aberrant cortical adrenal tissues are not generally identified in adults. Herein, we present a very rare case of an ectopic adrenal tumor located in the renal hilum that caused gross hematuria.

Case presentation

A 33‐year‐old man suddenly presented with asymptomatic gross hematuria. Abdominal computed tomography revealed a 35‐mm mass in the left renal hilum encroaching the renal vein. Following the surgical removal with frozen section of the mass, his gross hematuria immediately improved. Pathological analysis of the specimen revealed the features adrenal adenoma. Immunohistochemical staining for key steroidogenic enzymes confirmed the adrenocortical origin without excessive hormone production.

Conclusion

This is the first case of an ectopic adrenocortical adenoma in the renal hilum that caused gross hematuria without hormonal symptoms.

Renal Endometriosis: The Case of an Endometrial Implant Mimicking a Renal Mass

Background: Endometriosis is a multifactorial benign disorder characterized by the abnormal presence of endometrial tissue in an extraendometrial site. Although extrapelvic endometriosis is uncommon, symptomatic involvement of the kidney is exceedingly rare. This benign disease can mimic several urologic processes, but because of its scarcity in clinical practice, it is seldom considered in the differential.

Case Presentation: In this report, we describe the case of a 45-year-old woman with flank pain and hematuria, who was found to have a left renal mass on cross-sectional imaging. After robotic partial nephrectomy, pathologic analysis revealed an endometrial implant within the renal parenchyma.

Conclusion: This case of renal endometriosis highlights how this benign disease process can mimic several more sinister urologic processes.

Microscopic hematuria predicts lower stage in patients with upper tract urothelial carcinoma

Background

The aim of this study was to assess the association between the severity of hema-turia (microscopic or gross) and the tumor stage and grade in a population of histopathologically confirmed upper tract urothelial carcinoma (UTUC) patients.

Patients and methods

We conducted a multicenter, observational study of patients who were newly diagnosed with UTUC between January 2011 and December 2016. Demographic information, pathology, and the status of hematuria were retrospectively reviewed. The association between the severity of hematuria and the tumor stage and grade was evaluated using logistic regression.

Results

The UTUC patients presented with gross hematuria (GH, 76.7%), microscopic hematuria (MH, 11.1%), and no hematuria (12.2%) at the time of diagnosis. The pathological stages at diagnosis for those with MH were Ta in 5.1%, T1 in 47.5%, and ≥T2 in 47.5%. The stages at diagnosis for those with GH were Ta in 1.7%, T1 in 35.5%, and ≥T2 in 62.7%. On univariate and multivariate logistic regression analyses, after adjusting for clinical factors such as age, gender, and smoking history, GH was an independent risk factor for muscle-invasive UTUC (≥T2 disease) at diagnosis (OR 1.89, 95% CI 1.073–3.329; P=0.027). High-grade tumor was found in 47.8% of patients with GH and 39.0% of those with MH. The severity of hematuria was not associated with tumor grade.

Conclusion

We are the first to report evidence that microscopic hematuria at presentation accurately predicts lower pathological stage in patients with newly diagnosed UTUC. Earlier detection of disease, before the development of GH, may influence the treatment decision and survival. The type of hematuria at the time of diagnosis does not impact the tumor grade.

Case Report: A Child with Gross Hematuria and the Importance of Travel History

We report a case of a 5-year-old girl who presented with a 3-month-long history of gross hematuria. She underwent an extensive laboratory workup (including an automated urine microscopy) and a kidney biopsy, all of which were within normal limits. While being prepared for a cystoscopy and more advanced imaging of the urinary tract, the family mentioned history of travel to a schistosomiasis endemic area prompting a more thorough ova and parasite examination of the urine. Urine microscopy confirmed the diagnosis of Schistosoma hematobium.

Determining the optimum way to maintain quality of life for very elderly patients with advanced bladder cancer and poor performance status: A case report

Locally advanced bladder cancer causes unpleasant symptoms such as irritative voiding symptoms, lower abdominal pain, gross hematuria and urinary retention, and lowers the quality of life. Treatment decisions in elderly patients may be difficult, as elderly patients are physically and psychologically different from younger patients. An 89-year-old male was referred to hospital for the treatment of an invasive bladder tumor with right hydronephrosis from tumor obstruction. The patient was elderly and did not have a good performance status; therefore curative radical cystectomy or chemotherapy was not indicated. Left retroperitoneoscopic ureterocutaneostomy was performed to alleviate gross hematuria and voiding difficulty. Intensity-modulated radiotherapy was administered 9 days after the surgery to control bleeding in the bladder tumor. After completing 8 days of radiotherapy, the patient was discharged from hospital. The patient exhibited no signs of either postrenal failure or gross hematuria for 7 months prior to mortality. Retroperitoneoscopic ureterocutaneostomy for very elderly patients with advanced bladder cancer with a poor performance status may be an important procedure for alleviating symptoms and improving quality of life.

Migrated Mesh Plug Masquerading as a Bladder Tumor

Background: The purpose of this case presentation is to demonstrate how erosion of mesh into the bladder can initially present with the same symptoms as bladder malignancy. Case Presentation: A 62-year-old Hispanic male presented with 2 years of hematuria along with imaging concerning for a bladder tumor. The patient underwent cystoscopy with biopsy of a lesion at the anterior bladder. It was ultimately determined that a mesh plug from a prior hernia repair had migrated into the bladder. The mesh plug was excised using the Da Vinci Si robot, which allowed for efficient mobilization of the bladder and other anatomic structures, as well as rapid recovery. Conclusion: Our case demonstrates the need to consider mesh erosion as a cause of hematuria and, furthermore, shows how the robotic approach can help facilitate excision of migrated mesh into the bladder.

Clinical significance of preoperative renal function and gross hematuria for intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVES

To investigate the predictive values of perioperative factors and to develop a nomogram for intravesical recurrence after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma.

METHODS

A retrospective analysis of 144 patients who underwent radical nephroureterectomy from 1996 to 2014 was carried out. The actuarial probabilities of the intravesical recurrence-free survival rate were calculated using the Kaplan-Meier method. Prognostic indicators for intravesical recurrence were identified using competing-risks regression analyses.

RESULTS

Intravesical recurrence occurred in 63 patients during the follow-up period. The intravesical recurrence-free survival rates at 1, 3, and 5 years were 65.7%, 50.6% and 47.1%, respectively. In univariate analysis, the presence of gross hematuria (P = 0.028) and the preoperative serum creatinine level (P = 0.033) were significantly associated with intravesical recurrence. In multivariate analysis, the presence of gross hematuria (subdistribution hazard ratio 2.03, 95% CI 1.145-3.496; P = 0.013) and the preoperative serum creatinine level (subdistribution hazard ratio 3.15, 95% CI 1.161-3.534; P = 0.021) were independent predictors for intravesical recurrence after radical nephroureterectomy. Accordingly, a nomogram based on the model was developed. The concordance index of this model was 0.632.

CONCLUSION

The presence of gross hematuria and preoperative serum creatinine levels seem to be independent predictors for intravesical recurrence after radical nephroureterectomy. Our nomogram developed based on these factors might aid in appropriate patient selection for clinical trials of novel therapeutic interventions, including administration of intravesical chemotherapy.

Stenosing ureteritis in Henoch-Schönlein purpura: report of two cases

Stenosing ureteritis (SU), a rare complication of Henoch-Schönlein purpura (HSP), typically presents with severe symptoms. We report the cases of two HSP patients presenting with gross hematuria, blood clotting, and colicky flank pain, followed by purpura on the lower extremities. Early-stage ultrasonography indicated hydronephrosis, thickened renal pelvic mucous membrane, and ureteral dilatation (UD), suggesting HSP complicated with SU. After early SU treatment with prednisolone, kidney function, thickened renal pelvic mucous membrane, and UD progressively normalized and the pain gradually disappeared. Regular ultrasonography of HSP patients from the onset of gross hematuria can be useful to detect early SU and facilitate conservative therapy with prednisolone. Diagnosis of SU can be easily missed by assuming HSP nephritis, particularly owing to the non-specific symptoms. Common characteristics as well as treatment methods and prognosis of SU are given in the literature review.

[Gross hematuria in sickle cell disease at Tokoin teaching hospital in Lomé (Togo)]

The renal complications of sickle cell anemia are well known. Gross hematuria is one of these, although it is associated more often with the sickle cell trait than with the disease. Nonetheless, in Togo, where the frequency of S gene is 16%, hematuria is rarely report in people with this gene. We describe 3 cases of gross hematuria in patients with sickle cell disease: primary hematuria associated with sickle cell disease. We found no promoting factors in our patients. The course was short, and after 4 to 15 years, there have been no recurrences.

Chronic lymphocytic leukemia of the bladder: an atypical etiology of gross hematuria

Chronic lymphocytic leukemia (CLL) is a rare hematologic disorder with affected patients having complications of frequent infections and possible transformation to a more aggressive malignancy. The occurrence of CLL in the bladder is a rare event, with few reported cases. As a result, its aggressiveness and the optimal course for treatment are unknown. Despite this, its presence in the bladder warrants continued surveillance, as recurrence and progression to other bladder malignancies are possible. We present a 71-year-old woman initially diagnosed with CLL who was plagued by recurrent hematuria and dysuria for over a decade, which lead to multiple negative urologic workups. However, these continued workups eventually lead to her diagnosis of bladder CLL with a subsequent finding of carcinoma in situ that was prompted by a suspicious surveillance cystoscopy performed 4 months after her initial bladder diagnosis. Hence, infiltration of CLL in the urinary bladder merits close follow up, including additional urologic procedures.

Primary pediatric stage III renal diffuse large B-cell lymphoma

BACKGROUND

Although secondary renal involvement of non-Hodgkin lymphoma is frequently encountered, primary renal lymphoma is quite rare. We present a pediatric case of primary renal diffuse large B-cell lymphoma.

CASE REPORT

A 12-year-old girl presenting with gross hematuria was referred to our hospital. Abdominal ultrasonography and imaging revealed a mass lesion in the superior pole of the right kidney. Serum creatinine and blood urea nitrogen levels were within normal ranges. Preoperative assessment of the mass indicated unspecified renal tumor. Right nephrectomy was performed and pathological examination showed diffuse large B-cell lymphoma. Postoperative fluorodeoxyglucose-positron emission tomography/computed tomography showed a small high-uptake lesion in the thyroid gland and aspiration cytology of the thyroid tumor demonstrated involvement of lymphoma, so stage III tumor diagnosed. After one course of chemotherapy, the patient achieved complete remission. She remains alive without disease, 3 years after completing a total of six courses of chemotherapy.

CONCLUSIONS

Primary renal lymphoma is a very rare entity and preoperative diagnosis may be difficult. However, this entity is often reported to show clinically aggressive characteristics and therefore should be considered among the differential diagnoses for unusual renal tumors in pediatric patients.

Gross Hematuria: Assessment and Management at the End of Life

A distressing complication for patients and families, gross hematuria at the end of life challenges hospice and palliative care clinicians to utilize skills in medical and nursing management, communication and clarification of patient goals, and relief of symptom burden. Massive hemorrhage in the genitourinary tract can radically alter the terminal trajectory for patients and necessitate intensive interventions aimed at promoting comfort. Here, a case of gross hematuria in an adult hospice patient serves to broaching decision-making challenges and management strategies.

The influence of renal manifestations to the progression of autosomal dominant polycystic kidney disease

BACKGROUND

Renal stones, urinary tract infections (UTI) and gross hematuria (GH) are the most important renal manifestations of autosomal dominant polycystic kidney disease (ADPKD). They are not only common, but are also frequent cause of morbidity, influencing renal dysfunction. The aim of this study was to evaluate the frequency of these manifestations in our patients with ADPKD and their impact on renal function.

METHODS

One hundred eighty ADPKD patients were included in the study. Subjects were studied for the presence of UTI, gross hematuria frequency and responsible factors of nephrolithiasis. Survival times were calculated as the time to renal replacement therapy or time of serum creatinine value up to 10 mg/dl. Kaplan-Meier product-limit survival curves were constructed, and log rank test was used to compare the survival curves.

RESULTS

Kidney stones were present in 76/180 (42% of pts). The stones were composed of urate (47%) calcium oxalate (39%), and other compounds 14%. UTI was observed in 60% (108 patients). Patients treated with urinary disinfectants had a significant lower frequency of urinary infection (p<0.001) and hematuria (p<0.001) after one year than untreated patients. Gross hematuria was present in 113 patients (63%). In 43 patients hematuria was diagnosed before age 30 (38%), while in 70 patients it was diagnosed after age 30 (62%).

CONCLUSIONS

UTI is frequent in our ADPKD patients. The correct treatment of UTI decreases its frequency and has beneficial role in the rate of progression to renal failure in ADPKD patients. Patients with recurrent episodes of gross hematuria may be at risk for more severe renal disease.