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

Background: Emphysematous pyelonephritis (EPN) is a rare and severe necrotizing infection of the kidney with a high rate of complications and mortality. Our aim was to investigate risk factors of urosepsis and mortality in case of EPN. Materials and methods: Between January 2010 and December 2022 the charts of patients diagnosed with EPN were retrospectively reviewed. Patients medical records were collected and data including demographics, BMI, EPN type, the organism causing the infection and biochemical variables were registered. The authors performed an univariate and multivariate logistic regression analysis for sepsis, septic shock, and mortality. Statistical significance was defined as a P-value of <0.05. Results: Our study included 68 patients (63% females, mean age 58.6 years old). Forty-eight patients (70.6%) had diabetes. Half of the patients (50%) presented with sepsis and 11 patients (16.2%) developed a septic shock. The following factors were associated with sepsis by univariate analysis: diabetes (P=0.01), higher blood sugar on admission (P=0.01), higher leukocytic count (P<0.001), higher lymphocytic count (P<0.001), and lower platelet to leukocytes ratio (P<0.001). Multivariate regression analysis revealed that the main risk factors of urosepsis were the leukocytic (OR: 85.7; 95% CI: 9.177-800.486; P<0.001) and lymphocytic count (OR: 6.65; 95% CI: 1.228-36.050; P=0.028). Neither of the variables was significantly associated with a higher risk of mortality. Conclusion: Leukocytic and lymphocytic count on admission are independent simple predictors for sepsis in patients with EPN.

Predictors of successful outcome after adrenalectomy for unilateral primary aldosteronism.

Introduction: Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. The cause of resistant hypertension after surgery is still a matter of debate. Our aim was to investigate cure rates after surgery and to evaluate preoperative factors that might influence the surgical outcome. Methods: Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Preoperative medical records were collected and follow-up data (1-158 months) were registered. Antihypertensive medication doses were calculated using defined daily doses (DDD) and postoperative outcomes were assessed using the Primary Aldosteronism Surgical Outcome (PASO) criterion. Results: Of 91 enrolled patients, 71 (59% women, mean age 46 years, median length of follow-up 21 months) were suitable for evaluation. Thirty-four patients (48%) had complete clinical success according to the PASO criteria. The most relevant factors associated with complete clinical success on univariate analysis were: absence of diabetes (p= 0.007), low body mass index (BMI) (p= 0.001), lower preoperative DDD (p= 0.01), preoperatively controlled blood pressure (p= 0.024), higher plasma aldosterone to renin ratio (ARR) (p= 0.001), adenoma subtyping (p <0.001) and aldosteronoma resolution score (ARS) (p= 0.002). Multivariate regression analysis showed that the major predictors of complete clinical success were absence of diabetes (OR: 5.205), a BMI < 30 (OR: 4.930), a plasma ARR > 332 (OR: 4.554) and an ARS ≥ 3 (OR: 2.056). Conclusion: Complete and partial clinical response rates were achieved in respectively 48 and 43% of cases. The main predictors of complete resolution of hypertension were absence of diabetes, low BMI, high plasma ARR and high ARS. Taking these factors into account may help identify patients at risk of persistent postoperative hypertension who may require long-term surveillance and medication.

Prostatic cystadenoma presenting as a large multilocular pelvic male mass.

Multilocular cystadenoma are benign lesions located most commonly between the rectum and the bladder. Their presence manifests as obstructive or/and irritative lower urinary tract symptoms or transit disorders. Computed tomography scan and magnetic resonance imaging may help to establish the diagnosis. Surgery is the established treatment standard, with a high risk of recurrence in case of incomplete excision of the lesions. Here we report a case of 59-year-old man presenting with an acute urinary retention due to a giant multilocular prostatic cystadenoma treated by complete excision. The diagnosis has never been suspected before surgery and has been confirmed histologically after complete excision.

Primary Hydatid Cyst of the adrenal gland: A case report and a review of the literature.

INTRODUCTION: In North Africa which is an endemic region for Hydatid Cyst, Tunisia is considered as an endemic country. The liver and lungs are common locations for Hydatid Cysts, whereas the Adrenal Glands are unusual and rare locations. PRESENTATION OF CASE: Here is a report of primary Hydatid Cyst in a 55-year old patient, with left hypochondrium pain as chief complain. No remarkable findings were revealed by physical examination and blood analysis showed normal range. Hydatid serology was negative. The diagnosis of Hydatid Cyst was suspected based on CT Scan results which showed a well-circumscribed, non-enhanced, multi-cystic, 12 cm mass with scattered calcifications located in the left adrenal gland. Therefore, the patient underwent an open surgery with resection of the protruding dome of the cyst as it was attached to the renal pedicle, the pancreatic tail, the spleen and the jejunum. The final pathological examination of the specimen led to a Hydatid Cyst. DISCUSSION: Throughout an extensive literature review that we have made, we have analyzed 54 reported cases, with their clinical presentations, biological exams, radiological features and surgical managements. The treatment should be surgical and has to be as conservative as possible. The prevention of the parasite transmission has to be the cornerstone of the disease management. CONCLUSION: The hydatid cyst of the adrenal gland remains a rare diagnosis that has to be evoked in case of an adrenal gland cyst, especially in an endemic country.

Is imagery distinctive in papillary renal cell carcinoma subtypes?

INTRODUCTION: The subdivision into two entities of papillary renal cell carcinoma (PRCC) was established on histological criteria. It's in fact possible to distinguish the two subtypes by the means of radiological and progressive data. The subtype 1 is associated with the favorable profile. The ultrasound and especially CT urography ensure an accurate diagnostic approach with substantial therapeutic and prognostic involvement. The aim of the study is to define the radiological features that distinguish the two subtypes of renal papillary carcinoma, and to study the radiological predictive factors of locoregional recurrence, metastases free survival and specific survival. METHODS: It's about a monocentric, retrospective study led between January 2005 and June 2017, gathering 49 cases of operated PRCC. The study concerned patients over the age of 18, who were diagnosed after anatomopathological examination of the operative specimen (enlarged nephrectomy or conservative surgery). Cases in which diagnosis was made by renal biopsy were excluded. The comparative study concerned ultrasound and CT scan data. Univariate and multivariate analysis were performed to determine factors having a prognostic value in terms of locoregional recurrence, metastases-free and specific survival. RESULTS: On the ultrasound, the subtype 1 tumors were significantly homogenous with regular contours. Tumors were globally spontaneously hypodense and hypo vascular in 97,8% of cases. Enhancement was significantly more heterogonous for subtype 2 (p=0,01). Intratumoral necrosis and adenomegalies were associated with subtype 2 (p=0,0001 and 0,005). The predictive factors of locoregional recurrence, metastases-free survival and specific survival in univariate analysis were the contours' aspect, moderate enhancement and the presence of adenomegalies. On multivariate analysis, only the irregular contours were retained for locoregional recurrence-free survival and specific survival. CONCLUSIONS: Significant differences between the PRCC subtypes were observed when studying the radiological data. Irregular contours, adenomegalies and enhancement degree seemed to predict the progression of PRCC after curative surgery.

State of the art: Open prostatectomy for benign prostate hyperplasia: Should we avoid it in all cases?

Surgical procedures for benign prostate hyperplasia (BPH) had considerably evolved during last decades. New techniques can nowadays treat prostate big in size, which are classically treated by open prostatectomy (OP). Therefore, the place of this procedure that has been used for over 150 years is nowadays questioned. Is it outdated? Is there emerging techniques that are more efficient, safer and cost effective? This state of the art based on literature review will assess the place of OP in BPH surgery from efficacy on functional outcomes, security, competitiveness with modern and minimally invasive techniques and socio-economic perspectives. Currently, OP has excellent functional outcomes, with low rate of retreatment after surgery, low morbidity and affordable cost in our country. It remains competitive with new surgery techniques for BPH, even if the latter offer the advantages of a minimally invasive surgery, especially in hospitalization length. Taking in consideration the social and economic context in Tunisia, it remains the most accessible and affordable surgical technique. Besides, OP is a procedure that has to be handled by every urologist given the theoretical risk of conversion during endoscopic surgery of BPH, and its use under certain circumstances (In case of bladder lithiasis ou diverticle or impossibility of lithotomy position).

[Rare complication of renal transplantation: Emphysematous pyelonephritis]. / Complication rare de la transplantation rénale : la pyélonéphrite emphysémateuse.

Emphysematous pyelonephritis is a necrotizing infection of the renal parenchyma and peri-renal tissues, characterized by the presence of air within the parenchyma of the urinary tract and peri-renal space. This is a severe complication, which involves the functional prognosis of the kidney and the patient's prognosis. The emphysematous pyelonephritis is a rare complication of renal transplantation. Its gravity is linked particularly to the fragility of immunosuppressed patients. The authors report the case of an emphysematous pyelonephritis having occurred 9 months after transplantation in a patient 58 years. The evolving risks and therapeutic modalities will be outlined and discussed.

Thirty Years of Experience at the First Tunisian Kidney Transplant Center.

OBJECTIVES: The aim of this study was to report the results of 30 years of experience at the first kidney transplant center in Tunisia. MATERIALS AND METHODS: All kidney transplants performed at the center between June 1986 and June 2016 were included. The study period was divided into 3 decades. Recipient and donor data and follow-up information were obtained from a local database and patient medical records. Comparative analyses were performed using the t test for continuous variables and the Χ² test for qualitative variables. Patient and graft survival rates were calculated according to the actuarial method, and comparison of survival curves was performed according to the logrank test. RESULTS: The mean age of recipients was 32.7 ± 11.5 years (range, 6-65 y) with a gender ratio of 2.2. Duration of prekidney transplant dialysis varied from 2 months to 20 years (median, 27.5 mo); 1.7% of patients underwent transplant preemptively. Kidneys were recovered from deceased donors in 21.2% of cases and from living donors in 78.8%. The proportion of deceased donors dropped from 27.4% during the period 2006-2010 to 12.9% during the period 2011-2015 (P < .04). Patient survival rates at 1, 5, 10, 15, and 20 years were 96%, 89.3%, 79.5%, 71.1%, and 65.4%. Graft survival rates were 95%, 86.5%, 76.2%, 66.3%, and 57.2%. The annual graft loss was 2.9%, with a mortality rate of 2.4% and without significant differences between patients receiving deceased-donor and living-donor organs. CONCLUSIONS: Kidney transplant activity remains suboptimal in our country. The reduction in deceased-donor organs could be related to the political transformations facing our country with their resulting social and economic consequences. Efforts should be made to increase governmental resources and to improve both public awareness of organ donation and the motivation of transplant teams.

[Results of conservative management of emphysematous pyelonephritis]. / Résultats du traitement conservateur de la pyélonéphrite emphysémateuse.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a rare and severe, necrotizing infection of the kidney. Diagnosis should be precocious based on computed tomography (CT). Its management remains controversial and its treatment is currently increasingly conservative. The aim of this paper is to discuss the conservative treatment of this disease through our experience in 21 patients. MATERIAL AND METHODS: A retrospective analysis including 21 patients managed conservatively for an emphysematous pyelonephritis in our department from January 2010 to April 2015. Follow-up ranged from three to 24 months. RESULTS: Of the 24 patients, seven belonged to class 1, twelve to class 2 and two to class 4. Obstruction of the upper urinary tract was found in 16 cases. On the risk factor stratification, thrombocytopenia was found in five cases, renal function impairment in 10 cases and a septic shock in four cases. All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad-spectrum antibiotics. Drainage of the urinary tract was performed by double-J stent in 14 patients and with ureteral catheter in six patients. One patient had urinary distension secondary to a urethral stricture with bilateral emphysematous pyelitis. In this case, drainage consisted in suprapubic bladder catheter only. The outcome was favorable in 18 patients and the control CT showed a decline or complete disappearance of gas in urinary tract and/or renal parenchyma after an average period of 12 days. A secondary nephrectomy was performed in two cases. Specific mortality rate was zero. CONCLUSION: PNE remains a severe infection involving the vital prognosis. Computed tomography makes an early diagnosis. Treatment should be conservative based on the association of medical intensive care and drainage, percutaneous or endoscopic, urgently. Nephrectomy should be reserved for extensive forms with multiple organ dysfunction or failure of conservative treatment.

Bilateral Orbital Metastasis of Prostatic Adenocarcinoma.

Despite the high incidence of prostate carcinoma, metastases of the uvea are very rare and bilateral localization is even more. We report here the case of a 77-year-old man diagnosed with a metastatic prostate carcinoma. Two months later, he presented a decreased vision in his right eye and blurred vision in the left eye relevant to metastatic lesion on his right iris and left choroidal metastasis. The urologist should evoke possibility of ocular metastasis in patients with prostate cancer presenting visual disorders.

Vasitis: An Uncommon Diagnosis Mimicking Incarcerated Inguinal Hernia.

Vasitis or inflammation of the vas deferens is a rarely described condition. Clinically, it presents with nonspecific symptoms that can be confused with other more common conditions, especially an incarcerated inguinal hernia. The diagnosis may be suggested by ultrasound or, more precisely, by computed tomography.

Retrovesical hydatic cyst: About 4 cases.

INTRODUCTION: The hydatid cyst is a real public health problem in Tunisia. The retrovesical localization is rare. It is considered an aberrant or ectopic location defined by the development of the parasite in the subvesical and retrovesical fat. METHODS: From 2004 to 2013, 4 patients with retrovesical hydatid cyst were hospitalized and operated in the Department of Urology at the Charles Nicolle hospital of Tunis in Tunisia. The average patient age was 40.75 years (range: 23-76). Signs of bladder irritation were the most frequent presenting complaint. No cases of hydaturia were noted. The diagnosis was made on the ultrasound and the computed tomographic urography. Hydatid serology was positive for 3 patients. In 3 cases, a hydatid cyst of the liver was associated. A total cysto-pericystectomy was performed for 1 patient, for others it was partial. RESULTS: The postoperative course was uneventful. No urinary fistula or infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation. CONCLUSION: Retrovesical location of hydatid cyst is rare and treatment is primarily surgical.

Pseudotumoral Eosinophilic Cystitis.

Eosinophilic cystitis is a rare inflammatory disease of the bladder which origin and pathogenesis are unknown. Since the first description in 1960, hundreds of cases have been reported, 20 Pseudotumor forms. We report a case of cystitis eosinophils in tumor-form, a patient of 72 years without urological or allergic history. The patient was treated with endoscopic resection alone. The outcome was favorable with disappearance symptoms and no recurrence at 1, 3 and 6 months controls. We carry a literature review of cystitis eosinophils on the different clinical manifestations, the means diagnostic and therapeutic modalities.

Discovery of Renal Tuberculosis in a Partial Nephrectomy Specimen Done for Renal Tumor.

The association of renal cancer and renal tuberculosis is uncommon. While the incidental discovery of renal cell carcinoma in a tuberculous kidney is a classical finding, the discovery of tuberculous lesions after nephrectomy for cancer is exceptional. We report the case of a female patient aged 60 who had a partial nephrectomy for a 5 cm exophytic kidney tumor. Pathological examination concluded that renal clear cell carcinoma associated with follicular caseo tuberculosis.

A case of ureteral duplication in adult presenting with symptoms of bladder outlet obstruction.

BACKGROUND: Ureteral duplication is a rare congenital anomaly usually found in childhood. It manifests in various anatomic forms. AIM: To report a case of a ureteral duplication in adult man and a review of the literature in attempt to categorize this rare entity. CASE: This report describes a case of a Y-type ureteral duplication presenting in a 30-y-old man with symptoms of bladder outlet obstruction. CONCLUSION: Ureteral duplication is quite rare but a very distinct entity. It occurs exclusively in children and male adolescents. Its occurrence in adulthood imposes serious diagnostic and therapeutic difficulties.

[Renal adenocarcinoma in horseshoe kidney, report of a case]. / L'adénocarcinome rénal sur rein en fer à cheval. A propos d'un cas.

Tumors arising within horseshoe kidney are uncommon and may be difficult to identify. The incidence of tumor within horseshoe kidney is higher than in the normal one. Adenocarcinoma is the most common tumor. The nephrectomy is considered as partial and the patients need a strict follow up. Horseshoe kidneys show a lot of variety with regard to supporting arteries and veins. Therefore, a selective study of the renal vessels should be performed preoperatively. Abdominal angiography should be done to study this vasculature.