Nephrectomy for xanthogranulomatous pyelonephritis-a not-so-simple solution.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is a rare chronic inflammatory condition of the kidney, associated with high patient morbidity, often requiring targeted antibiotic therapy and surgical removal of the affected kidney. AIM: We report the outcomes of patients undergoing nephrectomy for XGP in our institution over a 12-year period. METHODS: Following ethical approval, a retrospective review of histological samples of renal tissue demonstrating features of XGP from June 2010 to 2022 was conducted. Laboratory, imaging, and clinical data of included participants were collected. RESULTS: Eleven patients were included (8 women, 3 men), mean age of 58.1 (35-81). Recurrent urinary tract infection was the most common clinical presentation (55%, n = 6). Other presentations included flank pain (36%, n = 4), collection/ abscess (45%, n = 5), and nephro-cutaneous fistulae (9%, n = 1). The majority of patients had bacteriuria (91%, n = 10), and Escherichia coli was the most common bacteria isolated (55%, n = 6). Antibiotic resistance was seen in 60% of positive urine samples (n = 6). An open nephrectomy was performed in all but one case (91%, n = 10). A postoperative complication occurred in 73% (n = 8), with 50% (n = 4) of complications Clavien Dindo grade 3 or higher, including one patient mortality. CONCLUSIONS: XGP is a difficult and complex condition to treat. All patients in this series presented with infection or associated sequelae thereof. Complex XGP cases therefore often require open nephrectomy and have high rates of postoperative complications. Careful consideration of antibiotic and operative intervention is therefore essential to ensure the best outcome for these patients.

Erectile device insertion following phalloplasty in transgender and non-binary individuals assigned female at birth: a narrative review.

Genital gender affirmation surgery (gGAS) for individuals assigned female at birth (AFAB) is complex and requires the staged insertion of an erectile device to permit penetrative intercourse. This final stage of gGAS is challenging, owing to the variable anatomy and lack of supportive structures within the neophallus when compared with erectile device insertion for individuals assigned male at birth. There is a paucity in the literature at present regarding erectile device insertion in trans-sex AFAB patients. Hence, a narrative review following a literature review and supplemented by expert opinion from a high-volume centre of expertise is presented. The choices available for erectile device in this patient cohort are discussed. Principle surgical steps required for this complex surgery is outlined along with the recommended postoperative management of the patient. Postoperative outcomes and complications are also summarised in this fast-developing surgical procedure.

Wunderlich's syndrome in pregnancy: a shocking triad.

Wunderlich's syndrome, non-traumatic renal haemorrhage into the subscapular and perinephric space, in pregnancy, is a very rare clinical entity. We describe a case of Wunderlich's syndrome in a 29-year-old gravida 5 para 4 who presented to our emergency department with sudden onset severe left flank pain. On assessment, she was clinically shocked-hypotensive, tachycardic and perfused poorly peripherally. Ultrasound of the abdomen and pelvis and subsequent MRI of the left kidney revealed a large hypervascular exophytic lesion arising from the left renal pole-appearance consistent with an angiomyolipoma. This specific presentation is clinically characterised as Lenk's triad-acute flank pain, flank mass and hypovolaemic shock. The patient was adequately resuscitated and interventional radiological embolisation of the mass was performed. She went on to have an uneventful pregnancy and delivered vaginally after induction at 38 weeks of gestation.

To tube or not to tube? Utilising a tubeless antegrade ureteric stenting system in a tertiary referral hospital.

INTRODUCTION: To assess the benefits and complications of developing a practice of single-stage primary ureteral stenting in a university hospital. METHODS: A practice change developed from the traditional practice of multi-stage stenting to single-episode stent placement. To evaluate this change of practice, we retrospectively analysed data of 70 patients who underwent primary tubeless antegrade ureteric stenting and compared this group to the previous 54 patients who had a covering nephrostomy. RESULTS: There was an overall success rate of 91.3% (85/93 stents having had tubeless antegrade stenting). There were no major and 33 minor complications. The comparative group of 54 patients whose stents had a covering nephrostomy had a median length of stay of 13.2 days compared to 7.4 days for the tubeless group. CONCLUSION: Single-stage primary ureteric stenting is a safe practice to employ and has universal benefits for both the patient and the health service.

Methicillin-resistant Staphylococcus aureus as a uropathogen in an Irish setting.

Urinary tract infections are one of the most common infectious diseases diagnosed in the community and in the hospital setting. Their treatment is complicated by drug-resistant pathogens and the colonization by microbes of indwelling urinary catheters. This study assessed the occurrence and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) uropathogens isolated for 5 consecutive years at University Hospital Waterford between 2010 and 2014. We created 4 clinically relevant subdivisions, based on urine source: hospital inpatients, patients from the Emergency Department, patients referred from their General Practitioner, and Nursing Home patients. We performed a retrospective review from the hospital's electronic microbiological system and calculated resistance rates for each of the standard antimicrobial agents. During the 5-year study period, we studied 151 urine isolates obtained from 128 patients who had an MRSA cultured in their urine sample. There was 100% resistance of all MRSA isolates to Flucloxacillin and Coamoxiclav. Ninety-eight percent of isolates were resistant to Ciprofloxacin. The resistance rate for Trimethoprim was 7.4% and there was only 2.7% resistance for Nitrofurantoin. For a clinical subset of patients, we also demonstrated 100% sensitivity for samples tested against Teicoplanin and Vancomycin. Urinary MRSA is an infrequently studied phenomenon, but with the rising trend of hospital superbugs nationally, its management is of critical importance. Suitable agents to address this within our population include Nitrofurantoin in the well patient requiring urinary MRSA eradication or Vancomycin/Teicoplanin in the unwell patient requiring intravenous therapy. In all groups, fluoroquinolones should be avoided due to significant resistance rates.

Clinico-pathological analysis of renal cell carcinoma demonstrates decreasing tumour grade over a 17-year period.

INTRODUCTION: Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort. METHODS: A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group 1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland. RESULTS: In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed over time (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022). CONCLUSION: There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

Sexual function outcomes following fracture of the penis.

INTRODUCTION: Fracture of the penis is a rare urological emergency which occurs as a result of abrupt trauma to an erect penis. There is paucity of data regarding long-term sexual function or erectile potency following fracture of the penis. The aim of this study is to objectively assess the overall sexual function following fracture of the penis. METHODS: A retrospective analysis of 21 penile fractures was performed. A voluntary telephone questionnaire was performed to assess long term outcomes using three validated questionnaires-the Erection Hardness Grading Scale, the International Index of Erectile Function (IIEF-5) and the Brief Male Sexual Function inventory (BMSFI). RESULTS: The mean age was 33.1 years (range: 19-63). The median follow up was 46 months (range: 3-144). All fractures were a result of sexual misadventure and all were surgically repaired. There were two concomitant urethral injuries. Seventeen patients were contactable. Fourteen patients demonstrated no evidence of erectile dysfunction (ED) (IIEF-5>22), 1 patient reported symptoms of mild ED (IIEF-5, 17-21) and one patient reported mild to moderate ED (IIEF-5, 12-16). No patients reported insufficient erection for penetration (EHGS: 1 or 2). Regarding the overall BMSFI, 13 (83%) patients were mostly satisfied or very satisfied with their sex life within the previous month. CONCLUSION: In a small surgical series of men with penile fracture managed within a short time frame from presentation, we demonstrate erectile potency is maintained. Long-term overall sexual satisfaction is promising.