Analysis of percutaneous nephrostomy exchange intervals: insights from a retrospective Merative MarketScan analysis between 2009-2021.

BACKGROUND: Current practices in nephrostomy exchange are guided by institutional or societal expert-consensus rather than evidence-based recommendations. OBJECTIVE: To examine the temporal distribution of exchanges and assess whether the observed distributions align with institutional, or expert-recommended guidelines where routine exchanges would be expected to occur within 60-89 days. Non-routine exchanges would be expected to occur either after 60 days or after 89 days. METHODS: Data were collected from the Merative™ MarketScan Commercial Claims and Encounters Databases and included all patients who underwent a PCN exchange from 2009 to 2021. The dataset was queried using ICD-9/10 and CPT coding systems. Outpatient exchanges were classified as routine exchanges, whereas inpatient exchanges were classified as non-routine exchanges. Chi-Square Goodness-of-Fit tests were used to compare observed frequencies against expected distributions of routine exchanges within the 59-89 day window, and non-routine exchanges to occur after either 60 or after 89 days. RESULTS: There was a total of 19,689 exchanges: of those, 41% (n = 8,058) exchange encounters occurred within 29 days, 67% (n = 13,213) occurred within 59 days, and 81% (n = 15,899) occurred within 89 days. Routine exchanges accounted for 76% of total exchanges: of those routine exchanges, 39% (n = 5,863) of routine exchanges occurred within 29 days, 67% (n = 10,057) occurred within 59 days, and 82% (n = 12,256) occurred within 89 days. Non-routine exchanges account for 24% of all exchanges in the study cohort. Of all non-routine exchanges (n = 4,737), 46% (n = 2,035) of non-routine exchange encounters occurred within 29 days, 67% (n = 3,156) within 60 days, and 77% (n = 3,643) within 89 days. Chi-square tests indicated significant deviations from the expected distributions for both routine (p < 0.01) and non-routine (p < 0.01) exchanges. CONCLUSION: A significant proportion of routine exchanges occur outside a 60-89 day window, and with a majority of routine exchange observations occurring prior to 59 days. A significant proportion of non-routine exchanges occur prior to 60 days and prior to 89 days. CLINICAL IMPACT: Significant disparities between existing guidelines and clinical practice, underscoring the need for evidence-based guidelines to reduce complication rates, improve patient outcomes, and reduce the burden of cost on the healthcare system.

High risk and low prevalence diseases: Infected urolithiasis.

INTRODUCTION: Infected urolithiasis is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of infected urolithiasis, including presentation, diagnosis, and management in the emergency department based on current evidence. DISCUSSION: Although urolithiasis is common and the vast majority can be treated conservatively, the presence of a concomitant urinary tract infection significantly increases the risk of morbidity, to include sepsis and mortality. Identification of infected urolithiasis can be challenging as patients may have symptoms similar to uncomplicated urolithiasis and/or pyelonephritis. However, clinicians should consider infected urolithiasis in toxic-appearing patients with fever, chills, dysuria, and costovertebral angle tenderness, especially in those with a history of recurrent urinary tract infections. Positive urine leukocyte esterase, nitrites, and pyuria in conjunction with an elevated white blood cell count may be helpful to identify infected urolithiasis. Patients should be resuscitated with fluids and broad-spectrum antibiotics. Additionally, computed tomography and early urology consultation are recommended to facilitate definitive care. CONCLUSIONS: An understanding of infected urolithiasis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Preoperative parent education and postoperative nurse-led care for boys versus routine hospital care for urethroplasty for hypospadias in Western China: a retrospective study.

Background/aim: Urethroplasty is the preferred treatment for hypospadias but is affected by the severity of anomalies, making it a complex procedure with potential postoperative complications. Following surgery, parents receive instructions and recommendations, whether from nurses or physicians, regardless of complication rates. However, nurses play a crucial role in educating caregivers before surgery and providing postoperative care during follow-up. The study aims to assess parents' knowledge and practices, as well as the frequency of complications in boys who underwent urethroplasty for hypospadias and received postoperative nurse-led care and whose parents received preoperative education against those of boys who underwent urethroplasty under routine hospital care. Materials and methods: In this retrospective study, Han Chinese boys aged 21-41 months in Western China who underwent urethroplasty for hypospadias were divided into two groups: the NI cohort (n = 103), where they received postoperative nurse-led care and their parents received preoperative education, and the RH cohort (n = 142), where boys underwent routine hospital care. Results: After urethroplasty, higher numbers of caregivers with satisfactory knowledge (96 (93%) vs. 80 (56%), p < 0.0001) and practice (102 (99%) vs. 132 (93%), p = 0.0276) were reported in the NI cohort compared to the RH cohort. Additionally, a higher number of boys in the RH cohort experienced adverse effects such as moderate bleeding (13 (9%) vs. 1 (1%), p = 0.0052), wound infection (17 (12%) vs. 4 (4%), p = 0.0356), urinary obstruction (35 (25%) vs. 10 (10%), p = 0.0049), burning sensation (47 (33%) vs. 15 (15%), p = 0.0019), and urinary stent fall (32 (23%) vs. 6 (6%), p = 0.0008) compared to those in the NI cohort. Conclusion: Preoperative instructions enhance caregivers' knowledge and practices following urethroplasty, while postoperative nurse-led care reduces immediate postoperative complications associated with hypospadias in boys.

Evaluation of predictive factors of renal function recovery in renal failure secondary to urinary tract obstruction.

Objective: To determine the factors associated with renal function recovery in individuals with kidney failure due to obstruction in the urinary tract. METHODS: The prospective, descriptive study was conducted July 2020 to August 2021 at the Department of Urology, Sindh Institute of Urology and Transplantation, Karachi, and comprised adult patients of either gender who had renal failure secondary to obstructive urinary tract. Baseline data regarding patients' variables, including age, gender, duration of symptoms (<25 days or >25 days), haemoglobin (<9.85g/dl or >9.85g/dl), serum creatinine and renal cortical thickness (<16.5mm or >16.5 mm), was noted on a proforma. The variables were stratified to assess impact on renal recovery. Data was analysed using SPSS 23. RESULTS: Of the 126 patients, 43(34.13%) were males and 83(65.87%) were females. The overall mean age was 44.13±14.18 years. Renal recovery occurred in 67(78.8%) patients having duration of symptoms ≤25 days, and in 13(31.7%) patients with duration of symptoms >25 days (p<0.001). Renal recovery occurred in 41(58.6%) patients having haemoglobin ≤9.85g/dL and in 39(69.6%) patients having haemoglobin >9.85g/dL (p=0.2). Renal recovery occurred in 26(37.7%) patients with parenchymal thickness ≤16.5mm and in 54(94.7%) patients with renal cortical thickness >16.5mm (p<0.001). Conclusion: Symptom duration ≤25 days, and renal parenchymal thickness >16.5mm were found to be predictive factors of good recovery in renal failure cases secondary to obstructive uropathy.

The endocrinology of the urinary bladder.

The urinary bladder primarily functions as a reservoir for urine. Apparently, it serves only a mechanical and passive role in the urinary tract, but closer scrutiny reveals that it has several meaningful endocrine interactions. This vital organ has an intricate plexus of neurons that release neurohormones concerned with the functioning of the bladder. Endocrine disorders, most notably diabetes, can cause a broad spectrum of bladder dysfunction. The current review explores the bladder as a source of neurotransmitters, a target for organ damage due to uncontrolled endocrinopathy, a beneficiary of hormonal therapy, and a tool to improve endocrine health.

Interventional radiology in renal emergencies: a pictorial essay.

Renal emergencies necessitate prompt diagnosis and management to stop active bleeding and retain kidney function. Causes of renal emergencies can be classified into traumatic, atraumatic, iatrogenic, and obstructive etiologies. Interventional radiology (IR) has emerged as an acceptable alternative to surgical treatment in the management of renal emergencies due to its minimally invasive nature. With the rise of interventional procedures, there is a need for further discussion of angiographic and fluoroscopic imaging in the setting of renal emergencies.

Successful Treatment of Ureteral Obstructive Lithiasis by Ureterotomy in a Domestic Hen.

A 2-year-old domestic hen was presented for a 15-day history of intermittent left leg lameness. The owners also observed a decrease in egg quality during that period. Physical examination of the bird revealed a generalized weakness with a flattened pale comb. Neurological evaluation of the left leg found a proprioceptive deficit with no loss of pain sensitivity. Whole body radiographic images showed a marked reduction of abdominal detail, a large amount of "grit" (mineral opacity) in the ventriculus, intestinal dilation, and a metallic foreign body (nail) in the digestive tract. Abnormal results from a plasma biochemistry panel were hypercalcemia, hypertriglyceridemia, hyperglobulinemia, hypophosphatemia, increased creatine kinase, and decreased uric acid. After initial stabilization of the patient, a computed tomographic scan was obtained, which revealed multiple right-sided ureteral calculi, the largest of which measured 10 mm in diameter, and changes compatible with cystic right renal nephrosis. Suspected compensatory enlargement of the left kidney was also observed. Considering the renal lesion and associated neurological limb impairment, surgery was recommended and approved by the owner. A right lateral approach was used for the coeliotomy, and a ureterotomy was performed to remove all calculi. Analysis of the ureteral stones confirmed they were 100% uric acid salts. The hen fully recovered left leg function 1 week postsurgery. Urolithiasis is well described in hens, but surgical treatment is uncommon. This report describes the successful removal of ureteral stones by ureterotomy in a domestic hen.

Fetal Urinoma Due to Circulatory Disorders in an Umbilical Artery: Case Report.

Fetal urinoma is defined as an encapsulated accumulation of extravasated urine within the perirenal space or retroperitoneum. It is an uncommon finding in prenatal practice, and the vast majority of known cases are strongly associated with the existence of a urinary obstruction, such as posterior urethral valves, ureteropelvic junction obstruction, or ureterocele. We report a unique case of prenatally detected fetal bladder urinoma that occurred in the absence of an apparent obstructive uropathy, but was associated with extensive ischemic necrosis and calcifications of adjacent bladder wall, coexistent with signs of vascular supply decompensation.

Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape.

STUDY OBJECTIVE: To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape. DESIGN: Demonstration video. SETTING: Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2). INTERVENTIONS: (1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3). CONCLUSION: Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.

A 30-Month Complete Urinary Obstruction Resulting from Trapped and Incarcerated Uterus: A Case Report.

Uterine incarceration is rare, but it can caus e serious complications, in which the uterus is trapped in the pelvic cavity behind the sacral promontory. Fibroid uterus can cause urinary frequency and retention, which can result from compression of the urinary bladder with an enlarged fibroid uterus and the compression of the bladder neck or urethra, respectively. To our knowledge, there is no report on prolonged complete urinary obstruction because of an incarcerated uterus in nonpregnant women to date. A 51-year-old woman was referred for uterine myomas. She could not void for 30 months after she received an intradetrusor injection of botulinum toxin for urinary frequency management at the urology department of another hospital. She underwent clean intermittent catheterization for 30 months. She was referred to the gynecologic department for the evaluation of uterine myoma found on using abdominopelvic computed tomography. On physical examination, the uterine cervix was extremely displaced in the upward direction and was not exposed on speculum examination. Sonography and magnetic resonance imaging revealed that the urethra and the bladder neck were compressed by an extremely retroflexed fibroid uterus. Manual reduction of the incarcerated uterus failed; hence, we performed robot-assisted laparoscopic total hysterectomy with left salpingo-oophorectomy. She immediately urinated immediately after the operation and had normal urination at 1- and 48-month follow-up visits. Uterine incarceration by a fibroid uterus can cause complete urinary obstruction, as in this case. Uterine incarceration should be considered in women with urinary frequency or retention to avoid prolonged, serious complications.

Cowper's Syringocele: A Rare Cause of New-Onset Voiding Dysfunction.

Cowper's syringocele is a condition caused by dilatation of the main duct of Cowper's gland. It is a very uncommon cause of urethral obstruction. Closed type causes urinary obstruction. The aim of this article is to report a case of closed type syringocele causing new-onset urinary obstruction in a 10-year-old boy.

Milky White Urine After Relief of Urinary Retention.

BACKGROUND: Chyluria is a rare condition where chyle is excreted into the urine. Clinically, most patients manifest with intermittent passage of milky urine. Patients may also present with dysuria, urinary frequency, urgency, retention, or with the sequelae of chronic malnutrition. CASE REPORT: We present a 55-year-old African American man who presented to the emergency department complaining of milky white urine, dysuria, decreased urine output, and suprapubic abdominal pain once a day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may present to the emergency department complaining of milk-colored urine, hematuria, urinary retention, or the sequelae of malnutrition. Initial evaluations should include laboratory investigations of common causes of chyluria and the severity of the potential malnutrition. If the patient presents with urinary retention, after relieving the obstruction in the emergency department, assessment for clot/chyle burden and likelihood of recurrence of urinary retention should be performed by urology. Arrangements for proper outpatient follow-up should be made if the disease manifestations are not severe enough to warrant admission.

Long-term outcomes of combining prostate brachytherapy and metastasis-directed radiotherapy in newly diagnosed oligometastatic prostate cancer: A retrospective cohort study.

BACKGROUND: Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE) trial showed the survival benefit for prostate radiotherapy in newly diagnosed prostate cancer patients with a low metastatic burden. The result raises the next question whether additional radiotherapy to metastatic sites could improve the survival in those with a low metastatic burden. METHODS: We evaluated the efficacy and safety of prostate-directed radiotherapy (PDRT) with or without metastasis-directed radiotherapy (MDRT) in newly diagnosed oligometastatic patients who underwent combination of high-dose-rate prostate brachytherapy, external beam radiotherapy, and androgen deprivation therapy. Forty patients with bone metastasis and node positive prostate cancer were retrospectively analyzed. Of these, 22 (55%), 3 (7%), and 15 (38%) patients had N1M0, M1a, and M1b, respectively. Eighteen patients (45%) received MDRT to all metastatic sites. All patients initially underwent ≧6 months of androgen deprivation therapy. Oligometastatic disease was defined as presence of five or fewer metastatic lesions. Median follow-up period was 62.5 months. RESULTS: Of the 40 patients, the 5-year castration-resistant prostate cancer (CRPC)-free survival rate and cancer-specific survival was 64.4% and 87.9%, respectively. Pre- or post-treatment predictive value including prostate-specific antigen (PSA) at diagnosis ≥20 ng/mL, Gleason grade group 5, positive biopsy core rate ≥51%, PSA nadir level of ≥0.02 ng/mL after the radiotherapy, and no MDRT were significantly associated with progression to CRPC. Patients with MDRT had significantly higher probability of achieving a PSA level of <0.02 ng/mL than those without the therapy (88.8% vs 54.5%, P = 0.0354) and consequently had a better CRPC-free survival than those without the therapy (HR 0.319, 95%CI: 0.116-0.877). Comparing PDRT alone, PDRT with MDRT did not significantly increase the incidences of genitourinary and gastrointestinal toxicities. CONCLUSIONS: This single-institutional study revealed the feasibility of combining prostate brachytherapy and MDRT for newly diagnosed oligometastatic prostate cancer. This combined approach has potential to prolong CRPC-free survival.

Is hydrogen sulfide a potential novel therapy to prevent renal damage during ureteral obstruction?

In prolonged complete unilateral ureteral obstruction, reduced renal blood flow places the kidney in a state of ischemia, which can cause tubular injury and inflammation. Infiltrating inflammatory cells release transforming growth factor beta 1, which is a cytokine that initiates fibrosis through the epithelial-mesenchymal-transition pathway. Persistent fibrosis can lead to irreversible renal injury and loss of function. While surgical intervention can remove the obstruction, relief of obstruction may not fully reverse renal injury. Additionally, patients often encounter long wait-times between initial consultation and medical intervention, resulting in the accumulation of renal injury that may cause permanent dysfunction. Currently, accepted pharmacological therapies to mitigate the symptoms of ureteral obstruction include acetaminophen, cyclooxygenase-inhibitors, non-steroidal anti-inflammatory medications, opioids and alpha-receptor blockers. However, there is no evidence that they mitigate renal injury. Therefore, identifying potential therapies that could be administered during obstruction may help to improve renal function following decompression. Evidence suggests that endogenously produced gasotransmitters can exhibit anti-inflammatory and antioxidant effects. Nitric oxide, carbon monoxide, and hydrogen sulfide have been identified as gasotransmitters and have been shown to have cytoprotective effects in various models of tissue injury. Studies have shown that treatment with sodium hydrogen sulfide (a hydrogen sulfide donor salt) mitigated transforming growth factor beta 1 expression, oxidative stress, fibrosis, and inflammation associated with urinary obstruction. More recently, the use of more directed hydrogen sulfide donor molecules, such as GYY4137, has led to significant decreases in inflammation, fibrosis, and expression of epithelial mesenchymal transition markers following urinary obstruction. Taken together, these findings suggest that hydrogen sulfide may be a novel potential therapy against renal injury caused by urinary obstruction. This review will highlight the existing literature about the pathogenesis and treatment of renal damage caused by chronic urinary obstruction and propose novel upcoming strategies that could improve patient outcomes.

Crystalluria and Chronic Kidney Disease.

Crystalluria can involve the kidney and lower urinary tract, can produce acute and chronic effects, and occurs in all mammalian species. Most commonly urinary crystals contain calcium. Numerous other endogenous and exogenous substances can produce crystalluria. Crystals are identified in kidneys of many species, up to 100% in certain rat strains. More severe renal disease (acute tubular necrosis and chronic renal disease) can be secondary to crystal accumulation, such as observed with melamine-cyanuric acid in cats and dogs. Aggregation of crystals leads to calculi that act as urothelial abrasives with consequent regenerative proliferation. Accumulation in the kidney pelvis or bladder can lead to partial or complete obstruction and hydronephrosis. Long-term presence of urinary tract calculi in rodents leads to increased risk of urothelial tumors, but not in humans. Crystals in the lower urinary tract can act as irritants in rodents, but not in humans. It is critical that specific procedures are followed to optimize the presence of crystals in urine for diagnosis, including not fasting the animals. Numerous factors have been identified which can enhance or inhibit crystal formation. Extrapolation from animals for the threshold toxicity of crystals/calculi is appropriate but is not relevant for cancer risk assessment.

Enterolith causing bladder outlet obstruction in patient with imperforate anus. A rare case presentation.

Imperforate anus is a rare anomaly associated with defects commonly referred to as vertebral defects, anal atresia, cardiac defects, tracheo-oesophageal fistula, renal anomalies and limb abnormalities (VACTERL). With modern surgical procedures the overall outcome is excellent. Permanent colostomy which is required in some cases of this disease can result in some rare complications such as enteroliths formation, as illustrated in the case we are presenting here related to a 28-year-old male who reported at urology emergency with features of urinary and acute large bowel obstruction. On investigation he was found to have two enteroliths in his distal loop of sigmoid colostomy. The more distal of the two enteroliths caused urinary retention and hence acute renal failure, and the proximal one caused large bowel obstruction by compressing the proximal loop of colostomy. This case demonstrates that the blind distal sigmoid colostomy loop can grow enteroliths secondary to stasis of its own contents over a long period.

Pyelolymphatic backflow demonstrated by an abdominal CT: A case report.

BACKGROUND: Pyelolymphatic backflow phenomenon, which is a subtype of pyelorenal backflow, is a rare condition that occurs during the acute phase of urinary obstruction. Pyelorenal backflow has already been described in humans with retrograde pyelography. Our report presents a rare case of pyelolyphatic backflow demonstrated by a computed tomography. CASE REPORT: A 67-year-old man with a history of bladder carcinoma was admitted to the emergency department due to right-sided flank pain and hematuria. Hematuria resolved after insertion of a 3-way urinary catheter, but flank pain persisted. As a result, an abdominopelvic CT was performed. CT revealed numerous tiny, serpiginous tubular structures connected with each other and filled with urine. They began intrarenally and extended caudally surrounding the ureter in the retroperitoneum. Subsequently, the patient underwent an ultrasound-guided nephrostomy to decompress the collecting system of the right kidney. Antegrade pyelography revealed minimal hydroneprosis. However, no leakage from the ureter to the retroperitoneum was observed, proving that the changes demonstrated by a CT were due to pyelolymphatic reflux caused by increased pressure in the collecting tubules filling the lymphatics with opaque urine. CONCLUSIONS: This report presents a very rare case of pyelolymphatic reflux demonstrated by a CT. We present this case report as a reminder that although rare, pyelolymphatic reflux can occur as a result of obstruction without manifestations of hydronephrosis and it can be confused with leakage from the ureter.

Risk factors, complications, and outcomes of cystotomy in guinea pigs: 25 cases (2010-2023).

OBJECTIVE: To describe the complications, surgical outcome, and prognosis associated with cystotomies in guinea pigs. METHODS: A retrospective review of medical records of guinea pigs undergoing cystotomy for uroliths or urethroliths between 2010 and 2023. RESULTS: 25 guinea pigs were included in the study. Uroliths were confirmed on radiographs in all 25 cases, with 9 patients (36%) having at least 1 stone within the urethra. The cystotomy procedure was associated with an intraoperative complication rate of 24% and a short-term complication rate of 76%. Discomfort was the only presenting clinical sign significantly associated with survival, with a risk of dying prior to discharge that was a sixth of the risk of dying if a patient presented without signs of discomfort (risk ratio = 0.177). For patients with a stone within the urethra, the probability of death prior to discharge was 6 times that of patients with a stone within the bladder (P = .010; risk ratio = 5.966). CONCLUSIONS: Cystotomies were associated with a mortality rate of 40% prior to discharge and 56% within the first month postoperatively. Further studies are needed to determine what specifically may lead to the high mortality rate as well as whether alternative minimally invasive procedures may be helpful in improving outcomes. CLINICAL RELEVANCE: This study is the first to document risk factors, complications, and outcomes of a cohort of guinea pigs specifically undergoing cystotomy for urolithiasis. Given the high risk for complications and mortality, caution and owner preparation must be considered when a cystotomy is recommended for guinea pig patients.