A case of emphysematous cystitis caused by Klebsiella pneumoniae.

Emphysematous cystitis is a rare type of urinary tract infection that is characterized by air pockets within the bladder wall and lumen, which come from gas that is mainly produced by gram-negative bacteria, notably Escherichia coli. This infection is more common in older women with poorly controlled diabetes. An abdominal computerized tomography (CT) scan is the gold standard method to make the diagnosis. The infection can be life-threatening, so prompt treatment is essential. We present a case of a 39-year-old woman with poorly controlled type 2 diabetes who developed emphysematous cystitis after a bilateral adrenalectomy. The infection was diagnosed by a CT scan that revealed gas in the bladder wall. A urine culture revealed 106 colonies/mL of Klebsiella pneumoniae. After a month of treatment with intravenous antibiotics (vancomycin plus meropenem plus colistin), bladder drainage, and strict glycemic control, the patient had a good outcome.

Association between sociodemographic factors and diagnosis of lethal prostate cancer in early life.

OBJECTIVE: A subset of patients are diagnosed with lethal prostate cancer (CaP) early in life before prostate-specific antigen (PSA) screening is typically initiated. To identify opportunities for improved detection, we evaluated patient sociodemographic factors associated with advanced vs. localized (CaP) diagnosis across the age spectrum. METHODS: We conducted a retrospective cohort study using the National Cancer Database, identifying patients diagnosed with CaP from 2004 to 2020. We compared characteristics of patients diagnosed at the advanced (cN1 or M1) versus localized (cT1-4N0M0) stage. Using multivariable logistic regression, we evaluated the associations among patient clinical and sociodemographic factors and advanced diagnosis, stratifying patients by age as ≤55 (before screening is recommended for most patients), 56 to 65, 66 to 75, and ≥76 years. RESULTS: We identified 977,722 patients who met the inclusion criteria. The mean age at diagnosis was 65.3 years and 50,663 (5.1%) had advanced disease. Overall, uninsured (OR = 3.20, 95% CI 3.03-3.78) and Medicaid-insured (OR 2.58, 95% CI 2.48-2.69) vs. privately insured status was associated with higher odds of diagnosis with advanced disease and this effect was more pronounced for younger patients. Among patients ≤55 years, uninsured (OR 4.14, 95% CI 3.69-4.65) and Medicaid-insured (OR 3.39, 95% CI 3.10-3.72) vs. privately insured patients were associated with higher odds of advanced cancer at diagnosis. Similarly, residence in the lowest vs. highest income quartile was associated with increased odds of advanced CaP in patients ≤55 years (OR 1.15, 95% CI 1.02-1.30). Black vs. White race was associated with increased odds of advanced CaP at diagnosis later in life (OR 1.17, 95% CI 1.09-1.25); however, race was not significantly associated with advanced stage CaP in those ≤55 years (P = 0.635). CONCLUSIONS: Sociodemographic disparities in diagnosis at advanced stages of CaP were more pronounced in younger patients, particularly with respect to insurance status. These findings may support greater attention to differential use of early CaP screening based on patient health insurance.

Stereotactic Magnetic Resonance-guided Adaptive Radiation Therapy for Localized Kidney Cancer: Early Outcomes from a Prospective Phase 1 Trial and Supplemental Cohort.

Stereotactic magnetic resonance (MR)-guided adaptive radiotherapy (SMART) for renal cell carcinoma may result in more precise treatment delivery through the capabilities for improved image quality, daily adaptive planning, and accounting for respiratory motion during treatment with real-time MR tracking. In this study, we aimed to characterize the safety and feasibility of SMART for localized kidney cancer. Twenty patients with localized kidney cancer (ten treated in a prospective phase 1 trial and ten in the supplemental cohort) were treated to 40 Gy in five fractions on a 0.35 T MR-guided linear accelerator with daily adaptive planning and a cine MR-guided inspiratory breath hold technique. The median follow-up time was 17 mo (interquartile range: 13-20 months). A single patient developed local failure at 30 mo. No grade ≥3 adverse events were reported. The mean decrease in estimated glomerular filtration rate was -1.8 ml/min/1.73 m2 (95% confidence interval or CI [-6.6 to 3.1 ml/min/1.73 m2]), and the mean decrease in tumor diameter was -0.20 cm (95% CI [-0.6 to 0.2 cm]) at the last follow-up. Anterior location and overlap of the 25 or 28 Gy isodose line with gastrointestinal organs at risk were predictive of the benefit from online adaptive planning. Kidney SMART is feasible and, at the early time point evaluated in this study, was well tolerated with minimal decline in renal function. More studies are warranted to further evaluate the safety and efficacy of this technique. PATIENT SUMMARY: For patients with localized renal cell carcinoma who are not surgical candidates, stereotactic magnetic resonance--guided adaptive radiotherapy is a feasible and safe noninvasive treatment option that results in minimal impact on kidney function.

Role of Surgery in Metastatic Renal Cell Carcinoma.

Surgery has historically been the mainstay of treatment for metastatic renal cell carcinoma (mRCC), but recent clinical trials demonstrated that contemporary systemic therapies alone are non-inferior to cytoreductive nephrectomy (CN). Thus, the current role of surgery is not precisely defined. CN remains an appropriate upfront treatment for the palliation of severe symptoms, select cases of metastatic non-clear cell renal cell carcinoma, for consolidation following systemic therapy, and in the setting of oligometastatic disease. Metastasectomy is ideally utilized to achieve a disease-free state when there is minimal morbidity associated with surgery. Given the heterogenous nature of mRCC, the decision for systemic therapy and surgery should be made through a multidisciplinary approach tailored to each individual patient.

Biomarkers for the Detection and Surveillance of Renal Cancer.

Renal cell carcinoma (RCC) is a heterogeneous disease characterized by a broad spectrum of disorders in terms of genetics, molecular and clinical characteristics. There is an urgent need for noninvasive tools to stratify and select patients for treatment accurately. In this review, we analyze serum, urinary, and imaging biomarkers that have the potential to detect malignant tumors in patients with RCC. We discuss the characteristics of these numerous biomarkers and their ability to be used routinely in clinical practice. The development of biomarkers continues to evolve with promising prospects.

The association of marital status with kidney cancer surgery morbidity - a retrospective cohort study.

Purpose: To better understand whether the marital status impacts 90-day postoperative outcomes following kidney cancer surgery. Methods: We performed a retrospective cohort study of adult patients undergoing elective partial or radical nephrectomy to manage kidney masses from 2003 to 2017 using the Premier Hospital Database, a national hospital discharge dataset. Multinomial logistic regression models controlling for a wide range of clinicodemographic, surgical, and hospital characteristics were used to assess an association between marital status and postoperative complications. The primary outcome was 90-day complications, including minor complications (Clavien grades 1-2), non-fatal major complications (Clavien grades 3-4), and mortality (Clavien grade 5). Secondary outcomes included patient disposition and readmission rates. Results: The study cohort comprised 106,752 patients, of which 61,188 (57.32%) were married. The overall incidence of minor complications, major complications, and death was 24.04%, 6.00%, and 0.71%, respectively. Marriage was associated with a significantly lower incidence of minor (RR 0.97; 95% CI: 0.94-0.99) complications following open or radical nephrectomy and major complications (RR 0.89; 95% CI: 0.84-0.95) for all surgical types and approaches. There was no association between marital status and mortality (RR 0.94; 95% CI: 0.81-1.10). Conclusion: Marriage is associated with a significant reduction in major complications following kidney cancer surgery, likely because it is associated with greater social support, which is beneficial in the postoperative phase of care. Marital status and social support may play a role in the preoperative decision-making process and counseling for patients considering kidney cancer surgery.

Smoking status among cancer patients by specialty: A U.S. nationwide representative analysis.

BACKGROUND: Persistence in tobacco use among cancer survivors has been associated with a multitude of clinicodemographic factors. However, there is a paucity of understanding regarding the role the healthcare professional's specialty plays in tobacco cessation in tobacco-related cancer survivors. METHODS: We conducted a cross-sectional analysis of data from cancer survivors with a smoking history using the Behavioral Risk Factor Surveillance System (BRFSS) database to examine differences in the proportion of patients continuing tobacco use among patients with a diagnosis of cancer segregated by cancer site specialty over the 2016-2020 period. We accounted for complex survey design and used sampling weights to obtain a nationwide representative sample. We employed modified Poisson regression adjusting for age, gender, education, income, race, marital status, and medical specialty. RESULTS: We analyzed 19,855 cancer survivors with a current or past history of tobacco use, of whom 5222 (26,3%) self-reported to be current smokers. Patients with urological and gynecological tobacco-related malignancies had a higher relative risk (RR) of being current smokers with a RR of 1.30 (95% confidence interval, 1.12-1.51) and 1.25 (95% confidence interval, 1.12-1.39) respectively. Malignant Hematology had the lowest RR of smoking status among all other specialties RR 0.85 (95% confidence interval, 0.59-1.21). CONCLUSIONS: Continuing smoking rates among tobacco-related cancer survivors were different between specialties. One in four cancer survivors were current smokers; this emphasizes health professionals' paramount role in tobacco cessation counseling.

Impact of smoking status on health-related quality of life (HRQoL) in cancer survivors.

Introduction: The Health-Related Quality of Life (HRQoL) often declines among cancer survivors due to many factors. Some cancer patients who smoke before the cancer diagnosis continue this harmful habit, potentially contributing to a more significant decline in their HRQoL. Therefore, this study investigates the association between smoking status and HRQoL in cancer survivors. Methods: We conducted a cross-sectional study utilizing self-reported cancer history from 39,578 participants of the Behavioral Risk Factor Surveillance System (BRFSS) database, leveraging 2016 and 2020 year questionaries. A multidimensional composite outcome was created to assess HRQoL, integrating four distinct dimensions - general health, mental health, physical health, and activity limitations. After accounting for the complex survey design, logistic regression models were used to analyze the association between smoking status and poor HRQoL, adjusting for demographic, socioeconomic, and health-related confounders. Results: Our study found that, after adjusting for potential confounders, current smokers exhibited a significantly poorer HRQoL than never smokers (OR 1.65, 95%CI 1.40-1.93). Furthermore, former smokers showed a poorer HRQoL than never smokers; however, this association was not as strong as current smokers (OR 1.22, 95%CI 1.09-1.38). Conclusion: Our findings highlight the adverse association of smoking with poor HRQoL in cancer survivors, underscoring the importance of healthcare professionals prioritizing smoking cessation and providing tailored interventions to support this goal.

[Current role of bilateral adrenalectomy in Ectopic Cushing syndrome.] / Rol actual de la adrenalectomía bilateral en el manejo del síndrome de Cushing Ectópico.

OBJECTIVES: The aim of this paper is to describe the clinical features and the perioperative results of the bilateral laparoscopic adrenalectomy (BLA) of salvaje in 5 patients treated for an Ectopic Cushing Syndrome (CS) who were refractory to medical treatment. MATERIALS AND METHODS: We performed a retrospective analysis of the clinical records of our institution. Five BLAs were performed in patients with Ectopic CS refractory to medical treatment during the period from January 2009 and June 2017. All patients were evaluated by a multidisciplinary team that jointly decided the most appropriate time for surgery. The following protocol data were analyzed: age, sex, location of the secreting tumor, duration of hypercortisolism, reason for hospitalization, initial therapeutic management), biochemical data (pre-op serum cortisol, plasma ACTH and free urinary cortisol), surgical data (surgical approach, surgical time, type of surgery, need for conversion toopen surgery), perioperative data (post op surgical stay, post op complications according to the Clavien-Dindo scale 14, mortality, clinical cure rate and biochemical cure rate, follow up time). RESULTS: Five patients underwent BLA. The approach for the BLA was minimally invasive, either trans peritoneal (n=3) or posterior retroperitoneoscopic (n=2). Mean hospitalization time was 23.4 days (r=4-81). None of the patients died because of surgical complications, and all of them achieved biochemical and clinical remission of their hypercortisolism after surgery. CONCLUSIONS: BLA is an effective salvage alter native to control the symptoms associated with overproduction of corticosteroids in patients with ectopic CS refractory to medical treatment.

OBJETIVO: Describir las características clínicas y los resultados perioperatorios de la adrenalectomía bilateral laparoscópica (ABL) en 5 pacientes tratados con diagnóstico de Síndrome de Cushing Ectópico (SCE).MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo y descriptivo de todos los pacientes con SCE sometidos a una ABL, entre enero de 2009 y junio de 2017. Todos los pacientes fueron evaluados por un equipo multidisciplinario que decidió conjuntamente el momento más adecuado para la cirugía. Fueron analizados los siguientes datos protocolares: edad, sexo, origen del tumor secretor, duración del hipercortisolismo, motivo de internación, manejo terapéutico inicial, datos bioquímicos (cortisol sérico preoperatorio, ACTH plasmática y cortisol libre urinario), datos quirúrgicos (vía de abordaje, tiempo quirúrgico, tipo de cirugía, necesidad de conversión a cirugía abierta), datos perioperatorios (tiempo de internación postoperatoria, complicaciones según la escala de Clavien-Dindo, mortalidad, tasa de curación clínica y tasa de curación bioquímica, tiempo de seguimiento). RESULTADOS: Cinco pacientes fueron sometidos a ABL. El abordaje fue mínimamente invasivo, ya sea transperitoneal (n=3) o retroperitoneoscópico posterior (n=2). El tiempo de internación fue de 23,4 días (r=4-81). Ningún paciente falleció por complicaciones quirúrgicas, y todos lograron la curación bioquímica y clínica de su hipercortisolismo después de la cirugía. CONCLUSIONES: ABL es un procedimiento de rescate eficaz para controlar los síntomas asociados al hipercortisolismo en pacientes con SCE refractario al tratamiento médico.

[Study on most common overnight urological service consultations.] / Principales consultas urológicas a la guardia de un hospital de alta complejidad.

INTRODUCTION: In Argentina, our institutionhas a urology resident on call who handles requests to the single radio during nighttime. Few studies address this important issue that provides useful information to promote education and optimize hospital dynamics. OBJECTIVE: To describe the characteristics of the calls received in the urology radio during night shifts. MATERIALS AND METHODS: During the night shifts, all calls to the radio were recorded during the period between June and July 2019. We determined: time, source, sex, and age of the patient, reason for the call and classified the calls according to: calls for immediate resolution (which required urological instrumental intervention, bladder catheterization or lavage, etc.), unnecessary calls (wrong number), and the number of emergencies that require calling a superior for immediate surgical resolution. RESULTS: We registered a total of 325 calls, most of them male patients. The main reason for calling was for placement, replacement, or washing of the urinary catheter or suprapubic catheter. We obtained 139 calls that required urological intervention. The highest number of calls was from the emergency department (119), followed by the Internal Medicine staff (47). Most of them (242) did not require patient admission. The total of unnecessary calls was three, corresponding to wrong number. CONCLUSION: This study helped us to characterize the calls to the Urology radio from other services and emergency department, allowing us to identify the most common problems and educate based on this.

INTRODUCCIÓN: En Argentina nuestra institución cuenta con un residente de guardia activa de urología que se ocupa de las llamadas al radio único durante la noche. Existen pocos trabajos que tratan este tema que resulta importante, ya que brinda información útil para promover educación y optimizar la dinámica hospitalaria.OBJETIVO: Describir las características de las llamadas al radio de urología durante la guardia.MATERIALES Y MÉTODOS: Durante la guardia activa, se registraron llamadas al radio durante el período comprendido en junio y julio de 2019. Determinamos:  hora, fuente, sexo y edad del paciente, motivo de la llamada y los clasificamos según: llamadas para guardia inmediata (que necesitó intervención instrumental urológica como sonda, talla o lavado vesical, etc.), llamadas innecesarias (número equivocado) y número de urgencias que requieren llamar a médico urólogo de pasiva para guardia quirúrgica inmediata.RESULTADOS: Se recopilaron un total de 325 llamadas, la mayoría de pacientes de sexo masculino. El principal motivo de la llamada fue para colocación, recambio o lavado de sonda vesical y/o talla vesical. Obtuvimos 139 llamadas que requirieron intervención urológica. El mayor número de llamadas fue de la Guardia externa (119), seguidos de Clínica Médica (47). La mayoría de las llamadas (242) no fueron ingresos. El total de llamadas innecesarias fueron 3 que corresponden al número equivocado.CONCLUSIÓN: Este trabajo permitió detallar las llamadas al radio de Urología provenientes de otros servicios y guardia externa, pudiendo identificar las problemáticas más comunes y educar en base a esto.