TFE3-rearranged RCC with osseous metaplasia found on bone mass densitometry.

Introduction and importance: Renal cell carcinoma (RCC) is the most common primary renal malignancy in patients between the ages of 50 and 70. A rare described variant of RCC is transcription factor for immunoglobulin heavy-chain enhancer 3 (TFE3) rearranged RCC. Osseous metaplasia, which refers to the occurrence of normal bone tissue in soft tissue, has been observed in all subtypes of renal cell carcinoma (RCC); however, only three previous case reports have documented the occurrence of osseous metaplasia in TFE3-rearranged RCC. Case presentation: We present a case of a 65-year-old woman presenting with an incidentally discovered calcified Bi-lobed renal mass detected on bone densitometry composed of a calcified thick-walled cyst measuring 7×6.5×6.5 cm showing intraluminal densities and heterogeneous content, and a lobulated partially exophytic renal mass measuring 4.5×5.5×4.5 cm. The patient underwent robotic-assisted radical nephrectomy confirming the diagnosis of RCC with osseous metaplasia extending into the pelvic calyces and renal sinus fat implicating a pathological stage of T3a. Clinical discussion: TFE3-rearranged RCCs represent a rare sub-classification in adult RCCs. It may be associated with unfavorable prognosis and aggressive patterns of disease in the presence of osseous metaplasia. Conclusion: This is the first case in the literature of TFE3-rearranged RCC with osseous metaplasia on bone mass densitometry scan and the fourth case of TFE3-rearranged RCC with osseous metaplasia. The patient is to be treated as a high-risk patient and to be monitored closely for recurrence of malignancy, as indicated in the EAU guidelines.

Cystic dysplasia of the rete testis in adulthood: a case report and review of the literature.

Background: Rete testis dysplasia is a cystic anomaly arising from the rete testis presenting normally in the pediatric population. These cases usually regress spontaneously without the need for surgical intervention. There are rare, reported cases of rete testis dysplasia in adulthood, which have been managed surgically. Case presentation: A 58-year-old man presented with lower urinary tracts symptoms and found to have a slightly larger right testicle namely in the lower pole near the epididymis. Investigation was done using ultrasound of the testicles with Doppler showing an 8 mm cyst contained in 16.5×12.1 mm cystic dysplasia near the rete testis. MRI of the testicles revealed a small intratesticular cyst with adjacent band-like signals, in keeping with rete testis dysplasia. This patient was placed under surveillance and the rete testis dysplasia is stable after 6 months and will not be operated on unless progression on ultrasound is encountered. Clinical discussion: The management of cystic dysplasia of the rete testis has been evolving with time. While there have never been clear-cut guidelines on the treatment of this condition, a radical orchiectomy of the affected testicle had traditionally been the preferred treatment option. There have only been three case reports of cystic dysplasia of the rete testis in adults, none of which are known to have been managed by observation. Conclusion: In conclusion, the authors report a unique case of rete testis dysplasia being managed conservatively showing the benign features of such a pathology, which may be actively surveyed through sequential imaging.

Are urologists underrepresented on fertility clinic websites? A web-based analysis.

Introduction: Infertile couples frequently utilize the Internet to find various reproductive clinics and research their alternatives. Patients are increasingly using self-referral because of online information on health-care providers. The objective is to compare the image of infertility specialists to other team members on the websites of reproductive clinics. Methods: Information was gathered during November and December 2022 from two publicly accessible online registries which include the Human Fertilization and Embryology Authority located in the United Kingdom and the Society for Assisted Reproductive Technology located in the United States. We looked over every website that was accessible, paying close attention to how each team member was portrayed online. Results: We examined a total of 447 clinic websites. Only 8% of the profiles of male infertility doctors were included. Contrarily, most websites (96%), which specialize in reproductive endocrinology and infertility, feature the profiles of female infertility experts. Male infertility professionals also had significantly lower representation than other clinic employees, such as nurses (55.7%, P < 0.0001), directors of embryology laboratories (46.5%, P < 0.0001), office personnel (39.6%, P < 0.0001), and embryology specialists (29.7%, P < 0.0001). Conclusion: Although male factor infertility explains the existence of over half of all cases of infertility, urologists who specialize in male infertility are glaringly understated on websites for fertility clinics. By improving this issue, fertility clinics can draw in more patients by making all members of the care team more visible.

Bacillus cereus infection of the penis: an unusual infection.

Background: Bacillus cereus (B. cereus) is a Gram-positive, rod-shaped, motile organism, found in the environment and may exist in contaminated food sources such as reheated rice, vegetables and may lead to gastrointestinal symptoms after ingestion including diarrhea, nausea, and vomiting due to enterotoxigenic and emetic toxins. Non-gastrointestinal infections of Bacillus cereus have been reported in the literature, which include cutaneous and non-cutaneous infections in immunocompetent and immunocompromised individuals. Case presentation: A 38-year-old man presented with a one-week history of penile swelling and redness that started after an episode of severe diarrhea and vomiting, which soiled his genital region few hours after vigorous intercourse with his wife. This has led to infection of the penile skin by an unusual organism: Bacillus (B.) cereus. The patient was treated using fucidic acid ointment applications for 2 weeks achieving complete recovery. Clinical discussion: The recovery of B. cereus from the penile infection in our patient reveals the first case of such an unusual infection, though this pathogen has been reported to cause a wide range of non-GI tract infections, which include bacteremia, meningitis, endocarditis, endophthalmitis, pneumonia, and soft tissue diseases. Virulence factors allow this organism to induce diarrhea in addition to having dermonecrotic, cytotoxic, hemolytic properties resulting in a wide range of dermatologic presentations. Conclusion: The authors report a unique case of penile skin infection caused by B. cereus, an unusual culprit for an uncommon presentation successfully treated with fucidic acid ointment. This is the first case in literature describing such an entity.

Peno-scrotal metastasis of colorectal adenocarcinoma: A case report and review of the literature.

INTRODUCTION: Colorectal cancer is the second most common cause of death worldwide and may present as metastatic disease involving the liver, lungs and bones, and pelvic organs. Penile and scrotal metastasis may occur secondary to primary tumors originating from the genito-urinary tract. CASE PRESENTATION: We present a case of rectal adenocarcinoma metastatic to the penis and scrotum s/p chemotherapy and radiotherapy. His metastatic involvement was complicated by infections, necrosis and growth of maggots. Patient underwent wide excision and debridement of the metastatic deposits in the pubic, penile, scrotal and perineal region in addition to split-tissue skin graft from the right anterior thigh to cover the pubic region, the remainder of the penile shaft, and the scrotum. CLINICAL DISCUSSION: Peno-scrotal metastasis secondary to rectal adenocarcinoma is a rare condition. It may present as malignant priapism, hematuria, obstructive urinary symptoms occurring when there is urethral involvement. The mechanism of metastasis may be due to retrograde venous flow from the vesical, pudendal, hemorrhoidal plexuses, and the prostatic venous plexus draining the cavernosal veins of the penis. Additionally, lymphatic involvement and spread may play an important role in the spread of the disease. Treatment of such conditions relies on chemotherapy and radiotherapy and surgery for local control and symptomatic treatment. CONCLUSION: This article describes the rare occurrence of peno-scrotal metastasis of rectal adenocarcinoma and provides an overview on diagnosis, etiology, and management of the disease.

Impact of kidney disease on perioperative outcomes of endoscopic BPH surgery: a propensity score matched analysis from the NSQIP database.

INTRODUCTION: To assess the impact of kidney function in patients with BPH undergoing surgery prior to Transurethral resection of prostate (TURP), Laser enucleation of the prostate (LEP), and Laser Vaporization of the prostate (LVP) on operative and post-operative outcomes using the ACS-NSQIP database. METHODS: The ACS-NSQIP database was reviewed for patients that underwent TURP, LEP and LVP for treatment of patients with BPH between the years of 2008 and 2021. Demographics, comorbidities, bleeding disorders, operative time, and surgical procedure performed were collected for comparison between Kidney function groups: G1, normal/high function; G2-G3, mild/moderate kidney disease; and G4-G5, severe kidney disease. The 30-day peri-operative complications were measured and a multivariate logistic regression analysis was performed while adjusting for all confounding variables. Propensity score matching was performed between the G1 and G4-G5 cohorts. RESULTS: A total of 83,020 patients were included. On multivariable regression, in the G2-G3 cohort, patients were at significantly increased risk for renal complications with OR = 2.43[1.56-3.79]. After propensity score matching, the G4-G5 cohort showed increased odds of pneumonia OR = 4.02[1.343-12.056], renal complications with OR = 7.62[2.283-25.411], cardiac complications OR = 4.53[1.531-13.411], and sepsis/septic shock OR = 1.76[1.091-2.834]. They also had a higher need for blood transfusion OR = 3.58[2.242-5.714], and prolonged hospital stay with OR = 1.49[1.296-1.723]. CONCLUSION: Pre-operative kidney disease may pose an increased risk of complications for patients undergoing endoscopic BPH surgery. The literature lacks information on the effect of pre-operative kidney disease on endoscopic BPH surgeries. Further studies are required to compare post-operative outcomes of LEP and LVP as compared to TURP across kidney function status.

Gastric Outlet Obstruction as a presentation of Metastatic Squamous Cell Carcinoma of the Bladder: A case report and review of the literature.

INTRODUCTION: Gastric outlet obstruction presents with a range of symptoms which include abdominal pain, early satiety, weight loss and vomiting caused obstruction secondary to tumors from outside the gastrointestinal tract or due to motility disorders. Bladder cancer is rarely associated with Gastric outlet obstruction. It usually presents with painless hematuria and urinary symptoms. Squamous cell carcinoma is a subtype of bladder malignancies that tends to present at a later stage and is associated with poorer prognosis in terms of metastasis and survival. CASE PRESENTATION: We present the case of a 79-year-old man, non-smoker, who presented to the emergency department with gastric outlet obstruction and was found to have non-bilharzial squamous cell carcinoma of the bladder metastatic to the retroperitoneal lymph nodes causing duodenal and small bowel obstruction. CLINICAL DISCUSSION: Squamous cell carcinoma of the bladder, tends to present at later stages and spread to adjacent organs or spread through lymphatics to lymph nodes, liver, bone, brain, lungs, and the gastro-intestinal tract. Diagnosis is made through cystoscopy, pathology and imaging. Non-Bilharzial Squamous cell carcinoma of the bladder is associated with increased morbidity and mortality than its Bilharzial counterpart. CONCLUSION: This is a unique case of non-bilharzial squamous cell carcinoma of the bladder, metastatic to retroperitoneal lymph nodes that lead to compression of the duodenum and small bowels and eventual gastric outlet obstruction. There are few reports of gastro-intestinal obstruction secondary to bladder cancer, however this is the first case metastatic non-bilharzial Squamous cell carcinoma of the bladder presenting as gastric outlet obstruction.

Urethral meatus edema with peno-scrotal edema in a patient with transfusion-dependent beta-thalassemia major.

Urethral meatus edema is a rare finding and may infer a more severe form of volume overload. Management of patients with thalassemia vary in terms of the severity of the kidney injury due to transfusion, chronicity, and severity of volume overload.

Florid Cystitis Glandularis with Intestinal Metaplasia in the Prostatic Urethra: a case report and review of the literature.

INTRODUCTION: Cystitis glandularis is a proliferative disease of the bladder epithelium usually presenting in the setting of chronic inflammation, characterized by the formation of glands in the bladder mucosa and submucosa. Intestinal metaplasia is a described process in cystitis glandularis characterized by the presence of intestinal cells and mucin production which is rare as compared to cystitis glandularis. CASE PRESENTATION: We present a case of cystitis glandularis with intestinal metaplasia located in the bladder and concomitantly in the prostatic urethra. Patient underwent transurethral resection of the lesion which was unusually found in the prostatic urethra. CLINICAL DISCUSSION: Florid cystitis glandularis is a rare condition found in women more than in men. It usually presents with irritative lower urinary tract symptoms or hematuria which leads to its eventual diagnosis. It is usually causes by inflammation to the bladder mucosa due to infections or irritation. Patients are diagnosed through Transurethral resection of these bladder lesions found in the trigone and bladder neck region. Surgery is the standard treatment of choice. However, medical treatment may also be used to treat underlying inflammatory conditions using antibiotics, steroids, and non-steroidal anti-inflammatory agents. Radical or partial cystectomy may be performed for severe refractory cases. CONCLUSION: This article describes the rare occurrence of florid cystitis glandularis in the prostatic urethra and provides an overview on diagnosis, etiology, and management of the disease.

Systemic Mastocytosis: A Mimicker of Reactive Arthritis.

Objectives: Illustration of a case of systemic mastocytosis mimicking reactive arthritis in the absence of an infectious etiology. Methods: Review of the patient's medical records. Results: We report a case of systemic mastocytosis relapse, presenting with pancytopenia accompanied by knee monoarthritis, cystitis, and bilateral conjunctivitis occurring simultaneously at the same time interval within 2-4 days, mimicking reactive arthritis in the absence of an infectious etiology. Conclusion: Our case demonstrated reactive arthritis features (triad of urethritis, conjunctivitis, and arthritis) without an infectious trigger but rather a relapse of mastocytosis. We should think outside the box when faced with such a clinical scenario in the absence of an infectious etiology. Paraneoplastic reactive arthritis is to be considered after excluding an underlying infection.

A rare case of bilateral para-rectal hydatid disease: A case report.

INTRODUCTION: Cystic hydatidosis is a parasitic infection caused by the organism Echinococcus Granulosus that is well known to be endemic in the Mediterranean region, eastern Europe and South America and usually presents as hydatid disease of the liver but may affect other organs. The disease occurs when humans become the accidental host through ingestion of the eggs from contaminated food. CASE PRESENTATION: We present a case of Hydatid disease presenting as hives refractory to medical therapy over 4 years duration which was revealed to be caused by para-rectal hydatid cysts. Patient received Albendazole for a duration of 2.5 months and then underwent laparoscopic resection of the para-rectal cysts. CLINICAL DISCUSSION: Pelvic Hydatidosis is a very rare condition accounting for 0.7 % of all cases reported. In most cases, it is coexistent with cysts present elsewhere in the body, namely the liver, which is the case in the presented patient. Imaging is used as a modality to establish the diagnosis of cystic hydatidosis namely Ultrasound (US), Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI). The incidental finding of the hydatid cysts in this patient demonstrated the efficiency of a CT scan as a tool for detection and subsequently diagnosis of the disease in the pelvis. Surgery is the treatment of choice for cysts with daughter vesicles that are not candidates for percutaneous drainage, large liver hydatid cysts of more than 10 cm in diameter, cysts with a risk of rupture in case of trauma, and extrahepatic disease such as the lung, bone, brain, kidneys or pelvis. CONCLUSION: This article reports the rare occurrence of para-rectal hydatid disease which is only described in few case reports in the literature and provides an overview on diagnosis, and management of the disease.

Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index.

Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer-Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R 2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection.

Multisystem inflammatory syndrome in children (MIS-C) and "Near MIS-C": A continuum?

Introduction: Reports of multisystem inflammatory syndrome in children (MIS-C), following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, have been increasing worldwide, with an incidence varying significantly across studies based on the definition used for the diagnosis. At our tertiary medical center in Lebanon, we encountered several cases that presented a diagnostic challenge because they mimicked MIS-C but did not meet the US Centers for Disease Control and Prevention (CDC) definition. We decided to review these cases and describe their features in comparison with cases that met the CDC criteria of MIS-C and those that had an alternative diagnosis. Methods: This is a retrospective chart review of subjects aged <19 years old admitted to the American University of Beirut Medical Center (AUBMC) between March 1, 2020, and May 31, 2021, with suspected or confirmed MIS-C, following documented COVID-19 infection, with sufficient or insufficient criteria for diagnosis. Subjects were classified into 3 groups: "MIS-C", "Near MIS-C" and "Alternative Diagnosis". Results: A total number of 29 subjects were included in our cohort. Fever was present in all subjects. In the MIS-C group, evidence for cardiovascular system involvement was the most common feature followed by the mucocutaneous and gastrointestinal systems. In the "Near MIS-C" and "Alternative Diagnosis" group, gastrointestinal symptoms were the most common with only one patient with cardiac abnormalities and none with coagulopathy. Subjects with typical MIS-C presentation had higher inflammatory markers when compared to subjects in the other groups. Almost all the subjects had positive IgG for SARS-CoV-2. Of the 29 subjects, the Royal College of Paediatrics and Child Health (RCPCH) case definition would have identified all suspected cases without an alternative diagnosis as MIS-C, whereas the World Health Organization (WHO) and the CDC definitions would have excluded 6 and 10 subjects, respectively. Conclusion: MIS-C presents a diagnostic challenge due to the nonspecific symptoms, lack of pathognomonic findings, and potentially fatal complications. More research is needed to fully understand its pathogenesis, clinical presentation spectrum, and diagnostic criteria. Based on our experience, we favor the hypothesis that MIS-C has a continuum of severity that necessitates revisiting and unifying the current definitions.

Spontaneous ureteral stone passage: a novel and comprehensive nomogram.

BACKGROUND: Ureteral stones pose a high economic and medical burden among Emergency Department (ED) admissions. Management strategies vary from expectant therapy to surgical interventions. Since predictors of ureteral spontaneous stone passage (SSP) are still not well understood, we sought to create a novel nomogram to guide management decisions. METHODS: Charts were retrospectively reviewed for patients who presented to our institution's ED with non-febrile renal colic and received a radiological diagnosis of ureteral stone ≤10 mm. Demographic, clinical, laboratory, and non-contrast CT data were collected. This novel nomogram incorporates the serum neutrophil-to-lymphocyte ratio (NLR) as a potential predictor of SSP. The model was derived from a multivariate logistic regression and was validated on a different cohort. A receiver operator characteristic (ROC) curve was constructed and the area under the curve (AUC) was computed. RESULTS: A total of 1186 patients presented to our ED between January 2010 and October 2018. We randomly divided our population into a derivation and validation cohort in one to five ratio. A stone size ≥7 mm was the strongest predictor of SSP failure; OR=9.47; 95% CI: 6.03-14.88. Similarly, a NLR≥3.14 had 2.17; (1.58-2.98) the odds of retained stone. SSP failure was also correlated with proximal position, severe hydronephrosis, and leukocyte esterase ≥75, P=0.02, P=0.05, and P=0.006, respectively. The model had an AUC of 0.804 (0.776-0.832). The nomogram was also used to compute the risk of SSP failure (AUC 0.769 [0.709-0.829]). CONCLUSIONS: Our novel nomogram can be used as a predictor for SSP and can be used clinically in decision making.