Clear Cell Renal Cell Carcinoma with Neovascularization and Ureteral Extension in a 63-Year-Old Female Unravelled by Pelvicalyceal Penetration.

Approximately 3% to 4% of all newly diagnosed cancers are kidney tumours, which can develop from either the renal parenchymal tissue or the renal pelvis. Kidney cancer is one of the 13 most prevalent kinds of malignancy worldwide. 85% of all malignant kidney neoplasms are renal cell carcinomas (RCC). We present a rare instance of an RCC that had a thrombus in the ureter and had directly extended into the renal pelvicalyceal system. A thorough diagnostic workup was required because the patient had a number of symptoms, including flank pain, hematuria, and weight loss. Imaging tests identified a renal parenchymal-derived infiltrative tumour with remarkable pelvicalyceal penetration. Neovascularization was found within the tumour as a result of additional search. The discovery of ureteral extension, a peculiar characteristic, raised questions regarding both local and distant metastases. R.E.N.A.L nephrometry score was 11 with high complexity. Multidisciplinary management of the intricate clinical problem was employed. After removing the tumour mass, the ureteral involvement was treated with surgical resection, adjuvant therapy, and CT monitoring over the three-month high-risk follow-up period. With surgery, targeted treatment was employed to stop the cancer from growing. Conclusion: The importance of identifying unusual RCC presentations and employing a comprehensive diagnostic and treatment strategy is emphasised by this study. The complex interaction of ureteral extension, neovascularization, and pelvicalyceal penetration highlights the aggressiveness of advanced RCC. Since we are not aware of any literature documented instances including this combination, there are few studies explaining pelvicalyceal system invasion that defies commonly recognised diagnostic and treatment paradigms for renal cell carcinoma.

Post-donation health-related quality of life, mood and life satisfaction in livingkidney donors; an explorative study from kidney transplant centre, Lahore Pakistan.

Objective: To explore post-donation life satisfaction, quality of life and mood status among kidney donors. METHODS: The cross-sectional study was conducted from February 5 to July 10, 2021, at the Department of Kidney Transplant Surgery, Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan, and comprised living kidney donors who had donated a kidney at least 6 months before the interview date. Data was collected through telephonic interviews, and, in addition to demographics, the questionnaire comprised the World Health Organisation Quality of Life Brief Version scale, the Satisfaction with Life Scale, and the Patient Health Questionnaire and General Anxiety Disorder. Data was analysed using SPSS 20. RESULTS: Of the 41 subjects, 22(53.7%) were females and 19(46.3%) were males. The overall mean age was 41.10±9.648 years (range: 19-62 years). The most common donor-recipient relationship was brother-sister 10(34.1%) and wife-husband 10(24.4%). Among the donors, there was a significant positive correlation between quality of life and satisfaction with life (r=0.381, p=0.014). Quality of life had a negative correlation with anxiety (r=-0.429, p=0.005), and a negative but non-significant association with depression (r=-0.283, p=0.073). Anxiety and depression were highly positively correlated (r=0.681, p=0.000). Quality of life was significantly associated with donor age (p=0.029) with a negative effect (Beta=-0.588), while satisfaction with life had a positive relationship with age (Beta=0.147). Conclusion: Higher life satisfaction among living kidney donors was associated with an improved quality of life, while increased anxiety levels were linked to a lower quality of life. Age was a critical determinant, with older donors reporting a lower quality of life.

Challenges and technical aspects in the management of muscle invasive bladder cancer as retrograde radical cystectomy with ileal conduit.

Objective: To evaluate long-term outcomes in patients homogenously treated with radical cystectomy and ileal conduit for muscle invasive bladder cancer. METHODS: The retrospective study was conducted at the Urology Department of Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan, and comprised data from December 25, 2017, to January 16, 2023, related to patients who underwent radical cystectomy with ileal conduit with or without neo-adjuvant and adjuvant radiation, chemotherapy, or immunotherapy for papillary urothelial carcinom of the bladder. Clinical trajectory, histopathological characteristics and long-term clinical outcomes were noted. Data was analysed using SPSS 20. RESULTS: In our study of 40 patients with muscle invasive bladder cancer, males predominated (32, 80%), with a median age of 57.4 years (IQR: 29-80). Diagnosis was early in 5 (12.5%) patients with varying haematuria durations, while 34 (85%) patients had a smoking history. Comorbidities included hypertension in 17 (42.5%) patients, diabetes in 1 (2.5%) patient, both hypertension and diabetes in 9 (22.5%) patients and a combination of hypertension, diabetes, and ischaemic heart disease in 3 (7.5%) patients. Transurethral resection was performed once in 13 (32.5%) patients and multiple times in 27 (67.5%) patients. Additionally, 5 (12.5%) patients received immunotherapy, 11 (27.5%) patients underwent non-adjuvant radiation, and 14 (35%) patients received non-adjuvant chemotherapy. Papillary urothelial carcinoma was the predominant histological subtype among 37 (92.5%) patients. Patients receiving chemotherapy had significantly better overall survival (p=0.02). No significant differences were noted in recurrence or survival by therapy modality (p>0.05). These findings highlight the significance of early diagnosis, tailored treatments, and comorbidity management in muscle invasive bladder cancer patients. Age stratification revealed significant survival differences across groups (χ²=10.923, df=3, p= 0.012). Analysis by complications did not show age-related survival variations (χ² =3.978, df = 3, p=0.264). Conclusion: Achieving excellent long-term survival in MIBC patients requires a multidisciplinary approach, emphasizing early diagnosis, tailored treatment, and adherence to guidelines and protocols.

Topical Anesthetics and Premature Ejaculation: A Systematic Review and Meta-Analysis.

This meta-analysis was conducted to assess the effectiveness of topical anesthetics in preventing premature ejaculation. We conducted an online database search for original studies comparing topical anesthetic agents with placebo in patients with premature ejaculation. After selecting relevant articles, we extracted data on baseline characteristics and predetermined endpoints. Intravaginal ejaculatory latency time (IELT) was the primary outcome for efficacy. Mean differences and corresponding 95% confidence intervals were used to present continuous data. A random-effects model was used to pool the data, and subgroup analysis was performed based on the type of anesthetic agent used. Eleven randomized controlled trials were examined, involving a total of 2008 participants. After analyzing the combined results, it was found that Severance Secret (SS) cream (CJ CheilJedang Corporation, Seoul, South Korea) demonstrated significantly higher effectiveness than a placebo in increasing IELT (P = 0.001). Similarly, the topical eutectic mixture for premature ejaculation (TEMPE), lidocaine, and the eutectic mixture of local anesthetics (EMLA) were significantly more efficient than a placebo (P<0.00001; P = 0.0001; P<0.00001). Additionally, it was found that lidocaine gel was more efficient than paroxetine or sildenafil (P = 0.04; P<0.00001). In conclusion, topical anesthetics increase IELT in men with premature ejaculation more effectively than placebo, sildenafil, tadalafil, paroxetine, and dapoxetine.

Primary retroperitoneal teratoma in a young woman: a case report.

Teratomas are usually seen in gonads but they do occur in other extra gonadal regions such as sacrococcygeal region, mediastinum, head and neck, and retroperitoneum. Rarely in the retroperitoneal area, such tumours mostly develop in the pararenal area and usually on the left side. They have bimodal presentation at the age of six months and then in early adulthood. They originate from the germ cells that have failed to migrate to normal anatomical destinations. Many of such patients are diagnosed incidentally. Here, we report a case of symptomatic primary retroperitoneal mature teratoma in a young lady managed at Pakistan kidney and Liver Institute, Lahore.

Renal Oncocytoma and Pelvic Urothelial Carcinoma in a Nephrectomy Specimen of a 72-Year-Old Patient.

We present the case of a 72-year-old gentleman who presented with a left renal mass. His Computerized Tomography Angiogram showed an 11.8 x 11.3 cm mass involving the upper pole of the left kidney. The mass showed a central stellate scar. There was no locoregional lymphadenopathy. His radical nephrectomy specimen was received in our lab. Sectioning showed a large tumor in the upper pole with a central stellate scar. Microscopically, it showed sheets and nests of round cells with eosinophilic cytoplasm and round nuclei. It was positive for CD117 and negative for CK7. The sections from the renal pelvis showed a urothelial carcinoma arising from the urothelial lining and infiltrating the muscular wall of the renal pelvis. This tumor was positive for CK7 and GATA3. In this case report, we present a rare collision tumor of renal oncocytoma and pelvic urothelial carcinoma.

Renal cell carcinoma presenting as painless jaundice and unintentional weight loss.

Painless jaundice and unexplained weight loss is an exceedingly rare presentation for renal cell carcinoma (RCC). Such a presentation is more typical of a hepatocellular pathology. Stauffer syndrome is a paraneoplastic syndrome seen in RCC and is characterized by deranged hepatic enzymes and in association with fever, fatigue and weight loss. These symptoms typically resolve following nephrectomy. The predominant picture of this syndrome is that of an anicteric patient. Here we report the case of a 48 year old man who presented with a 3 week history of painless jaundice, malaise, anorexia and unintentional weight loss of 10 kilograms. Imaging revealed a solid right renal mass measuring 11 cm × 11 cm × 14 cm. There were also findings consistent with the presence of an inferior vena cava thrombosis and multiple pulmonary lesions. Biopsy confirmed the pulmonary lesions as metastatic clear cell renal carcinoma. Following multi-disciplinary discussion, cytoreductive nephrectomy was recommended to the patient, however multiple paraneoplastic syndromes subsequently developed and the patient experienced hypertension, severe coagulopathy and hypercalcaemia. Subsequently, the patient opted for supportive and palliative care. The patient died 2 weeks after initial presentation. Paraneoplastic syndromes associated with RCC are often underdiagnosed due to their variety and often non-specific nature. Paraneoplastic syndromes may lead to patient presentation, where they often suggest advanced or metastatic disease, and those caring for such patients should remain vigilant as further syndromes may complicate patient care.

Strategies to maximise patient comfort during extracorporeal shockwave lithotripsy - A randomised controlled trial.

BACKGROUND/PURPOSE OF STUDY: We aim to assess if distraction techniques improve patient comfort tolerability of SWL. METHODS: We carried out a prospective randomised controlled trial of SWL-naïve patients attending for treatment. Patients were randomised into three groups and offered oral analgesia as standard of care. Group 1 (n = 19) received stress balls to squeeze during treatment. Group 2 (n = 19) listened to music during treatment. Group 3 (n = 17) received standard of care only. All patients completed a validated health anxiety inventory score prior to treatment. All patients completed a validated pain questionnaire and visual analogue scale (VAS) after treatment. Primary outcomes were completion of SWL treatment and pain score results. RESULTS: 55 patients attending for SWL were randomised. There was no difference in stone size or position, presence of a stent, height or weight between the groups. VAS scores were lower in controls compared to Group 1 (1.93 vs 3.69, p = 0.08). On subgroup analysis of non-anxious patients, pain questionnaire scores were lower in controls compared to Group 1 (2.58 vs 4.77, p = 0.06). VAS scores were lower in patients who received optional analgesia alone than in patients who received stress balls alone (1.92 vs 4.07, p = 0.05). Across all subgroups, pain scores were lower in the control group compared to the distraction groups, but did not achieve significance. CONCLUSIONS: In conclusion, distraction techniques should not replace standard of care for analgesia during SWL. This study was registered with clinicaltrials.gov (identifier NCT03379922).

Chromosomal Breakage in Fanconi Anemia and Consanguineous Marriages: A Social Dilemma for Developing Countries.

Introduction A clear picture of the prevalence of Fanconi anemia is not known due to limited studies and research of the subject. This study will detect the frequency of positive chromosomal breakage in pediatric aplastic patients and provide the evidence-based guidelines which help in consideration of appropriate treatment and awareness to the society. Methods A total of 104 aplastic anemia patients were recruited of age <18 years whose samples were tested for chromosomal breakage with mitomycin C (MMC). History of consanguinity between parents were documented for all the patients referred to us. Result Out of 104 diagnosed aplastic anemia patients, 35 (33.7%) patients were found to be Fanconi positive. Mean age of all hypoplastic patients for aplastic anemia and Fanconi anemia was 10.7 ± 4.5 and 10.6 ± 3.5, respectively. Male preponderance was found to be higher (64, 61.5%) as compared to females (40, 38.5%) in aplastic patients. The male to female ratio was observed as 2.5:1 in Fanconi patients while 1.3:1 in non-Fanconi aplastic patients. Parental consanguinity was observed in 33 (94.2%) with Fanconi anemia. Conclusion Fanconi anemia accounts for significant number of patients with hypoplastic bone marrow, therefore consanguineous marriages should be avoided through mass education in Pakistan.

Outcomes from the Introduction of a Combined Urology Outpatient Clinic.

BACKGROUND: A combined urology clinic staffed by four consultants and four non-consultant hospital doctors (NCHDs) was introduced in our institution in October 2015. This clinic is supported by a pre-clinic radiology meeting and a synchronous urology clinical nurse specialist (CNS) clinic with protected uroflow/trial of void slots. Herein, we report on the outcomes of this clinic in comparison with the standard format of urology outpatient review. METHODS: We carried out a retrospective review of clinic attendances from May to July 2016. We recorded the number of new and return attendances, which team members had reviewed the patient and patient outcomes. We also calculated the waiting times for new patients to be reviewed in the outpatient clinic. RESULTS: The combined urology clinic reviewed an average of 12 new and 46 return patients per clinic. The standard urology clinic reviewed an average of 8 new and 23 return patients per clinic. 54% of patients were seen by a consultant in the combined urology clinic, and 20% of patients were seen by a consultant in the standard urology clinic. The rate of patient discharge for new patients was 14.8% in the combined clinic compared to 5.9% in the standard clinic. Overall patient outcomes are outlined in the table. The waiting time for review of new patients in the combined clinic was reduced by 39% from 144 days to 89 days over a one-year period. CONCLUSIONS: The introduction of a combined urology outpatient clinic with the support of pre-clinic radiology meeting and synchronous urology CNS clinic facilitates patient discharge.

A Case of Migrating "Saf-T-Coil" Presenting With a Vesicovaginal Fistula and Vesicovaginal Calculus.

Intrauterine devices (IUDs) are reliable method for contraception. Although, they are generally regarded as safe, serious consequences may occur in case of uterine perforation or intravesical migration. We present a rare case of a 74 year old lady with a forgotten IUD for 42 years resulting in intravesical migration, formation of vesicovaginal fistula (VVF) without uterine perforation, complete urinary incontinence, recurrent urinary tract infections (UTIs) and a large vesicovaginal calculus.

Paediatric sutureless circumcision--an alternative to the standard technique.

INTRODUCTION: Circumcision is one of the most commonly performed surgical procedures in male children. A range of surgical techniques exist for this commonly performed procedure. The aim of this study is to assess the safety, functional outcome and cosmetic appearance of a sutureless circumcision technique. METHODS: Over a 9-year period, 502 consecutive primary sutureless circumcisions were performed by a single surgeon. All 502 cases were entered prospectively into a database including all relevant clinical details and a review was performed. The technique used to perform the sutureless circumcision is a modification of the standard sleeve technique with the use of a bipolar diathermy and the application of 2-octyl cyanoacrylate (2-OCA) to approximate the tissue edges. RESULTS: All boys in this study were pre-pubescent and the ages ranged from 6 months to 12 years (mean age 3.5 years). All patients had this procedure performed as a day case and under general anaesthetic. Complications included: haemorrhage (2.2%), haematoma (1.4%), wound infection (4%), allergic reaction (0.2%) and wound dehiscence (0.8%). Only 9 (1.8%) parents or patients were dissatisfied with the cosmetic appearance. CONCLUSION: The use of 2-OCA as a tissue adhesive for sutureless circumcisions is an alternative to the standard suture technique. The use of this tissue adhesive, 2-OCA, results in comparable complication rates to the standard circumcision technique and results in excellent post-operative cosmetic satisfaction.

Colonic pseudo-obstruction in sickle cell disease.

A young Arab woman with sickle cell-beta0-thalassemia disease developed acute colonic pseudo-obstruction that became chronic but showed some response to hydroxyurea. There was no evidence of microvascular or macrovascular occlusion. We also report the case of an Arab man with sickle cell anemia who presented with acute colonic pseudo-obstruction from which he recovered completely within a few days. Although the development of pseudo-obstruction in these two cases seems to have been a complication of sickle cell disease, its pathogenesis remains unclear. There are several reports of ischemic and inflammatory disorders of the colon complicating sickle cell disease; however, these two cases represent the first descriptions of large-bowel pseudo-obstruction in this hemoglobinopathy [corrected].