Tunisian Recommendations for resumption of Reproductive Medicine activity in the Covid-19 pandemic.

The activity of the Reproductive Medicine poses a dilemma in this pandemic Covid-19. In fact, this is a theoretically non-emergency activity except for fertility preservation with oncological reasons. The majority of fertility societies in the world such as the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) recommended stopping the inclusion of new patients and continuing only the In Vitro Fertilization (IVF) cycles that have already been initiated by promoting Freeze-all as much as possible. Initilaly, the "Société Tunisienne de Gynécologie Obstétrique" (STGO) issued national recommendations that echo the international recommendations. These recommendations were followed by the majority of IVF center in Tunisia. However, a number of new data are prompting us to update these recommendations.

Superselective embolisation of bilateral superior vesical arteries for management of intractable hematuria in context of metastatic bladder cancer.

Hematuria due to locally advanced or metastatic bladder cancer is a common condition and is often a management problem. Percutaneous embolisation is a mini-invasive option to handle this situation. We report a case of a patient with a metastatic bladder cancer and who presented with an abundant hematuria and severe anemia. After failure of endoscopic resections and "flush" of radiotherapy haemostatic and refusal of cystectomy by the patient, he was treated by superselective embolisation of bilateral superior bladder arteries with excellent immediate results. The technique is safe and effective in the short term. The long-term effectiveness requires further investigation.

[Rare complication of renal transplantation: Emphysematous pyelonephritis]. / Complication rare de la transplantation rénale : la pyélonéphrite emphysémateuse.

Emphysematous pyelonephritis is a necrotizing infection of the renal parenchyma and peri-renal tissues, characterized by the presence of air within the parenchyma of the urinary tract and peri-renal space. This is a severe complication, which involves the functional prognosis of the kidney and the patient's prognosis. The emphysematous pyelonephritis is a rare complication of renal transplantation. Its gravity is linked particularly to the fragility of immunosuppressed patients. The authors report the case of an emphysematous pyelonephritis having occurred 9 months after transplantation in a patient 58 years. The evolving risks and therapeutic modalities will be outlined and discussed.

Clear Cell Adenocarcinoma of the Female Urethra, Mimicking Cystocele.

Clear cell adenocarcinoma of the urethra is an extremely rare neoplasm mainly described in women. Anterior pelvic exenteration was the treatment performed in most reported cases. It seems to have poorer prognosis than urothelial carcinomas.

[Results of conservative management of emphysematous pyelonephritis]. / Résultats du traitement conservateur de la pyélonéphrite emphysémateuse.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a rare and severe, necrotizing infection of the kidney. Diagnosis should be precocious based on computed tomography (CT). Its management remains controversial and its treatment is currently increasingly conservative. The aim of this paper is to discuss the conservative treatment of this disease through our experience in 21 patients. MATERIAL AND METHODS: A retrospective analysis including 21 patients managed conservatively for an emphysematous pyelonephritis in our department from January 2010 to April 2015. Follow-up ranged from three to 24 months. RESULTS: Of the 24 patients, seven belonged to class 1, twelve to class 2 and two to class 4. Obstruction of the upper urinary tract was found in 16 cases. On the risk factor stratification, thrombocytopenia was found in five cases, renal function impairment in 10 cases and a septic shock in four cases. All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad-spectrum antibiotics. Drainage of the urinary tract was performed by double-J stent in 14 patients and with ureteral catheter in six patients. One patient had urinary distension secondary to a urethral stricture with bilateral emphysematous pyelitis. In this case, drainage consisted in suprapubic bladder catheter only. The outcome was favorable in 18 patients and the control CT showed a decline or complete disappearance of gas in urinary tract and/or renal parenchyma after an average period of 12 days. A secondary nephrectomy was performed in two cases. Specific mortality rate was zero. CONCLUSION: PNE remains a severe infection involving the vital prognosis. Computed tomography makes an early diagnosis. Treatment should be conservative based on the association of medical intensive care and drainage, percutaneous or endoscopic, urgently. Nephrectomy should be reserved for extensive forms with multiple organ dysfunction or failure of conservative treatment.

Bilateral Orbital Metastasis of Prostatic Adenocarcinoma.

Despite the high incidence of prostate carcinoma, metastases of the uvea are very rare and bilateral localization is even more. We report here the case of a 77-year-old man diagnosed with a metastatic prostate carcinoma. Two months later, he presented a decreased vision in his right eye and blurred vision in the left eye relevant to metastatic lesion on his right iris and left choroidal metastasis. The urologist should evoke possibility of ocular metastasis in patients with prostate cancer presenting visual disorders.

Vasitis: An Uncommon Diagnosis Mimicking Incarcerated Inguinal Hernia.

Vasitis or inflammation of the vas deferens is a rarely described condition. Clinically, it presents with nonspecific symptoms that can be confused with other more common conditions, especially an incarcerated inguinal hernia. The diagnosis may be suggested by ultrasound or, more precisely, by computed tomography.

[Retroperitoneal cystic lymphangioma: about 5 cases and review of the literature]. / Le lymphangiome kystique rétropéritonéal: à propos de 5 cas et revue de la littérature.

Cystic lymphangioma is a rare, benign malformation of the lymphatic vessels which may be observed on various locations. Retroperitoneal location is less common than mesenteric location. Cystic lymphangioma has a polymorphic clinical presentation. Diagnosis is based on imaging but requires histological confirmation. Surgery is the treatment of choice. The aim of our study is to analyze the clinical manifestations, complications, diagnostic and therapeutic aspects of this tumor. We report a case series of 5 patients with retroperitoneal cystic lymphangioma (4 women and 1 man) operated in our department between the years 2004 and 2014. Their medical records were reviewed retrospectively. Follow-up was based on clinical examination and abdominal CT scan. The average age was 45 years. The mean follow-up was 32.6 months. The most common symptoms indicative of retroperitoneal cystic lymphangioma were pains and/or an abdominal mass. Abdominal CT scan was the most useful diagnostic test. Total resection was immediately achieved in 4 patients and it was deferred for up to 5 years in one patient. He underwent annual ultrasound monitoring. One patient underwent nephrectomy. No recurrence or complications were noted in 5 patients. Retroperitoneal cystic lymphangioma is a rare condition. Its therapeutic management is based on complete resection in patients with symptomatic lesions or complications, in order to limit the risk of recurrence. Complete resection may be deferred in asymptomatic patients.

The effect of body mass index at the time of donation on postoperative and remote consequences of nephrectomy in 189 living-related kidney donors.

OBJECTIVE: To analyse the effects of baseline body mass index (BMI) on the postoperative and remote consequences of nephrectomy in living kidney donors, as body weight is conventionally used as an exclusion criterion for kidney donation and a BMI of <35 kg/m(2) is often required. PATIENTS AND METHODS: We retrospectively studied 189 living-related kidney donors who had their nephrectomy between 1986 and 2009 in our urology department. We recorded the BMI at the time of donation, and analysed variables after surgery, and clinico-biological factors remotely. The effect of the initial BMI after surgery and much later after nephrectomy was assessed. RESULTS: The mean follow-up was 9.28 years. The mean (range) BMI at the time of donation was 26.5 (18.5-41.1) kg/m(2); 33% of donors were overweight (BMI 25-30) and 21% were obese (⩾30), with 10.5% having a BMI of >35 kg/m(2). The duration of hospitalisation was not related to the BMI. There was no significant difference between the mean BMI of donors with a simple postoperative history and donors who had complications after surgery. Among obese donors, only 7.7% had a complication, which was a surgical-site infection in all cases. The baseline BMI was higher among donors who maintained normal renal function and no proteinuria than in donors with impaired renal function and/or proteinuria; the difference was not significant. The occurrence of hypertension or diabetes was independent of baseline BMI. Donors with dyslipidaemia had no significantly greater baseline BMI than those with no dyslipidaemia. CONCLUSION: The BMI at the time of kidney donation does not seem to influence the short- or long-term consequences of nephrectomy in living donors.

Retrovesical hydatic cyst: About 4 cases.

INTRODUCTION: The hydatid cyst is a real public health problem in Tunisia. The retrovesical localization is rare. It is considered an aberrant or ectopic location defined by the development of the parasite in the subvesical and retrovesical fat. METHODS: From 2004 to 2013, 4 patients with retrovesical hydatid cyst were hospitalized and operated in the Department of Urology at the Charles Nicolle hospital of Tunis in Tunisia. The average patient age was 40.75 years (range: 23-76). Signs of bladder irritation were the most frequent presenting complaint. No cases of hydaturia were noted. The diagnosis was made on the ultrasound and the computed tomographic urography. Hydatid serology was positive for 3 patients. In 3 cases, a hydatid cyst of the liver was associated. A total cysto-pericystectomy was performed for 1 patient, for others it was partial. RESULTS: The postoperative course was uneventful. No urinary fistula or infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation. CONCLUSION: Retrovesical location of hydatid cyst is rare and treatment is primarily surgical.

Anatomical variations of renal venous vascularisation. A study of 71 three-dimensional kidney endocasts.

BACKGROUND: A better understanding of the anatomy of the renal vein and its relationship with the arterial and excretory systems can prevent intra operative complications. METHODS: Three-dimensional endocasts of intrarenal vessels and renal collecting systems were obtained from fresh cadavers, by injecting a polyester resin coloured with different pigments. A total of 71 endocasts were studied: 37 right kidneys and 34 left kidneys. RESULTS: Renal vein was unique in 88% of cases and double in 11% of cases. It was formed in 52% of cases by 3 trunks. Intrarenal veins anastomosed together to form 2 levels of arcades in 28% of cases and 3 levels in 71% of cases. The venous drainage of the upper pole was provided by two anterior and posterior plexus in 38% of cases, and by a single anterior plexus in 61% of cases. In 22% of cases, the venous drainage of the lower pole was provided by both an anterior and a posterior plexus, and in 77% of cases, there was only an anterior plexus. Renal artery was posterior to the vein in 66% of cases. It was anterior to the vein in 29% of cases, and located directly above it in 4% of cases. In 60% of cases, we noted a close relationship between the anterior surface of the ureteropelvic junction and the lower branch of the renal vein. CONCLUSION: Venous vascularisation of the kidney appears to be variable and its relationship with the arterial and the excretory systems may be complex.

Efficacy and tolerance of one-third full dose bacillus Calmette-Guérin maintenance therapy every 3 months or 6 months: two-year results of URO-BCG-4 multicenter study.

OBJECTIVES: To assess bacillus Calmette-Guérin maintenance treatment schedule for non-muscle invasive bladder cancer at 2 years, using one-third of the full dose and fewer instillations every 3 months or 6 months. METHODS: This was a prospective, randomized, multicenter study. All patients had an intermediate- or high-risk non-muscle invasive bladder cancer. They received three weekly instillations of one-third dose bacillus Calmette-Guérin every 6 months (group I) and two weekly instillations every 3 months (group II) during 3 years. In the two schedules we assessed efficacy, tolerance, leukocyturia and prostate-specific antigen. RESULTS: No significant difference was observed between the two groups for recurrence at 6, 12 or 18 months. At 2 years, tumor recurrence was observed in 10.9% and muscle invasion in 2.9% of cases. Bacillus Calmette-Guérin tolerance was comparable - the adverse events score was 0.8 in group I and 1 in group II (P = 0.242). No statistical correlation was observed between the adverse events score over 2 years, either for leukocyturia (P = 0.8891) or prostate-specific antigen level (P = 0.7155). Leukocyturia level was not significantly associated with tumor recurrence or progression. CONCLUSION: One-third dose maintenance bacillus Calmette-Guérin is effective with no impact on tumor recurrence or muscle invasion. Furthermore, there seems to be no difference in tumor response or side-effects between patients receiving two or three maintenance instillations every 3 months or 6 months. In clinical practice, the use of leukocyturia or total prostate-specific antigen levels do not appear to be useful in predicting bacillus Calmette-Guérin toxicity.

Pseudotumoral Eosinophilic Cystitis.

Eosinophilic cystitis is a rare inflammatory disease of the bladder which origin and pathogenesis are unknown. Since the first description in 1960, hundreds of cases have been reported, 20 Pseudotumor forms. We report a case of cystitis eosinophils in tumor-form, a patient of 72 years without urological or allergic history. The patient was treated with endoscopic resection alone. The outcome was favorable with disappearance symptoms and no recurrence at 1, 3 and 6 months controls. We carry a literature review of cystitis eosinophils on the different clinical manifestations, the means diagnostic and therapeutic modalities.

Discovery of Renal Tuberculosis in a Partial Nephrectomy Specimen Done for Renal Tumor.

The association of renal cancer and renal tuberculosis is uncommon. While the incidental discovery of renal cell carcinoma in a tuberculous kidney is a classical finding, the discovery of tuberculous lesions after nephrectomy for cancer is exceptional. We report the case of a female patient aged 60 who had a partial nephrectomy for a 5 cm exophytic kidney tumor. Pathological examination concluded that renal clear cell carcinoma associated with follicular caseo tuberculosis.

Social aspects of kidney donation in Tunisia: a study of 189 living related donors.

INTRODUCTION: Our aim was to study the demographic and social characteristics of 189 living related kidney donors in Tunisia, and explore some of the social consequences of kidney donation. METHODS: This is a descriptive retrospective study of 189 living related kidney donors who had their nephrectomy in Charles Nicolle Hospital between 1986 and 2009. The demographic and social characteristics at the time of donation were studied and changes in the social and occupational status after donation were assessed. RESULTS: The average age at the time of donation was 41.8 ± 12.1 years (range: 20-67 years). Female predominance (59.2% of cases) was noted. Donors were siblings in 46% of cases, parents in 42% of cases and spouses in only 9% of cases. There were more mothers than fathers, more wives than husbands, but fewer sisters than brothers. Twenty-six percent of donors were illiterate and 40% were unemployed at the time of donation. After donation, the social status remained stable for 70% of donors. No divorces were reported. The occupational status was unchanged in 94% of cases. Sixteen percent of female donors had at least one pregnancy after nephrectomy. Nearly 90% of surveyed donors whose recipients were alive at the time of the survey were still in favor of kidney donation. CONCLUSIONS: Women play an important role in living related kidney donation in Tunisia. Family situation and occupational status did not seem to be compromised after nephrectomy, and most donors were willing to donate if the decision was to be repeated.

Seminal vesicle agenesis: An uncommon cause of azoospermia.

Seminal vesicle malformations are a rare cause of obstructive azoospermia, often associated with other internal genitalia and upper urinary tract birth defects. We report 5 new cases of seminal vesicle agenesis in men presenting with hypospermia and azoospermia. Imaging showed seminal vesicle unilateral agenesis in all patients. The remaining seminal vesicle was hypoplastic in 3 cases, dilated in 1 case and with abnormally thick content in another case. Vas deferens agenesis was observed unilaterally in 2 patients and bilaterally in 2 other patients. No renal malformations were detected. Genetic study showed in all cases a 46 XY karyotype without any microdeletions. A single heterozygous cystic fibrosis transmembrane regulator gene mutation was diagnosed in 1 man, but not found in his partner. Intracytoplasmic sperm injection using sperm from a testicular biopsy was performed in 3 couples, without success.