Pelvic fracture urethral injury in adolescents - Predictors of outcomes and surgical complexity.

INTRODUCTION: Pelvic fracture urethral injury (PFUI) is more severe in younger individuals. The adolescent group is prone to protracted morbidity due to severity of the injury and its impact on lifestyle. Hence, treatment options and data on outcomes are crucial in planning management. The adolescents are a subgroup in several series of PFUI, but literature exclusively studying this group is sparse. MATERIALS & METHODS: A retrospective review of all adolescents (aged between 10 and 19 years as defined by WHO) who underwent surgical repair for PFUI between January 2005 and December 2019 was conducted. Success was defined as a bell-shaped urine flow curve and Qmax of >15 ml/s, no evidence of re-stricture (on cystoscopy/MCU), and no re-intervention. Measurements of the length of the urethral defect and bulbar urethra were done using a digital scale by the radiologist from micturating cystourethrogram (MCU). The Gapometry/Urethrometry (GU) index was calculated as the ratio of the length of the urethral defect to that of the bulbar urethra. Data was analysed using SPSS software version 20.0 and Stata Version 16. The primary outcome was the success of anastomotic urethroplasty. Secondary outcomes were evaluating factors predicting operative complexity (simple perineal versus elaborate perineal approach). RESULTS: We studied 22 patients, out of which 8 were referred following prior failed intervention elsewhere. The mean age was 16.5 + 2.7 years. All the patients were treated using a perineal approach with an overall success rate of 90.9%. Two patients had a failure and were managed with Endoscopic Internal Urethrotomy (EIU), and urethral dilatation. The median follow-up was 24 months. All 8 patients with prior failed interventions had a successful outcome. Twelve patients required inferior pubectomy (elaborate perineal approach). The median length of the urethral defect (2.3 cm IQR- 1.45,3.30 vs. 1 cm, IQR-0.65, 1.6) and the mean GU index (0.45 ± 0.18 cm vs. 0.25 cm ± 0.12 cm) were significantly higher in those who required an elaborate perineal approach. CONCLUSIONS: The perineal approach for surgical repair (anastomotic urethroplasty) of pelvic fracture urethral injury has a favourable success rate of 90.9% in adolescents. Re-do anastomotic urethroplasty for prior failed repairs also had a high success rate of 100%. Cases requiring an elaborate perineal approach were associated with a significantly higher Gapometry/Urethrometry Index (>0.45) and length of the urethral defect (>2.3 cm). This information may assist in patient counselling and preparation for additional steps during repair.

Clinical Presentation, Microbiological Characteristics, and Their Implications for Perioperative Outcomes in Xanthogranulomatous Pyelonephritis: Perspectives from a Real-World Multicenter Practice.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic granulomatous infection of renal parenchyma. XGP is often associated with long-term urinary tract obstruction due to stones and infection. We aimed to analyze the clinical, laboratory, and microbial culture profiles from bladder and kidney urine of patients who were diagnosed with XGP. Databases of patients with histopathological diagnosis of XGP from 10 centers across 5 countries were retrospectively reviewed between 2018 and 2022. Patients with incomplete medical records were excluded. A total of 365 patients were included. There were 228 (62.5%) women. The mean age was 45 ± 14.4 years. The most common comorbidity was chronic kidney disease (71%). Multiple stones were present in 34.5% of cases. Bladder urine culture results were positive in 53.2% of cases. Kidney urine culture was positive in 81.9% of patients. Sepsis and septic shock were present in 13.4% and 6.6% of patients, respectively. Three deaths were reported. Escherichia coli was the most common isolated pathogen in both urine (28.4%) and kidney cultures (42.4%), followed by Proteus mirabilis in bladder urine cultures (6.3%) and Klebsiella pneumoniae (7.6%) in kidney cultures. Extended-spectrum beta-lactamases producing bacteria were reported in 6% of the bladder urine cultures. On multivariable analysis, urosepsis, recurrent urinary tract infections, increased creatinine, and disease extension to perirenal and pararenal space were independent factors associated with positive bladder urine cultures. On multivariable analysis, only the presence of anemia was significantly more frequent in patients with positive kidney cultures. Our results can help urologists counsel XGP patients undergoing nephrectomy.

Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study.

PURPOSE: To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS: A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS: A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION: Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

Systemic Bacillus Calmette-Guerin infection secondary to inadvertent intravenous injection.

Disseminated BCG infection (BCG-osis) secondary to intravesical BCG given for high-risk non-muscle invasive bladder cancer has been reported. We report the successful management of two cases of BCG-osis secondary to inadvertent intravenous BCG injection. Both cases are recurrence-free at the follow-up of 12 and 18 months, respectively. There is only one such case reported in English literature so far to the best of our knowledge.

Successful management of small cell neuroendocrine carcinoma of the ureter with neoadjuvant chemotherapy and adjuvant chemoradiation: case report and literature review.

Neuroendocrine tumours (NETs) of the urinary tract are rare, and the urinary bladder is the the most common primary site. Primary ureteric NET is rarer with under 80 cases reported in the literature thus far. Most of these tumours are of the high-grade small cell neuroendocrine carcinoma subtype, which has a worse prognosis. Neoadjuvant chemotherapy has a proven role in the management of NET of the bladder as it downstages the tumour, which may add to significant recurrence-free survival and overall survival. We report the successful management of a patient with locally advanced small cell neuroendocrine carcinoma of the ureter, who had a pathological complete response after neoadjuvant chemotherapy with etoposide and cisplatin. He subsequently received adjuvant chemotherapy followed by radiation and is recurrence-free at a follow-up of 1 year.