Out-of-Hospital Cardiac Arrest With Bilateral Urinary Tract Injury Resulting From Cardiopulmonary Resuscitation: A Case Report.

A man in his 70s suffered cardiac arrest, and his family initiated cardiopulmonary resuscitation after placing an emergency call. The initial waveform of the automated external defibrillator performed by emergency medical technicians revealed ventricular fibrillation. The patient received cardiovascular life support, including direct current countershock, and was transported to the hospital. Upon arrival, he underwent extracorporeal cardiopulmonary resuscitation using an automated chest compression device. Additionally, an intra-aortic balloon pumping was introduced after coronary angiography and percutaneous coronary intervention. Plain computed tomography images revealed leakage of the contrast medium used during coronary angiography in the bilateral renal pelvis and perirenal area as well as bladder retention. Furthermore, a urine test revealed gross hematuria. There were no findings of prostatic hypertrophy or urinary tract disease. Based on the patient's clinical course, injury caused by chest compression was the most likely etiology of urinary tract injury, which must be considered in such patients. The patient was discharged with cerebral performance category 1, without any complication except urinary tract.

Spectrum of Alport syndrome in an Indian cohort.

BACKGROUND: Next-generation sequencing has enabled non-invasive diagnosis of type IV collagen disease in clinical settings other than the typical presentation of Alport syndrome (AS). METHODS: We reviewed the clinical and histological records of children diagnosed with Alport syndrome based on next-generation sequencing. Variants on clinical exome sequencing were categorized using ACMG 2015 criteria. RESULTS: During 2015-2023, we found 43 patients (34 boys) with 39 variants in COL4A5 (n = 27), COL4A4 (n = 7), and COL4A3 (n = 5). Thirty, 8, and 5 patients had X-linked, autosomal recessive, and autosomal dominant disease, respectively. The median (IQR) age and eGFR at diagnosis were 10 (7-13) years and 100.1 (59-140) ml/min/1.73 m2, respectively. Fifteen patients were initially diagnosed with steroid-resistant nephrotic syndrome. Alport syndrome was suspected in these patients due to persistent microscopic hematuria, eGFR < 90 ml/min/1.73 m2, characteristic histology, and/or non-response to immunosuppression. Of 26 patients who underwent kidney biopsy, light microscopy revealed focal segmental glomerulosclerosis, minimal change disease, and mesangial proliferative glomerulonephritis in 9, 9, and 8 patients, respectively. Electron microscopy (n = 18) showed characteristic glomerular basement membrane changes and/or foot process effacement in 12 and 16 cases, respectively. Twenty-one patients (48.8%) had high-frequency sensorineural hearing loss, while two had lenticonus. Twelve patients progressed to chronic kidney disease stages 4-5. Median survival (IQR) with eGFR > 30 ml/min/1.73 m2 was 15.6 (13-18) years. CONCLUSIONS: The phenotype of Alport syndrome varies from asymptomatic urinary abnormalities to hematuria, proteinuria and/or low eGFR, and steroid-resistant nephrotic syndrome. Adverse outcomes are common, especially in boys with X-linked disease.

Urologist's role on smoking cessation counseling in patients presenting with asymptomatic hematuria: single academic institution experience.

Background: Bladder cancer is known to be strongly associated with smoking tobacco products. Urologists thus have an imperative role in providing smoking cessation counseling to patients to prevent the development of bladder cancer, recurrence, and other morbidities associated with smoking. Asymptomatic hematuria is often a presenting clinical symptom that warrants further investigation. This study aims to determine if smokers who have an episode of asymptomatic hematuria are more likely to quit smoking if urologists counsel them on formal smoking cessation. Methods: We completed a retrospective chart review of patients who presented for asymptomatic hematuria at our institution between January 2017 and March 2020. A total of 435 patients were identified, 134 of which were active smokers at the presentation time. We recorded smoking status at initial presentation, documentation of smoking cessation counseling, and smoking status at one year follow-up. Fischer's exact test was used for analysis. Statistical significance was set by convention at P<0.05. Results: The percentage of patients presenting with an episode of asymptomatic hematuria that quit or cut back at one year follow-up was 24.2% [95% confidence interval (CI): 13.8%, 34.7%]. In assessing the effect of formal smoking cessation counseling, 33.3% of patients with documented smoking cessation counseling quit or cut back at one year, compared to 22.8% of patients with no documented counseling. However, these findings were not statistically significant (P=0.68). Of note, smoking cessation counseling was recorded in 19 active smokers (14.2%), and 68 active smokers (50.7%) did not receive follow-up at one year. Conclusions: Smoking cessation remains a challenging endeavor for both patients and urologists. Formal counseling did not significantly contribute to quitting rates among patients, and rates of documented counseling from providers were unsubstantial. Urologists should use hematuria work-up visits as an opportunity to counsel patients on smoking cessation.

The impact of age, sex, comorbidities, and use of antithrombotics on the clinical course severity among patients surgically treated for urinary bladder tamponade.

Objectives: To examine the relationship between clinical patient characteristics and the severity of the disease course in patients hospitalized due to urinary bladder tamponade. The severity was assessed based on hemoglobin (Hgb) levels upon admission, the requirement for red blood cell transfusion (RBCT), and length of hospital stay. Materials and Methods: A retrospective analysis was conducted at a single center, involving 75 patients who were hospitalized due to urinary bladder tamponade. Results: Bladder cancer (33.3%) and postoperative bleeding (28%) were the most common causes of bladder tamponade. Patient age exhibited a negative correlation with Hgb levels upon admission (r = -0.539, P < 0.001) and a positive correlation with the quantity of administered RBCT units (r = 0.425, P < 0.001) and the length of hospitalization (r = 0.541, P < 0.001). The number of comorbidities exhibited a negative correlation with Hgb levels upon admission (r = -0.555, P < 0.001) and a positive correlation with the quantity of administered RBCT units (r = 0.522, P < 0.001) and the length of hospitalization (r = 0.543, P < 0.001). Patients taking antithrombotic therapy (AT) had lower mean Hgb levels on admission (87.8 ± 13.5 g/L vs. 107.6 ± 18.7 g/L, P < 0.001), a higher mean number of administered RBCT units (2.8 ± 2.1 vs. 1.1 ± 1.3, P < 0.001) and longer hospitalizations (4.6 ± 1.6 days vs. 3.1 ± 1.1 days, P < 0.001) compared to those not taking AT. Conclusion: Older patients with multiple comorbidities, particularly those taking AT, should be expected to have a more severe clinical course of bladder tamponade. Therefore, special clinical attention is necessary for this vulnerable patient group.

Advancements in Understanding and Managing Radiation Cystitis: A Comprehensive Review.

PURPOSE OF REVIEW: This manuscript aims to provide a comprehensive overview of the pathophysiology, risk factors, prevention strategies, and management options for radiation cystitis. RECENT FINDINGS: Recent studies have shed light on the pathophysiology of radiation cystitis, highlighting the role of inflammation, fibrosis, and vascular damage. Emerging preventive measures like stem cell therapy offer promise, alongside novel treatments such as amniotic bladder therapy and hyperbaric oxygen therapy. This review outlines the latest research on radiation cystitis, covering its pathophysiology, risk factors, prevention, and management. Major findings include insights into the mechanisms of RC development, promising preventive and therapeutic approaches, and the importance of standardized treatment pathways. Future research should focus on identifying genetic risk factors, improving treatment efficacy, and enhancing patient outcomes. This review offers valuable insights for clinicians and researchers, guiding future investigations into radiation cystitis management.

Ureteroarterial fistula - a severe manifestation of urological toxicity with possibly fatal consequences.

AIM: A retrospective audit from a urological center focused on urological fistulas that directly connect with the treatment of gynecological malignancy. Ureteroarterial fistulas, i.e., pathological communication between the ureter and the artery, are discussed in more detail. MATERIALS AND METHODS: Over a period of ten years, from 2011 to 2020, a group of 47 patients with a diagnosis of urinary fistula was retrospectively evaluated. These patients, with a history of treatment for gynecological malignancy, were sent to our clinic from local and non-regional departments in the Czech Republic. We found three cases of ureteroarterial fistula in the presented analysis that focused on urological toxicity of oncogynecological treatment. RESULTS: Within the mentioned period of ten years, we recorded 64 cases of urinary fistulas, and 47 patients (73.4%) were directly related to oncogynecological treatment. In the group with gynecological tumors, we found three patients (6.4%) with a diagnosis of ureteroarterial fistula, two of whom died directly related to this complication (exsanguination). These patients were treated for cervical cancer. All of them underwent radiotherapy during the treatment. CONCLUSION: Ureteroarterial fistulas are the most severe complications that can occur in medicine. This work confirms that we have encountered these cases even recently. Management is highly demanding for patients affected in this way and requires multidisciplinary cooperation. Endovascular intervention methods can control bleeding in emergency situations with non-surgical approaches. However, they are usually the first step towards a definitive surgical solution.

An Interesting Case of Paroxysmal Nocturnal Hemoglobinuria With Renal Involvement.

Paroxysmal nocturnal hemoglobinuria (PNH) is an uncommon genetic disorder that affects red blood cell production, causing symptoms like fatigue, abdominal pain, and shortness of breath. This condition can also result in dark urine and an increased risk of infections. Diagnosis of PNH involves genetic testing and flow cytometry, which can confirm the presence of the condition. Once a diagnosis is confirmed, personalized treatment plans should be developed to effectively manage the symptoms and improve the patient's quality of life. Treatment options for PNH may include bone marrow transplantation, blood transfusions, and the use of recombinant monoclonal antibody, eculizumab. Regular monitoring is also essential to identify and manage any complications that may arise due to this condition. With proper management and treatment, patients with PNH can lead a healthy and fulfilling life. In this case study, we present a young adult male with PNH who also suffers from renal failure, highlighting the importance of personalized care and ongoing monitoring for this complex condition.

Various Presentations of Scrub Typhus: A Case Series.

Scrub typhus is caused by Orientia tsutsugamushi, a Gram-negative coccobacillus. It comprises three strains: Karp, Gilliam, and Kato. Cases of scrub typhus are usually found in the Asia-Pacific region, and their presentation may range from minimal symptoms to multi-organ involvement, with or without the presence of an eschar mark. Varying manifestations of scrub typhus, such as gangrene, meningoencephalitis, anemia with jaundice, and hematuria, have been observed. In the Kumaun region of northern India, there has been a surge in the number of scrub typhus cases. Typically, this disease is accompanied by an eschar mark, but occasionally it can manifest without one. We report a series of four cases presenting with various unusual symptoms such as gangrene of the limbs, meningoencephalitis, jaundice, and hematuria. Serology for scrub typhus should be considered in all patients with acute febrile illness not responding to treatment, especially in mountainous regions, to prevent the associated mortality.

Acquired Hemophilia A Diagnosed Based on Gross Hematuria: A Case Report and Literature Review.

Acquired hemophilia A (AHA) is an acquired bleeding disorder caused by neutralizing antibodies (inhibitors) against Coagulation Factor VIII (FVIII:C), causing sudden hemorrhagic symptoms (i.e., subcutaneous bleeding, intramuscular bleeding, and hematuria). Herein, this study is aimed at presenting a case of AHA diagnosed based on hematuria and reviewing patients who were diagnosed with AHA due to hematuria. A 67-year-old woman was referred to Atsugi City Hospital with painless gross hematuria that began 4 weeks before presentation. Contrast-enhanced computed tomography (eCT) revealed an approximately 2 cm mass in the right renal pelvis, and the patient's activated partial thromboplastin time (APTT) was elevated (61.4 s). The day after the endoscopic biopsy, the patient was in shock due to a large retroperitoneal hematoma. Although her condition stabilized after intravenous radioembolization, she underwent emergency surgeries several times because of rebleeding within the next 3 weeks. At that time, APTT was more prolonged at 106.4 s, and the FVIII:C level was 2%. Mixing tests showed an upwardly convex curve after 2-h incubation, indicating the presence of an inhibitor. Factor VIII inhibitor titer was ≥5.1 Bethesda unit (BU)/mL. A combined product of Plasma-Derived Factors VIIa and X (pd-FVIIa/FX), as second-line hemostatic therapy, as well as cyclophosphamide (CYP), were administered after Recombinant Activated Factor VIIa (rFVIIa) had been ineffective. Following this, the Factor VIII inhibitor titer was undetectable, FVIII:C levels were restored, and APTT decreased to within the normal range. Gross hematuria was significantly alleviated. However, the patient died of cytomegalovirus and fungal infections due to prolonged immunosuppressive therapy. Although AHA diagnosed based on hematuria may have a better prognosis than others, there have been occasional cases with severe outcomes. APTT, detected upon initial hematological testing in patients with hematuria, may be a potential indicator of an existing AHA.

Prolonged detection of BPV2 in urine and blood of papillomatosis-affected cattle not grazing bracken fern.

BPV-2 infection can cause bladder infections in cattle that, when associated with bracken fern consumption, can progress to cancerous bladder tumors and also present as bovine enzootic hematuria (BEH). This study aimed to evaluate the prolonged natural BPV-2 infection in the blood and urine of cattle, excluding bracken fern consumption. Thirteen Girolando papillomatosis-affected cattle with no bracken fern contact history were monitored for 20 months. Blood, urine, and wart samples were collected for BPV-2 detection and clinical laboratory analyses. All animals showed the presence of BPV-2 in papillomas and blood, and 92.85% showed BPV-2 in urine, suggesting viral dissemination in the urinary tract. Despite all animals being infected with BPV-2, none showed BEH signs during the study. Thus, it was observed that BPV-2 infection alone didn't induce BEH over 20 months, implying a complex interaction with environmental factors or genetic predisposition. This underlines bracken fern consumption's critical role in urinary bladder carcinogenesis. The study underscores BEH's pathogenesis complexity, advocating longitudinal studies to comprehend BPV-2's role fully.

Efficacy and Safety of Hyperbaric Oxygen Therapy for Radiation-Induced Hemorrhagic Cystitis: A Systematic Review and Meta-Analysis.

Background: Radiation-induced hemorrhagic cystitis (RHC) is a chronic inflammatory disease in patients undergoing radiation therapy that causes a cluster of symptoms which may have a latent period of months to years. The current non-invasive treatments include drug treatment and hyperbaric oxygen therapy (HBOT), which has been widely applied for RHC so far but with limited evidence. Thus, we conducted a systematic review and meta-analysis to clarify the effects and safety of HBOT for RHC. Methods: A systematic review and meta-analysis were utilized, searching in the databases of Embase, Pubmed, and Web of Science. The primary endpoint of the present study was complete remission of hematuria. The meta-analysis was conducted using a random effects model, and a pooled odds ratio with 95% CI was calculated. Results: A total of 317 studies were searched and fourteen articles with 556 patients were collected. The results showed that a total of 500 patients (89.9%) had symptom improvement, and the pooled results demonstrated that 55% of patients with HBOT had complete remission of hematuria (95% CI 51-59%). Conclusions: A significant improvement of symptoms when treated with HBOT was shown in this meta-analysis for patients with RHC.

Contemporary review of IgA nephropathy.

IgA nephropathy (IgAN) is considered the most common primary glomerulonephritis worldwide with a predilection for Asian-Pacific populations and relative rarity in those of African descent. Perhaps 20%-50% of patients progress to kidney failure. The pathogenesis is incompletely understood. Mesangial deposition of immune complexes containing galactose-deficient IgA1 complexed with anti-glycan IgG or IgA antibodies results in mesangial cell activation and proliferation, inflammatory cell recruitment, complement activation, and podocyte damage. Diagnosis requires a biopsy interpreted by the Oxford criteria. Additional pathologic features include podocytopathy, thrombotic microangiopathy, and C4d staining. Biomarkers predicting adverse outcomes include proteinuria, reduced GFR, hypertension, and pathology. Acceptable surrogate endpoints for therapeutic trials include ongoing proteinuria and rate of eGFR decline. The significance of persisting hematuria remains uncertain. The mainstay of therapy is supportive, consisting of lifestyle modifications, renin-angiotensin inhibition (if hypertensive or proteinuric), sodium-glucose-transporter 2 inhibition (if GFR reduced or proteinuric), and endothelin-receptor antagonism (if proteinuric). Immunosuppression should be considered for those at high risk after maximal supportive care. Corticosteroids are controversial with the most positive results observed in Chinese. They carry a high risk of serious side effects. Similarly, mycophenolate may be most effective in Chinese. Other immunosuppressants are of uncertain benefit. Tonsillectomy appears efficacious in Japanese. Active areas of investigation include B-cell inhibition with agents targeting the survival factors BAFF and APRIL and complement inhibition with agents targeting the alternate pathway (Factors B and D), the lectin pathway (MASP-2), and the common pathway (C3 and C5). Hopefully soon, the who and the how of immunosuppression will be clarified, and kidney failure can be forestalled.

Paediatric diffuse oesophageal leiomyomatosis with Alport syndrome.

Diffuse oesophageal leiomyomatosis is a rare benign disease in the paediatric population. This report highlights a recent clinical case, together with a narrative review of current world literature.An early middle childhood girl with recurrent lower respiratory tract infections for 2 years was noted to have a retrocardiac lesion on chest X-ray, later confirmed to be an oesophageal mass on CT imaging. She underwent an Ivor-Lewis oesophagogastrectomy and a Heineke-Mikulicz pyloroplasty. Pathology examination revealed type I diffuse oesophageal leiomyomatosis. Alport syndrome was later confirmed following an episode of postoperative haematuria, which was corroborated by electron microscopy examination following renal biopsy.With an oesophageal mass lesion and Alport syndrome, oesophageal leiomyomatosis should be suspected in any patient with a clinical history of dysphagia and/or respiratory symptoms. Endoscopic ultrasound-guided tissue biopsy is valuable for diagnosis of all suspected lesions. Surgical resection is mandatory to effect cure.

Evaluating the Safety of Retrograde Intrarenal Surgery (RIRS): Intra- and Early Postoperative Complications in Patients Enrolled in the Global Multicentre Flexible Ureteroscopy Outcome Registry (FLEXOR)

ABSTRACT Purpose To assess the incidence of the most common intra- and early postoperative complications following RIRS in a large series of patients with kidney stones. Methods We conducted a retrospective analysis of patients with kidney stones who underwent RIRS across 21 centers from January 2018 to August 2021, as part of the Global Multicenter Flexible Ureteroscopy Outcome (FLEXOR) Registry. Results Among 6669 patients undergoing RIRS, 4.5% experienced intraoperative pelvicalyceal system bleeding without necessitating blood transfusion. Only 0.1% of patients, required a blood transfusion. The second most frequent intraoperative complication was ureteric injury due to the ureteral access sheath requiring stenting (1.8% of patients). Postoperatively, the most prevalent early complications were fever/infections requiring antibiotics (6.3%), blood transfusions (5.5%), and sepsis necessitating intensive care unit admission (1.3%). In cases of ureteric injury, a notably higher percentage of patients exhibited multiple stones and stone(s) in the lower pole, and these cases were correlated with prolonged lasing and overall surgical time. Hematuria requiring a blood transfusion was associated with an increased prevalence of larger median maximum stone diameters, particularly among patients with stones exceeding 20 mm. Furthermore, these cases exhibited a significant prolongation in surgical time. Sepsis necessitating admission to the intensive care unit was more prevalent among the elderly, concomitant with a significantly larger median maximum stone diameter. Conclusions Our analysis showed that RIRS has a good safety profile but bleeding requiring transfusions, ureteric injury, fever, and sepsis are still the most common complications despite advancements in technology.

Noninvasive Tests for Bladder Cancer Detection and Surveillance: A Systematic Review of Commercially Available Assays.

BACKGROUND: An important reason for the high health care costs associated with bladder cancer is the need for frequent cystoscopy for detection and surveillance of this disease. Cytologic analysis of voided urine specimens can assist, but is too inaccurate to replace cystoscopy. In an effort to create reliable, objective, noninvasive mechanisms for detecting bladder cancer, a number of urine-based molecular tests have been developed with the ultimate goal of reducing the frequency of cystoscopy. OBJECTIVE: To summarize the performance of urine-based biomarker tests, currently commercially available in the US, as part of the initial workup for hematuria and for bladder cancer surveillance. METHODS: In accordance with PRISMA guidelines we performed a systematic review of the literature on the performance of NMP22, BTA, UroVysion, ImmunoCyt/uCyt, CxBladder, and Bladder EpiCheck. Median sensitivity, specificity, negative (NPV) and positive predictive values (PPV) were calculated for each test based on the included studies. RESULTS: Twenty-eight studies met inclusion criteria for the performance of five urine-based biomarker tests in the setting hematuria workup. Median sensitivity ranged from 65.7% -100% and specificity ranged from 62.5% -93.8%. Median NPV ranged from 94.2% -98.3% and PPV ranged from 29% -58.7%. Fourteen studies met inclusion criteria for the performance of six tests in the setting of bladder cancer surveillance. Median sensitivity ranged from 22.6% -92.0% and specificity from 20.5% -97.9%. Median NPV ranged from 52.9% -96.5% and PPV ranged from 48.1% -75.7%. CONCLUSIONS: Our analysis finds that while these tests may provide some clinical utility, none of the assays have thus far demonstrated objective evidence to supplant the gold diagnostic standard.

Potential of an mRNA-Based Urine Assay (Xpert® Bladder Cancer Detection1) in Hematuria Patients - Results from a Cohort Study.

BACKGROUND AND OBJECTIVE: Assessment of patients with hematuria (aH) remains a challenge in urological practice, balancing the benefits of diagnosing a potentially underlying bladder cancer (UCa) against the risks of possibly unnecessary diagnostic interventions. This study analyzes the potential of an mRNA-based urine assay, the Xpert® Bladder Cancer Detection- CE-IVD (Xpert BC-D), in patients with hematuria. MATERIALS AND METHODS: Overall, 368 patients with newly observed painless hematuria and no history of UCa were included in this observational study. Patients received urological workup, including urethrocystoscopy (WLC), upper tract imaging, urine cytology and Xpert BC-D. Patients with positive WLC were recommended to undergo tumor resection (TUR-B). RESULTS: After excluding non-assessable cases, 324 patients were considered for analysis (188 males, 136 females; median age: 61 years). Eight of twenty-eight patients with a positive TUR-B had Ta low grade (LG) tumors; the others were diagnosed with high grade (HG) lesions (Ta: 4, CIS: 2, T1:11, > T1:3). The Xpert BC-D was more sensitive than urine cytology (96% vs. 61%) (p = 0.002). Increased risk ratios (RR) were observed for gross hematuria, gender, urine cytology, and positive Xpert BC-D (all p < 0.05). Age and positive Xpert BC-D remained independent predictors of UCa in multivariate analysis. Simulating a triage with WLC restricted to patients with positive Xpert BC-D could have saved 240 (74.1%) assessments at the cost of missing one pTa LG tumor. CONCLUSIONS: The results suggest a potential role for Xpert BC-D in preselecting patients with hematuria for either further invasive diagnosis or an alternate diagnostic procedure.

Comparative efficacy of palliative radiotherapy dose schedules in advanced bladder cancer-associated gross hematuria.

Introduction: Gross hematuria (GH) in advanced/inoperable bladder cancer patients causes significant morbidity. Patients frequently need multiple transfusions. Hypofractionated radiotherapy (RT) has been shown to be effective in symptom palliation. In this study, we explore the efficacy of various fractionation regimens in these patients. Methods: This single institute retrospective analysis was conducted on 60 consecutive patients treated with palliative RT. Fractionation (single versus multiple) and biologically equivalent doses (BED; high ≥36 Gy versus low <36 Gy) were used to compare the efficacy of various fractionation regimens. The primary outcome was the difference in objective response rate (ORR) between various strata at 2, 4, 8 and 12 weeks. Major secondary outcomes were differences in ORR according to Eastern Cooperative Oncology Group (ECOG) performance status (PS) and tumour node metastases (TNM) stage, and the proportion of patients requiring re-transfusion(s) at 12 weeks. Data were analysed using SPSS 23. Results: Overall ORR at 2, 4, 8 and 12 weeks was 86%, 77%, 67% and 55%, respectively. There was no statistically significant difference in response rates between single or multi-fraction, or high versus low BED groups (All p = >0.05). Moreover, ECOG PS (p = 0.11) or TNM stage (p = 0.58) also had no impact on the response rate at 12 weeks. Nearly one-third (31%) of patients required further transfusions at 12 weeks. Conclusion: RT is an effective modality to control GH. No difference in ORR was found between single fractions versus multiple fractions, or high versus low BED regimens. Single fraction RT can be offered to these patients considering low cost, patient convenience and minimal side effects.

Predicting the Lymphovascular Invasion in Carcinoma Bladder at Transurethral Resection.

INTRODUCTION: Bladder cancer is among the most common malignant neoplasms in the world. Transurethral resection of bladder tumor (TURBT) is considered the standard procedure for diagnosis, staging, and risk classification of bladder tumors. Lymphovascular invasion (LVI) is considered a poor prognostic factor. Its assessment of TURBT is very important for risk stratification and decision-making for further treatment. The purpose of our clinical study is to attempt to predict/assess the correlation between LVI and various preoperative (age, gender, history of smoking, hematuria, urine cytology, and hydronephrosis/hydroureteronephrosis), intraoperative (tumor number, size, and appearance - sessile/ pedunculated) and histopathological (tumor histology, grading, and muscle invasion) factors. METHODOLOGY: In this prospective study, 75 patients with bladder tumors underwent TURBT (standard monopolar TURBT with 1.5% glycine as irrigation solution) in the Department of Urology at Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati between October 2021 and March 2023. Histopathological examination (HPE) reports were looked for the presence or absence of LVI. Accordingly, patients were divided into two groups, i.e., those with LVI and those without LVI. Various preoperative and intraoperative variables were analyzed for each subject in both groups. Statistically significant variables occurring in those patients with LVI compared to those without LVI were considered predictors of LVI in bladder tumors.  Results: Sixteen patients out of 75 (21.33%) had LVI on their histopathology examination. The mean age was 68.19 years in the group with LVI and 64.14 years in the group without LVI. A total of 60 men (80%) and 15 women (20%) were included in our study. Thirteen men (21.7%) and three women (20%) were found to have LVI. We observed a significant association between the appearance of the tumor and LVI. Fifty-four subjects in our study had sessile tumors. Fifteen out of them (27.8%) had LVI, while only one out of 21 patients (4.8%) with pedunculated tumors had LVI (p-value=0.028). 30% of subjects who had high-grade tumors on HPE also had LVI. On the contrary, only one of 25 patients (4%) with low-grade tumors had LVI (p-value=0.010). Our study also showed a significant association between muscle invasion and LVI. Thirty-four (45.3%) and 41 (54.7%) patients had muscle-invasive and non-muscle-invasive tumors, respectively. While 12 (35.3%) patients with muscle-invasive tumors had LVI, only four (9.8%) patients with non-muscle-invasive tumors showed LVI (p-value=0.007). CONCLUSION: We observed that LVI of bladder tumors at first TURBT is significantly associated with tumor grade, tumor appearance, and depth of invasion of the tumor. Though statistically not significant, we further observed that LVI was more commonly found in smokers, patients with hematuria, and larger tumor sizes. We conclude that these factors can be used as reliable predictors of LVI of bladder tumors at their first TURBT.

Case Report: Mechanical hemolysis resulting from left ventricular outflow tract obstruction after aortic valve replacement relieved by transapical beating-heart septal myectomy.

Background: Aortic stenosis (AS) in combination with left ventricular outflow tract obstruction (LVOTO) has occasionally been reported. However, making a precise diagnosis and successfully treating this combination is challenging due to the hemodynamic interaction between the two conditions. Case summary: A 56-year-old male patient who had been diagnosed with severe AS and asymmetric left ventricular hypertrophy underwent aortic valve replacement (AVR) and a conventional septal myectomy. Immediately after the procedure, significant systolic anterior motion and mitral regurgitation developed, necessitating a surgical mitral edge-to-edge repair. Ten days after the procedure, the patient developed hematuria and LVOTO, which was confirmed by echocardiography. Because the LVOTO might have been the cause of the hematuria, the patient underwent alcohol septal ablation, but this had little effect. Three months later, a transapical beating-heart septal myectomy (TA-BSM) was performed in our hospital. Postoperatively, the LVOTO had been significantly ameliorated and the hematuria had resolved. Conclusion: For patients with AS and LVOTO due to a hypertrophic interventricular septum, inadequate amelioration of the LVOTO after AVR may lead to severe hemolytic hematuria. TA-BSM is a minimally invasive, safe, and effective surgical procedure for ameliorating LVOTO in patients with aortic valve prostheses.