Segmental artery angioembolization as an efficient treatment modality for delayed hematuria with normal angiography: two case reports.

BACKGROUND: Percutaneous nephrolithotomy is the most commonly used modality for the removal of kidney stones larger than 2 cm in size. Like other stone removal methods, percutaneous nephrolithotomy also has some complications, including bleeding and delayed hematuria. These complications are improved with conservative management and bed rest most of the time. However, it may require more invasive treatments. Angioembolization following an abnormal renal angiography is an efficient treatment modality for delayed hematuria. Furthermore, nephrectomy is suggested in uncontrolled cases of delayed hematuria when renal angiography is normal. CASE PRESENTATION: We described two cases of uncontrolled delayed hematuria after percutaneous nephrolithotomy and angioembolization were carried out rather than potential nephrectomies. The first case was a 61-year-old Iranian man with left kidney stones, for whom percutaneous nephrolithotomy was planned. The patient was referred to the hospital after discharge with massive hematuria and had normal angiographic findings. An angioembolization was suggested for the patient and was carried out. His hematuria was dramatically improved within 30 minutes, and his hemoglobin level started to increase 2 days later. The second case was a 53-year-old Iranian man with kidney stones who was a candidate for right kidney percutaneous nephrolithotomy. The patient was referred to the hospital 4 days after discharge with a decreased hemoglobin level and massive hematuria. The patient had normal angiographic findings and was planned for angioembolization to control his hemorrhage, which dramatically decreased after the angioembolization within 60 minutes. CONCLUSION: Embolization of the segmental arteries of the targeted calyx can eliminate hematuria of the patient and prevent further nephrectomy.

Haemorrhagic cystitis: a review of management strategies and emerging treatments.

Haemorrhagic cystitis (HC) is characterised by persistent haematuria and lower urinary tract symptoms following radiotherapy or chemotherapy. Its pathogenesis is poorly understood but thought to be related to acrolein toxicity following chemotherapy or fibrosis/vascular remodelling after radiotherapy. There is no standard of care for patients with HC, although existing strategies including fulguration, hyperbaric oxygen therapy, botulinum toxin A, and other intravesical therapies have demonstrated short-term efficacy in cohort studies. Novel agents including liposomal tacrolimus are promising targets for further research. This review summarises the incidence and pathogenesis of HC as well as current evidence supporting its different management strategies.

[Comparison of safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by flexible ure-teroscopy].

OBJECTIVE: To compare the safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by retrograde flexible ureteroscopy. METHODS: A total of 90 patients with 1-2 cm upper ureteral calculi treated in the urology department of Beijing Friendship Hospital from August 2018 to August 2020 were selected as the subjects. The patients were divided into two groups using random number table: 45 patients in group A were treated with in situ lithotripsy and 45 patients in group B were treated with active migration technique. The active migration technique was to reposition the stones in the renal calyces convenient for lithotripsy with the help of body position change, water flow scouring, laser impact or basket displacement, and then conduct laser lithotripsy and stone extraction. The data of the patients before and after operation were collected and statistically analyzed. RESULTS: The age of the patients in group A was (51.6±14.1) years, including 34 males and 11 females. The stone diameter was (1.48±0.24) cm, and the stone density was (897.8±175.9) Hu. The stones were located on the left in 26 cases and on the right in 19 cases. There were 8 cases with no hydronephrosis, 20 cases with grade Ⅰ hydronephrosis, 11 cases with grade Ⅱ hydronephrosis, and 6 cases with grade Ⅲ hydronephrosis. The age of the patients in group B was (51.8±13.7) years, including 30 males and 15 females. The stone diameter was (1.52±0.22) cm, and the stone density was (964.6±214.2) Hu. The stones were located on the left in 22 cases and on the right in 23 cases. There were 10 cases with no hydronephrosis, 23 cases with grade Ⅰ hydronephrosis, 8 cases with grade Ⅱ hydronephrosis, and 4 cases with grade Ⅲ hydronephrosis. There was no significant diffe-rence in general parameters and stone indexes between the two groups. The operation time of group A was (67.1±16.9) min and the lithotripsy time was (38.0±13.2) min. The operation time of group B was (72.2±14.8) min and the lithotripsy time was (40.6±12.6) min. There was no significant difference between the two groups. Four weeks after operation, the stone-free rate in group A was 86.7%, and in group B was 97.8%. There was no significant difference between the two groups. In terms of complications, 25 cases of hematuria, 16 cases of pain, 10 cases of bladder spasm and 4 cases of mild fever occurred in group A. There were 22 cases of hematuria, 13 cases of pain, 12 cases of bladder spasm and 2 cases of mild fever in group B. There was no significant difference between the two groups. CONCLUSION: Active migration technique is safe and effective in the treatment of 1-2 cm upper ureteral calculi.

Impact of a One-Stop Hematuria Clinic on Overall Survival and Bladder Tumor Recurrence.

BACKGROUND AND OBJECTIVE: One-stop clinics have emerged as a tool to optimize the therapeutic management of cancer patients. The main purpose of this study was to assess the role of the one-stop hematuria clinic (OSHC), as compared to a conventional clinic (CC), on the overall and disease-free survival of patients with bladder cancer. METHODS: A five-year follow-up retrospective and single-center study was conducted in patients with primary bladder tumor diagnosed between 2006 and 2015. The primary outcomes were five-year overall survival and one-year relapse rate. RESULTS: A total of 394 patients (160 in OSHC and 234 in CC) were included. No differences were observed in terms of age, sex, smoking habit or risk group between the OSHC and CC groups. The average times from first symptom to diagnosis (24.9 ± 29.1 vs. 100.7 ± 93.6 days) and from first symptom to treatment (70.2 ± 34.0 vs. 155.0 ± 102.9 days) were significantly lower in the OSHC group than in the CC group (p < 0.001 each). There was no significant difference in the five-year survival rate between OSHC and CC (103/160 vs. 150/234, respectively; p = 0.951), although the proportion of relapses during the first year was significantly lower in the OSHC group (35/139, 25.2%) than in the CC one (74/195, 38.0%; p = 0.02). CONCLUSIONS: OSHC significantly reduced the diagnosis and treatment times. The early-relapse rate was significantly lower in the OSHC group, although the five-year survival rate was similar.

Impact of a One-Stop Hematuria Clinic on Overall Survival and Bladder Tumor Recurrence

Background and Objective: One-stop clinics have emerged as a tool to optimize the therapeutic management of cancer patients. The main purpose of this study was to assess the role of the one-stop hematuria clinic (OSHC), as compared to a conventional clinic (CC), on the overall and disease-free survival of patients with bladder cancer. Methods: A five-year follow-up retrospective and single-center study was conducted in patients with primary bladder tumor diagnosed between 2006 and 2015. The primary outcomes were five-year overall survival and one-year relapse rate. Results: A total of 394 patients (160 in OSHC and 234 in CC) were included. No differences were observed in terms of age, sex, smoking habit or risk group between the OSHC and CC groups. The average times from first symptom to diagnosis (24.9 ± 29.1 vs. 100.7 ± 93.6 days) and from first symptom to treatment (70.2 ± 34.0 vs. 155.0 ± 102.9 days) were significantly lower in the OSHC group than in the CC group (p < 0.001 each). There was no significant difference in the five-year survival rate between OSHC and CC (103/160 vs. 150/234, respectively; p = 0.951), although the proportion of relapses during the first year was significantly lower in the OSHC group (35/139, 25.2%) than in the CC one (74/195, 38.0%; p = 0.02). Conclusions: OSHC significantly reduced the diagnosis and treatment times. The early-relapse rate was significantly lower in the OSHC group, although the five-year survival rate was similar (AU)

Complication rate after pediatric shock wave lithotripsy according to Clavien-Dindo grading system: results from a systematic review and meta-analysis of the existing literature.

PURPOSE: Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children. METHODS: MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data. RESULTS: Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1]. CONCLUSION: SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications.

High-frequency plasma exchange therapy for immunocompromised, type I crescentic glomerulonephritis complicated with IgA nephropathy: A case report and literature review.

RATIONALE: Anti-glomerular basement membrane (anti-GBM) disease has been reported to coexist with other immune-mediated glomerular disorders, including antineutrophil cytoplasmic autoantibody positive glomerulonephritis and membranous glomerulopathy. It is well known that anti-GBM disease often manifests as type I crescentic glomerulonephritis on renal biopsy. However, concurrent cases of both type I crescentic glomerulonephritis and IgA nephropathy are rare. PATIENT CONCERNS: We report the case of a 40-years-old woman with microscopic hematuria, mild proteinuria and an immunocompromised status. Laboratory data revealed serum creatinine showed progressive progress, suddenly rising from the normal range to 316.2µmol/L within 4 months. The CD4 lymphocyte count was 0.274 × 109/L (reference value 0.35-1.82 × 109/L). The anti-GBM antibody titer was 192.4 IU/mL (reference range: <20 RU/mL). DIAGNOSES: Renal biopsy was performed after admission. The pathological diagnosis was type I crescentic glomerulonephritis, IgA nephropathy, and clinical anti-GBM disease. INTERVENTIONS: The patient was seriously ill on admission and progressed rapidly. Combined with poor immune function, we immediately initiated high-frequency plasma exchange (PE). In addition, to avoid rebound of antibody levels, PE was performed for 5 times. Follow-up treatment was combined with standard-dose corticosteroids and cyclophosphamide. OUTCOMES: The patient was followed up for 1 year. On the last visit, her serum creatinine decreased to 103.5µmol/L, anti-GBM antibody remained negative, and proteinuria and hematuria disappeared. LESSONS: This case illustrates that when crescentic nephritis or anti-GBM disease is combined with other immune diseases, especially when the immune function is extremely low, if the application of high-dose steroid shocks may induce fatal infections, to some extent high frequency PE has certain advantages.

Endovascular Treatment Failure of Renal Arteriovenous Malformation due to an Extrarenal Feeding Artery: A Case Report.

Renal arteriovenous malformation (RAVM) is a rare pathology. It may present with heamturia, hypertension, and congestive heart failure. Digital subtraction angiography (DSA) is the standard diagnostic choice, and endovascular embolization is a preferred procedure of management in most cases. The feeding branches of RAVM are reported to originate from renal arteries. In this report, a 43-year-old female with recurrent massive hematuria and left flank pain was described. Renal angiography revealed double renal arteries supplying the left kidney and multiple renal arteriovenous fistula formation around the renal pelvis. Embolization with coils and gelfoam was performed after which her hematuria subsided. One month later, the patient was readmitted to our hospital due to the relapse of massive hematuria following heavy physical activities. DSA found another feeding artery of the RAVM originating from the aorta around the 4th lumbar vertebra. After embolization of this arterial feeder, hematuria settled. There was no recurrence during a 10-month follow-up. To our knowledge, this is the first case of RAVM with an extrarenal feeding artery, and omission of this scenario can lead to treatment failure.

Prostate arterial chemoembolization for treatment of refractory hematuria and urinary retention in patients with localized advanced prostate cancer.

OBJECTIVES: To evaluate the safety and efficacy transcatheter arterial chemoembolization (TACE) for the treatment of refractory gross hematuria (RGH) and urinary retention (UR) secondary to localized advanced prostate cancer (PCa). PATIENTS AND METHODS: Thirty-two patients (mean age 72.5 years, range 60-89) with advanced PCa-related RGH that failed conventional therapy were included. Twenty-two of these patients had catheter-dependent due to PCa-related UR. TACE was performed with epirubicin (EPI)-eluting HepaSpheres (HS) plus intra-arterial (IA) infusion of docetaxel. Technical success, adverse events (AEs), overall survival (OS), control of RGH, removal of indwelling catheters, and local disease control, were evaluated. RESULTS: Technical success was achieved in 100% without major AEs. Mean follow up post-TACE was 27 months (range 8-56 months) with a mean OS of 30 months. GRH stopped within 5 days after TACE in all patients, 26 (86.7%) of these patients exhibited good bleeding control during a mean follow-up of 24 months; 17 (77.3%) of the 22 patients with UR had recovered spontaneous urination, 15 (88.2%) patients were catheter-free at their last follow-up with a mean of 24 months. BS was obtained in 73.3% (22/30) of patients at a mean follow-up of 29 months. At the last visit, 22 patients had a mean of 36 months follow-up and the mean percentage reduction in prostate volume was 55.5%, with a statistically different from baseline (P = 0.022). Negative biopsy results were obtained in 84.2% (16/19) of the patients at 12-47 months after TACE. Compared with baseline values, there was a significant improvements in IPSS, QoL, Qmax, and PVR (all P < 0.05). CONCLUSIONS: TACE using EPI-eluting HS plus IA infusion of docetaxel is a safe and effective treatment option for the advanced PCa patients with GRH and UR, and it could be considered as an alternative if there was no other therapeutic choice.

Posttraumatic hemorrhagic bladder rupture managed with transurethral foley catheter placement and bilateral transcatheter vesical artery embolization.

BACKGROUND: Outcome of minimally invasive treatment of posttraumatic, hemorrhagic bladder rupture is unknown. METHODS: A 41-year-old male presented at the emergency department with pelvic and scrotal pain and macroscopic hematuria after a motor vehicle accident. Contrast-enhanced computed tomography revealed an open book fracture and an arterial phase contrast media extravasation posterior to the symphysis pubis and anterior to the urethra-vesical junction. RESULTS: The open book fracture was treated with an external fixation and the persistent bleeding was managed with insertion of a Foley catheter and bilateral embolization of the vesical arteries. CONCLUSION: Minimally invasive treatment, including vesical artery embolization and placement of a Foley catheter can be effective in the treatment of posttraumatic, hemorrhagic bladder rupture.

Discriminative capacity of guideline recommendations in the assessment of patients with asymptomatic microhematuria.

BACKGROUND & OBJECTIVE: Asymptomatic microhematuria (aMh) remains a diagnostic challenge in urological practice: while aMh is a risk factor of urothelial carcinoma (UC), prevalence of aMh is high. Guidelines were developed to permit risk stratification and reduce diagnostic workload. This study investigates the efficacy of several recommendations. MATERIAL & METHODS: Sixty hundred eight patients with newly diagnosed aMh without previous UC from an academic referral center (A; n = 320) and a private outpatient clinic (B; n = 288) were included. All patients underwent clinical workup including medical history, urine cytology, upper tract imaging and cystoscopy. Eleven former and current guidelines were applied to each patient individually; every patient was classified as either low risk (no further workup recommended) or high risk. Furthermore, a recently developed nomogram for hematuria assessment was included. RESULTS: The cohort comprised 142 females and 466 males (mean age 62 [range 18-92] years). Sixty-one patients (10.0%) were diagnosed with UC. Excluding the Swedish and recent NICE guideline generally advising against urologic workup, application of 9 other recommendations would have diagnosed all UCs and saved 1.6% to 16.1% of patients from workup. For the 2020 US guideline, solely applied to cohort B, 10.6% of patients were classified as low risk. The use of the nomogram would have saved 17.1% to 25% of patients from workup. CONCLUSIONS: Practical relevance of current guidelines is limited as they do not sufficiently identify patients not requiring clinical work up. Thus, guideline adherence may trigger overdiagnosis and even overtreatment. New ways of risk stratification are needed to improve aMh assessment.

Super-selective transcatheter vesical arterial chemoembolization with drug-loaded beads for muscle-invasive bladder cancer with hematuria.

PURPOSE: This retrospective study aimed to evaluate the clinical safety and efficacy of super-selective transcatheter vesical arterial chemoembolization with epirubicin-loaded CalliSpheres® beads (DEB-TACE) for treating muscle-invasive bladder cancer with hematuria. METHODS: We reviewed the retrospective records of 20 muscle-invasive bladder cancer patients with hematuria who were treated with super-selective transcatheter vesical arterial by oxaliplatin and 100-300-µm CalliSpheres loaded with epirubicin. The primary outcomes were the technical and clinical success rates. The secondary outcomes were complications, treatment responses, quality of life (QOL), median overall survival, and 1- and 2-year survival rates. QOL was routinely assessed by nurses at admission and during telephone follow-up 4 weeks after discharge. RESULTS: The technical success rate was 80.0% (16/20). Bleeding was controlled after the first embolization in 18/20 patients and after re-embolization within 7 days of the first embolization in the remaining two patients. The clinical success rate was 90% (18/20). After 4 weeks of follow-up, the mean hematocrit and hemoglobin levels improved significantly (P < 0.05). Four patients (20.0%) showed hematuria recurrence during a 4-8-month follow-up period. There were no severe complications, such as necrosis of the bladder, genitals, perineal skin, or procedure-related deaths. The complete response, partial response, stable disease, and progressive disease frequencies were 5.0%, 55.0%, 25.0%, and 15.0%, respectively, resulting in an objective response rate of 60.0% and a disease control rate of 85.0% after 1 month. 4 weeks after embolization, QOL was significantly higher than that pre-operation, except for social/family status (P < 0.05). The median overall survival was 18.5 months, and the 1- and 2-year survival rates were 75.0% and 46.7%, respectively. CONCLUSION: DEB-TACE is safe and effective for treating muscle-invasive bladder cancer with hematuria, preserving bladder function and improving the QOL.

An evidence-based microscopic hematuria care pathway optimizes decision-making among providers.

INTRODUCTION AND HYPOTHESIS: Microscopic hematuria (MH) has many etiologies in women and requires specific gynecologic evaluation. We created a standardized MH pathway to serve as an evidence-based decision aid for providers in our practice. METHODS: Using a modified Delphi process, a multidisciplinary team reviewed existing guidelines for MH diagnosis and treatment to reach consensus on care pathway components. RESULTS: Entry into the care pathway by an advanced practice provider is determined by the finding of ≥3 red blood cells per high-power field (RBC/HPF) on microscopic urinalysis. Initial evaluation includes history and physical exam. If there are signs of a gynecologic cause of MH, the conditions are treated and repeat urinalysis is performed in 6 months. If repeat urinalysis shows persistent MH or there are no other apparent causes for MH, we proceed with risk stratification. Through shared decision-making, low-risk patients may undergo repeat urinalysis in 6 months or cystoscopy with urinary tract ultrasound. For intermediate-risk patients, cystoscopy and urinary tract ultrasound are recommended. For high-risk patients, cystoscopy and axial upper urinary tract imaging are recommended. If evaluation is positive, urology referral is provided. If evaluation is negative, low-risk patients are released from care, but intermediate-risk or high-risk patients undergo repeat urinalysis in 12 months. If repeat urinalysis is positive, shared decision-making is used to determine a plan. CONCLUSIONS: We developed an MH care pathway to standardize care of women with MH across a multidisciplinary group. This pathway serves as a component of value-based care and supports evidence-based care by providers.

Comparison of safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by flexible ure-teroscopy / 北京大学学报(医学版)

OBJECTIVE@#To compare the safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by retrograde flexible ureteroscopy.@*METHODS@#A total of 90 patients with 1-2 cm upper ureteral calculi treated in the urology department of Beijing Friendship Hospital from August 2018 to August 2020 were selected as the subjects. The patients were divided into two groups using random number table: 45 patients in group A were treated with in situ lithotripsy and 45 patients in group B were treated with active migration technique. The active migration technique was to reposition the stones in the renal calyces convenient for lithotripsy with the help of body position change, water flow scouring, laser impact or basket displacement, and then conduct laser lithotripsy and stone extraction. The data of the patients before and after operation were collected and statistically analyzed.@*RESULTS@#The age of the patients in group A was (51.6±14.1) years, including 34 males and 11 females. The stone diameter was (1.48±0.24) cm, and the stone density was (897.8±175.9) Hu. The stones were located on the left in 26 cases and on the right in 19 cases. There were 8 cases with no hydronephrosis, 20 cases with grade Ⅰ hydronephrosis, 11 cases with grade Ⅱ hydronephrosis, and 6 cases with grade Ⅲ hydronephrosis. The age of the patients in group B was (51.8±13.7) years, including 30 males and 15 females. The stone diameter was (1.52±0.22) cm, and the stone density was (964.6±214.2) Hu. The stones were located on the left in 22 cases and on the right in 23 cases. There were 10 cases with no hydronephrosis, 23 cases with grade Ⅰ hydronephrosis, 8 cases with grade Ⅱ hydronephrosis, and 4 cases with grade Ⅲ hydronephrosis. There was no significant diffe-rence in general parameters and stone indexes between the two groups. The operation time of group A was (67.1±16.9) min and the lithotripsy time was (38.0±13.2) min. The operation time of group B was (72.2±14.8) min and the lithotripsy time was (40.6±12.6) min. There was no significant difference between the two groups. Four weeks after operation, the stone-free rate in group A was 86.7%, and in group B was 97.8%. There was no significant difference between the two groups. In terms of complications, 25 cases of hematuria, 16 cases of pain, 10 cases of bladder spasm and 4 cases of mild fever occurred in group A. There were 22 cases of hematuria, 13 cases of pain, 12 cases of bladder spasm and 2 cases of mild fever in group B. There was no significant difference between the two groups.@*CONCLUSION@#Active migration technique is safe and effective in the treatment of 1-2 cm upper ureteral calculi.

Hemorrhagic cystitis: a review of the literature and treatment options.

INTRODUCTION: Hemorrhagic cystitis (HC) is a morbid condition for patients and can be challenging for urologists to manage. There are many potential contributing etiologies and the severity of bleeding can be variable. It is important to consider each clinical scenario when formulating management strategies in order to provide the highest quality of care to patients. We provide a review of the literature including diagnosis and treatment options. MATERIALS AND METHODS: We performed a literature search on PubMed using the following keywords: hemorrhagic cystitis, cystitis, gross hematuria, intractable hematuria. We considered all available published articles with no specific inclusion or exclusion criteria for the purposes of this review. RESULTS: We reviewed a total of 41 articles and identified a broad differential diagnosis for intractable hemorrhagic cystitis including infection, chemical exposure, malignancy, nephropathy, trauma, radiation therapy, and idiopathic etiology. Depending on the severity of bleeding, many treatments have been described. These range from conservative strategies (bladder fulguration and continuous irrigation) to more extreme and morbid therapies (intravesical instillations, embolization, and urinary diversion). CONCLUSION: Hemorrhagic cystitis is a relatively common and can be a difficult condition to manage for urologists. It is important to understand the etiology and available treatments options in order to best treat our patients. We provide a comprehensive and thorough review of the literature and propose a stepwise treatment approach.

Great prognosis of concurrent anti-GBM disease and IgA nephropathy in a young woman: A case report.

RATIONALE: The causal relationship between anti-glomerular basement membrane (anti-GBM) disease and immunoglobulin A (IgA) nephropathy is still unclear and cases of concurrent anti-GBM disease and IgA nephropathy are very rare, especially with a good prognosis and long-term follow-up. Here, we report a case of concurrent anti-GBM disease and IgA nephropathy. By using corticosteroids and cyclophosphamide in combination with plasmapheresis, the patient achieved a very good prognosis with complete normalization of renal function and complete disappearance of hematuria and proteinuria at the subsequent follow-up. To our knowledge, no previous case with such a long follow-up and such a good prognosis have been reported. PATIENT CONCERNS: This case report describes a 26-year-old Chinese woman who presented with fever as the initial symptom, followed by dysmorphic hematuria, overt proteinuria and rapidly worsening renal function. Before admission, the patient received symptomatic supportive treatment such as intravenous albumin infusion, improvement of circulation, but the symptoms were not significantly improved. DIAGNOSIS: Per the results of kidney biopsy, the patient was diagnosed with crescentic glomerulonephritis and anti-GBM disease with IgA nephropathy. INTERVENTIONS: The key to obtain a good prognosis was the early application of corticosteroids and cyclophosphamide in combination with plasmapheresis to make the anti-GBM antibody turn negative quickly. OUTCOMES: After 2 weeks of therapy, the patients' anti-GBM antibody turned negative and serum creatinine improved to a normal range. After 10 months, the patient's proteinuria level reached complete remission. After 12 months, the patient's hematuria had disappeared completely. LESSONS: This case provides experience in the treatment of concurrent anti-GBM disease and IgA nephropathy and highlights the importance of early application of plasmapheresis and immunosuppressive therapy to obtain a good prognosis.

Efficacy of Flexible Ureteroscopic Lithotripsy and Percutaneous Nephrolithotomy in the Treatment of Complex Upper Urinary Tract Nephrolithiasis.

Objective: A case-control study was conducted to compare the efficacy and prognostic factors of flexible ureteroscopic lithotripsy (FURL) and percutaneous nephrolithotomy (PCNL) when treating complex upper urinary tract renal calculi based on a retrospective cohort study. Methods: The study period was from October 2019 to December 2021. A retrospective study was carried out on 100 patients with complicated upper urinary tract nephrolithiasis who underwent surgery in the Urology Department of our hospital. They were assigned into two groups: FURL and PCNL groups. The intraoperative blood loss, operation time, hematuria duration, hospital stay, primary stone removal rate, incidence of intraoperative and postoperative complications, VAS score, level of inflammatory factors, and micturition function were compared. According to the postoperative prognosis, the patients were reassigned into two groups: good prognosis group (n = 38) and poor prognosis group (n = 106). The factors related to poor prognosis after FURL and PCNL were screened, and multivariate loglistic regression analysis was adopted to determine the risk factors. Results: The primary stone clearance rate in the PCNL group was significantly higher than that in the FURL group, and there was no significant difference in the incidence of intraoperative and postoperative complications between the two groups (P > 0.05). The intraoperative blood loss and the duration of hematuria in the PCNL group were significantly shorter than those in the FURL group, and the operation time and postoperative hospital stay in the FURL group were longer than those in the FURL group. The postoperative VAS score in the study group was significantly lower than that in the control group (P < 0.05). The levels of CRP, IL-1, TNF-α, and NF-κB in both groups decreased after operation, and the level of inflammatory factors in the PCNL group was significantly lower than that in the FURL group (P < 0.05). The indexes of IPSS and Q max in the PCNL group were significantly lower than those in the control group 3 months after operation. The index of micturition function in the PCNL group was significantly lower than that in the FURL group. Preoperative use of immunosuppressant, preoperative stone fever, positive preoperative urine culture, preoperative urinary leukocyte count ≥ 544 × L, intraoperative urinary opacity, and pus fur were significantly correlated with poor prognosis of ureteral patients (P < 0.05). Preoperative stone fever, high preoperative urinary leukocyte count, intraoperative urinary turbidity, and suppurative fur were independent risk factors for postoperative SIRS in patients with ureteral calculi. Conclusion: PCNL is effective when treating complex upper urinary tract renal calculi. Compared with FURL, PCNL can remarkably reduce intraoperative blood loss and hematuria duration, can enhance micturition function, and will not remarkably increase the incidence of intraoperative and postoperative complications, high safety. High white blood cell count in urine before operation, fever due to stone before operation, turbid urine, and purulent fur during operation are independent risk factors for postoperative adverse outcome in patients with complex upper urinary tract renal calculi. Patients should be fully treated before surgery.

Management of Inpatient Macroscopic Haematuria: A Typical Urology Emergency With a High Mortality.

OBJECTIVE: To review the in-patient (IP) management patterns and 30-day outcomes of patients admitted with macroscopic haematuria (MH) over a 1-year-period in a single-institution, aiming to clarify management for such cases in the future. METHODS: Retrospective cohort study was conducted on all patients admitted with MH in a single-institution over 1-year, excluding patients not requiring an overnight stay. A case note review was performed for patient demographics, MH investigations, and management. RESULTS: A total of 120 patients were admitted with MH over a span of 1-year. 89% (107/120) were males, with an average age of 78 years (36-97 years), an average ASA of 3, mean length-of-stay (LOS) was 5 days (1-31days) and 68% (82/120) had pre-existing urological conditions. 62% (74/120) required bladder irrigation for a mean duration of 3 days (1-16days). 10% (12/120) required an emergency rigid cystoscopy and washout to manage the bleeding, of which 4% (5/12) had malignancy noted. Over 8% (10/120) patients discharged had unplanned readmissions within 30 days. The 1-year mortality for this cohort was 23% (28/120) of which 21% (6/28) died within 30 days from discharge. CONCLUSION: IP MH affects a vulnerable patient cohort. There is no specific pathway guiding the inpatient management of MH; therefore, research is required to produce standardized pathways for managing MH, considering the high-risk patient cohort, the prolonged LOS, and high 1-year mortality rate.

Trans-arterial embolization of renal cell carcinoma: a systematic review and meta-analysis.

PURPOSE: To evaluate if trans-arterial embolization (TAE) of the primary tumor in patients with renal cell carcinoma (RCC) improves symptomatology such as pain and hematuria or oncologic outcomes such as progression-free survival (PFS) and overall survival (OS). MATERIALS AND METHODS: The systematic review search included PubMed, Ovid/MEDLINE, and Embase for full-text English articles including randomized and non-randomized prospective trials as well as prospective and retrospective case series. To be included, prospective trials needed ≥ 25 patients in each arm while case series and retrospective chart reviews required at least two patients. Evaluated outcomes included PFS, OS, change in tumor size, improvements in pain, improvements in hematuria, and adverse events (AEs). RESULTS: 1327 articles were retrieved and screened. Nine studies met inclusion criteria (retrospective case series, n = 8; non-randomized prospective trial, n = 1) which included 237 patients (M = 156 (65.8%); F = 56 (23.6%); gender unreported = 25 (10.5%); mean age: 69.4 (range: 38-87)) with a mean tumor diameter of 9.3 cm (5.2-10.5). When reported, the TNM stages were stage I (n = 10), II (n = 18), III (n = 36), and IV (n = 121). 60 patients were treated for pain and hematuria. After TAE, pain improved in 59 patients (98.3%) and hematuria improved in 57 patients (95%). A meta-analysis for improvements in pain and hematuria demonstrated an event rate of pain improvement of 0.952 (0.788-0.990; p < 0.001) and an event rate for hematuria improvement of 0.923 (0.809-0.971; p < 0.001). Median OS ranged from 1 to 39 months but only one study reported PFS (10.5 months). Only one study demonstrated a statistically significant improvement in OS with TAE when compared with patients that did not undergo TAE (p = 0.02). A reduction in tumor size was only achieved in 17 patients (17/49; 34.7%) limiting evaluation. AEs included fever (n = 115/237; 48.5%), flank pain (n = 72/237; 30.4%), nausea (n = 58/237; 24.5%), hematuria (n = 12/237; 5.1%), hypertension (n = 12/237; 5.1%), reduced GFR (n = 6/237; 2.5%), hematoma (n = 6/237,2.5%), and ileus (n = 3/237; 1.3%). CONCLUSION: TAE monotherapy of the primary tumor in patients with RCC improves symptomatology such as pain and hematuria with an acceptable safety profile.