Anatomy and anatomical variations of adrenal veins and its application to adrenal venous sampling.

PURPOSE: Our aim was to study the anatomy of the left and right main adrenal veins (LAV and RAV) and to identify their anatomical variations in order to see the practical application of these findings to adrenal venous sampling (AVS). METHODS: Our work is based on dissection of 80 adrenal glands from fresh corpses in the forensic medicine department. We studied the number, the drainage, the direction and the level of termination of the main adrenal veins. RESULTS: The average length of the LAV was 21 mm. It ended in 100% of cases at the upper edge of the left renal vein with a mean connection angle of 70° and after an anastomosis with the lower phrenic vein in 36 cases(90%). The average length of the RAV was 9 mm. It ended in 100% of cases at the level of the retro hepatic inferior vena cava (IVC) mainly on its posterior face in 21 cases (53%) and on its right lateral border in 18 cases (45%). The mean angle of the RAV in relation to the vertical axis of the IVC was 40°, with extremes ranging from 15° to 90°. CONCLUSIONS: AVS seems to be easier on the left than on the right side because of the greater length of the adrenal vein (21 mm vs. 9 mm) and a greater angle of connection (70° with the left renal vein vs. 40° with the IVC), which explains the lower success rate of cannulation and the more frequent occurrence of blood sample contamination on the right side.

Validation of the Aldosteronoma Resolution Score as a Predictive Resolution Score of Hypertension After Unilateral Adrenalectomy for Primary Aldosteronism in a North-African Population.

BACKGROUND: Unilateral primary aldosteronism (UPA) is the most frequent surgically curable form of endocrine hypertension. Adrenalectomy is the cornerstone of treatment for UPA, but outcomes after surgery are variable. Aldosteronoma Resolution Score (ARS) is a four-item predictive score for the cure of hypertension after adrenalectomy for UPA and has been demonstrated to be valid in different populations. We aimed in this study to validate the accuracy of this score in a North-African population. METHODS: Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Postoperative outcomes were assessed using the primary aldosteronism surgical outcome (PASO) criterion. The accuracy of the ARS was determined retrospectively by receiver operating characteristic curve and area under the curve. RESULTS: Thirty-four patients (48%) had complete clinical success according to the PASO criteria. Multivariate regression analysis revealed that the main determinants of complete clinical success were the absence of diabetes (OR: 5.205), a BMI <30 (OR: 4.930), a number of antihypertensive medications ≤2 (OR: 8.667), a plasma ARR >332 (OR: 4.554) and an ARS score ≥3 (OR: 2.056). Cure rates were, respectively, 21.1, 51.6, and 66.6% for patients with a score ARS 0-1, 2-3, and 4-5. The AUC of the ARS was 0.837. CONCLUSION: The ARS is a sufficiently predictive score in our North-African population. It may be used preoperatively to predict the outcome after adrenalectomy in these populations.

A cadaveric anatomical study of the adrenals: vascular relationship.

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

Leiomyosarcoma of the bladder: A review and a report of four further cases.

INTRODUCTION AND IMPORTANCE: Our study aims to expose the experience of our department in dealing with bladder leiomyosarcomas and illustrate the management tools of this rare pathology. CASE PRESENTATION: We present a retrospective study of 4 cases of bladder leiomyosarcoma, gathered in the Department of Urology during the period of 1996-2022. All our patients were exclusively male and aged between 35 and 73 years. No history of pelvic irradiation nor chemotherapy was found in our patients. Three patients had high-grade leiomyosarcoma and pT2 stage whereas only one had a low-grade tumour. Three patients underwent radical treatment by cystoprostatectomy with extensive bilateral pelvic lymph node dissection and one patient was treated by endoscopic re-resection and endoscopic monitoring. We noticed 2 lymph nodes and liver metastasis recurrences in 2 patients treated by radical surgery while 2 patients didn't present recurrences at two years of follow-up. CLINICAL DISCUSSION: To date, there is no clear and precise therapeutic approach for the treatment of bladder leiomyosarcoma. Little is known about the long term survival associated with these tumours. All studies agree that the prognosis for bladder leiomyosarcoma is poor, if not diagnosed early, especially those presenting with an undifferentiated tumour grade, distant metastatis and treated without surgical therapy. CONCLUSION: Bladder leiomyosarcoma is a rare and highly aggressive tumour. The anatomopathological examination provides diagnosis and prognosis assessment. Radical surgery remains the most suitable therapeutic approach.

Giant retroperitoneal leiomyosarcoma: a case report.

Retroperitoneal leiomyosarcomas are rare tumors, mostly malignant. They are silent slow growing, and at the time of diagnosis, they are often of a considerable size. Management necessitates en bloc resection of the mass with adjacent organs, which is often challenging due to large size of the tumor. Herein, we present a case of 59-year-old male patient presenting for surgical management of 190 × 150 × 140 mm retroperitoneal leiomyosarcoma.

Can radiological scores predict difficulties in removal of encrusted ureteral stents?

In the present study, we aimed to report our single-center experience in encrusted ureteral stent management and to compare the utility of two different scoring systems in patient management. This is a retrospective study of patients who underwent various surgical procedures to remove encrusted ureteral stent. Encrusted stent grading was performed using KUB and FECal grading sytems. FECal grading system scored from Grade 1 to Grade 5 according to stone size, location, and degree of stent incrustation and the KUB score is the sum of the stone burden scores of three different parts of an encrusted stent within the kidney, ureter, and bladder determined using a scale from 1 to 5 according to the maximal diameter of encrustation. We compared these two classifications for the prediction of perioperative outcomes. Fifty patients were included in the study (52% female, mean age 48 years). The mean time from ureteral stent insertion until diagnosis of encrustation was 11.4 ± 13.6 months. High-grade incrustations (FECal Grade 3, 4, and 5) accounted for 62% of cases. The mean KUB score was 9.8 ± 2.7. The average number of procedures required to remove the stent was 1.71 ± 1.38. Multimodal surgery was required to remove 42% of the stents. Both, a total KUB score ≥ 9 and high-grade FECal classification were found to be significant predictors of longer operative time (> 100 min), need for multiple surgeries, and need for invasive surgery. While high-grade FECal classification showed a significant association with need for multimodal surgery (OR 6.92, p = 0.008), a total KUB score ≥ 9 showed no association (OR 2.91, p = 0.086). These two scores seem to be good indicators in predicting difficulties for surgical management of encrusted ureteral stent with a clear advantage of the FECal score in terms of prediction of multimodal surgery.

Urological activity at the time of COVID-19 pandemic: is there any difference between public and private field?

INTRODUCTION: as COVID-19 pandemic is rapidly evolving, there is a whole reorganization in hospitals to concentrate more resources to face the crisis. The purpose of this study is to evaluate the impact of COVID-19 disease on urological activity in Tunisia. To assess the differences in the management of urological conditions between the private and the public field. METHODS: a survey was addressed to all certified urologists working in Tunisia in both the public and private sectors (n=194) using the national database of active urologists available and updated. We either called them or looked them up through email or social media. The form was open from March the 28th to April the 3rd. Results were obtained via spreadsheet and analysed using SPSS 23.0. RESULTS: one hundred and twenty urologists have filled in the form. Consultations at the outpatient office were restricted to urgent cases in 66% (n=79). Telemedicine was more used by urologists in private than in public fields p=0.03. Urologists in private sector followed more the sterilization protocol of the hospital/clinic and used more disposable materials whenever possible p=0.011. Elective surgical activity has completely stopped in 85% of the responders (n=102). Elective surgery requiring transfusion or intensive care unit was performed in 38% (n=46) and 26% (n=31) if there was a risk of disease progression. Benign Prostate Hyperplasia (BPH) surgery was more performed as usual in private sector than in public sector p=0.012. It was the only condition managed differently between both sectors. CONCLUSION: the drop of the urological activity is essential in order to give relevant stakeholders room to act efficiently against the spread of the virus. The context of the pandemic and the hospital´s condition must be taken into consideration without compromising the patient´s outcome.

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.

[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.

Risk factors and consequences of delayed graft function.

The impact of delayed graft function (DGF) on the outcome of renal transplantation remains controversial. We analyzed the risk factors for DGF and its impact on graft and patient survival. A total of 354 renal transplants performed between June 1986 and April 2000 were analyzed. Variables analyzed included donor and recipient age, method and duration of renal replacement therapy, HLA mismatch, cold and warm ischemia times, biopsy-confirmed acute rejection, length of stay in the hospital, serum creatinine at the end of first hospitalization as well as graft and patient survival at one, three, five and ten years. The study patients were divided into two groups: patients with DGF (G1) and those without DGF (G2). DGF occurred in 50 patients (14.1%), and it was seen more frequently in patients transplanted from deceased donors (60% vs. 40%, P <0.0001). The cause of DGF was acute tubular necrosis, seen in 98% of the cases. Univariate analysis showed a statistically significant difference between the two groups G1 and G2 in the following parameters: average duration on dialysis (52.3 vs. 36.4 months, P = 0.006), HLA mismatch (44.9% vs. 32.11% P = 0.015), donor age (35.9 vs. 40.2 years, P = 0.026), cold ischemia time (23 vs. 18.2 h, P = 0.0016), warm ischemia time (41.9 vs. 38.6 mn, P = 0.046), length of stay in the hospital during first hospitalization (54.7 vs. 33.2 days, P <0.0001), serum creatinine at the end of first hospitalization (140 vs. 112 µmol/L, P <0.0001) and at three months following transplantation (159 vs. 119 µmol/L, P = 0.0002). Multivariate analysis revealed the following independent risk factors for DGF: deceased donor (RR = 13.2, P <0.0001) and cold ischemia time (RR = 1.17, P = 0.008). The graft survival at one, three, five and ten years was 100%, 93%, 88.3% and 78.3% in G1 versus 100%, 95.9% 92.8% and 82.3% in G2; there was no statistically significant difference. The patient survival at one, three, five and ten years was 100%, 91.3%, 83.6% and 74.4% in G1 versus 100%, 95.9%, 94% and 82.6% in G2 with a statistically significant difference (P = 0.04). Prolonged cold ischemia time and transplantation of kidneys from deceased donors were the main risk factors for DGF in our study. Also, DGF significantly affected patient survival but had no influence on graft survival.