[Retrospetive analysis of early postoperative complications of radical cystectomy and urinary diversion performed during a 17-year period]

We retrospectively analyzed early postoperative complications in 293 consecutive patients withbladder cancer who underwent radical cystectomy with urinary diversion from 1990 to 2007 at the Department of Urology of the Sapporo Medical University School of Medicine. The Common Terminology Criteria for Adverse Events (ver 3.0) was used to evaluate complications that occurred within 30 days after surgery, and grade 3 and higher grades according to the criteria were defined as complications in this study. The guidelines of the Centers for Disease Control and Prevention were used for the classification of surgical site infection. Early postoperative complications were found in 158 cases (54%). Acute pyelonephritis (APN), which was related to the removal of the ureteral catheter, was the most frequent complication, found in 96 (33%), followed by surgical site infection in 39 (13%), and ileus in 33 (11%). When transient APN was excluded, the rate for complications was 30%. Possible life-threatening complications were experienced in 15 patients (5%) including 2 (0.7%) who eventually died of the complications. The preoperative grade 3 score of the American Society of Anesthesiologists (ASA score) was significantly related to development of early postoperative complications in univariate analysis. In multivariate analysis, a grade 3 ASA score and the estimated blood loss were independent factors to predict development of early complications. Postoperative nasogastric tubing was not related to ileus after surgery, suggesting that postoperative indwelling of the tube is not routinely needed. Although about half of the patients experienced early postoperative complications, they were usually transient and manageable. Thus, careful evaluation of the preoperative ASA score and a reduction in the amount of bleeding during surgery may lower the development of early postoperative complications.

Ultrasound detection of obstructive pyelonephritis due to urolithiasis in the ED

Identifying acute pyelonephritis (APN) with early obstructive uropathy is clinically important in the emergency department (ED) because obstructive urolithiasis is an independent risk factor for inpatient death, prolonged hospitalization, and failure of outpatient APN therapy. Furthermore, diagnosis of an early obstructive uropathy can be difficult when based solely on clinical findings. Clinicians may assume the cause of the patient's symptoms to be APN alone, without considering the concurrent presence of an obstructing stone. A feasible screening test to detect early obstructive uropathy in cases of APN has not been previously identified. Plain film radiographs are insensitive in locating a suspected calcified stone. Computed tomography is readily available in most EDs and clearly defines urologic anatomy, but delivers unnecessary ionizing radiation, can prolong ED length of stay, and is not cost-effective as a screening test for all patients diagnosed with APN. We report a case in which a bedside ultrasound identifying hydronephrosis prompted confirmatory computed tomography imaging and emergency consultation of a patient with APN. In this case, hydronephrosis on bedside ultrasound examination was an indirect marker of a distal ureteral obstruction. By detecting the presence of hydronephrosis in patients with APN, emergency physicians may dramatically increase their ability to identify those patients that need further radiographic investigation and ultimately decrease the rate of outpatient treatment failure. Further surveillance data are needed to determine the statistical characteristics of this novel screening test and if routine renal evaluation of all patients with APN is warranted.

Pathogen specific, IRF3-dependent signaling and innate resistance to human kidney infection

The mucosal immune system identifies and fights invading pathogens, while allowing non-pathogenic organisms to persist. Mechanisms of pathogen/non-pathogen discrimination are poorly understood, as is the contribution of human genetic variation in disease susceptibility. We describe here a new, IRF3-dependent signaling pathway that is critical for distinguishing pathogens from normal flora at the mucosal barrier. Following uropathogenic E. coli infection, Irf3(-/-) mice showed a pathogen-specific increase in acute mortality, bacterial burden, abscess formation and renal damage compared to wild type mice. TLR4 signaling was initiated after ceramide release from glycosphingolipid receptors, through TRAM, CREB, Fos and Jun phosphorylation and p38 MAPK-dependent mechanisms, resulting in nuclear translocation of IRF3 and activation of IRF3/IFNβ-dependent antibacterial effector mechanisms. This TLR4/IRF3 pathway of pathogen discrimination was activated by ceramide and by P-fimbriated E. coli, which use ceramide-anchored glycosphingolipid receptors. Relevance of this pathway for human disease was supported by polymorphic IRF3 promoter sequences, differing between children with severe, symptomatic kidney infection and children who were asymptomatic bacterial carriers. IRF3 promoter activity was reduced by the disease-associated genotype, consistent with the pathology in Irf3(-/-) mice. Host susceptibility to common infections like UTI may thus be strongly influenced by single gene modifications affecting the innate immune response.

Acute pyelonephritis can have serious complications

Urinary tract infection (UTI) may predominantly involve the lower urinary tract, i.e. acute cystitis, or upper urinary tract consisting of the renal pelvis and kidney,, i.e. acute pyelonephritis The incidence of acute pyelonephritis is higher in young women than in men but the incidence in men over 65 is similar to that in older women. Women have up to a 10% risk of recurrent acute pyelonephritis in the year following a first acute episode. The equivalent risk in men is 6%. Acute pyelonephritis may be uncomplicated and resolve without serious sequelae. A minority of episodes may be complicated by acute kidney injury, papillary necrosis, renal or perinephric abscess or the development of emphysematous pyelonephritis. Acute pyelonephritis is generally caused by microorganisms ascending from the urethra via the bladder into the upper urinary tract. Rarely the kidney may be seeded by blood-borne infection. Ecoli is the most common uropathogen causing pyelonephritis accounting for 70-90% of infections. Species of Enterococci, Klebsiella, Pseudomonas, Proteus and Staphylococci are responsible for the remaining infections. There is a rising incidence in the community of UTI with bacteria that produce extended spectrum beta-lactamase (ESBL) enzymes. These ESBL bacteria have developed resistance to antibiotics such as penicillin, cephalosporins and increasingly to quinolones. Risk factors for uncomplicated acute pyelonephritis include recent sexual intercourse, acute cystitis, stress incontinence and diabetes and for complicated acute pyelonephritis include pregnancy, diabetes, anatomical abnormalities of the urinary tract and renal calculi.

[Echinocandins and the 2009 guidelines for treatment of candidiasis]

Candida is the most frequent cause of invasive fungal infections in humans that yield high levels of mortality and health-related costs. Several factors lead to the development of candidemia. The Infectious Diseases Society of America (IDSA) updated its guidelines for the management of candidiasis and proper use of antifungal agents in Candida infections. The echinocandins are novel antifungal 1,3-beta-glucan synthase inhibitors and are currently the first choice treatment for most Candida infections, with good responses to support its use.

[Emphysematous pyelonephritis]

Emphysematous pyelonephritis (EPN) is a rare, life-threatening infection of the kidney, characterized by production of gas within the renal parenchyma or perinephric tissue. Escherichia coli and Klebsiella are the most commonly isolated organisms. Most patients are diabetics. CT is diagnostic. Within half a year two patients with EPN were admitted. They were successfully treated with internal/percutaneous drainage (PCD), and antibiotics. Earlier, acute nephrectomy was first choice treatment, but recent studies point towards PCD and antibiotics as a better alternative.

Fulminant emphysematous pyelonephritis (EPN) in a diabetic patient suspected of having multiple tumors

Multiple tumors in the liver, kidney, and on the posterior side of the urinary bladder were accidentally found when a diabetic woman visited the hospital. She refused to undergo surgery; therefore, she was only observed for 2 months. Subsequently, she was found unconscious at home and diagnosed with urinary infection, sepsis, and hyperglycemic hyperosmolar non-ketotic coma. The case followed a fulminant course, and she soon died. Postmortem computed tomography revealed emphysematous pyelonephritis (EPN), a rare, life-threatening infection. This case highlights the importance of carefully managing infection in diabetic patients, and it may contribute to clarifying the pathogenesis of EPN.

[Rational approach to treatment of patients with polytrauma complicated by urinary tract infection]

Development of secondary immune dysbalance in patients with polytrauma complicated by urinary tract infection (acute pyelonephritis) was observed. In such cases bacterial complications were highly possible, that required the use of immunotropic drugs (cycloferon) increasing the host nonspecific resistance, responsible for Th1 immune response. The cycloferon therapy of the patients with chronic pyelonephritis normalized the lymphocyte electrophoretic mobility promoting efficient recovery of the immune homeostasis. Cycloferon was shown to be effective in the prophylaxis and therapy of infective inflammation in the patients with polytrauma, that was evident of the antibacterial therapy efficacy increasing and more rapid healing of the infective inflammation.

Emphysematous pyelonephritis: an unusual complication of blunt abdominal trauma

We report an unusual case of emphysematous pyelonephritis after blunt abdominal trauma in a 28-year-old woman. She was previously healthy and did not have diabetes. Treatment with antibiotics and percutaneous drainage was successful. We review the diagnostic and management strategies for this condition.

Cystitis, pyelonephritis, and urolithiasis in rats accidentally fed a diet deficient in vitamin A

Female Sprague-Dawley rats (n = 100; age, 3 wk) were fed diets that included a vitamin premix and either albumin or milk powder. Rats fed the albumin diet gained weight more slowly than did the other group. Between 19 and 28 wk of being fed the albumin diet, 12 rats died of bacterial cystitis and pyelonephritis. In addition, 2 more rats from the same dietary group developed peritonitis after ovariohysterectomy. Examination of the 44 rats fed the albumin diet that completed the 34-wk experiment revealed pyelonephritis in 68%, cystitis in 66%, urolithiasis in 27%, and nephrolithiasis in 5%. Squamous metaplasia of the transitional epithelium was present in all 44 rats, although other epithelia were histologically normal. Vitamin A deficiency was diagnosed after analyses of blood and liver samples. Analysis of the vitamin premix revealed approximately 25% of the expected amount of vitamin A. Because the milk powder contained sufficient vitamin A, deficiency did not occur in rats fed the milk powder diet. The major consequences of vitamin A deficiency in the rats were squamous metaplasia, bacterial infection, and calculus formation within the urinary tract. This report illustrates the importance of careful formulation and storage of vitamin premixes used in experimental diets. Vitamin A deficiency should be considered in rats with decreased weight gain and urinary tract disease even if ocular lesions are not present.

[Food additive urisan in combined treatment of urolithiasis]

Thirty three urolithiasis patients (13 males, 18 females aged 29-77 years, 2 children, duration of the disease 1-17 years) received food additive urisan in combined treatment of urolithiasis. Blood and urine biochemistry was studied by 11 parameters to evaluate renal function and lithogenesis before and after intake of urisan. Standard treatment was combined with intake of 2 capsules (1100 mg) of urisan twice a day at meal for 2-3 weeks. The data were processed statistically. It is shown that urisan contributes to intensification of renal filtration function, to reduction of hyperuricemia and urine pH, intensification of uric acid excretion, continuation of inflammation remission, attenuation of proteinurea in urolithiasis patients with exacerbation of chronic pyelonephritis.

Autoimmune Responses to Tamm-Horsfall Protein in the Pathogenesis of Chronic Pyelonephritis

Although the role of bacterial infection as the major determinant in the development of acute pyelonephritis has been well documented for years, the nature of the renal scarring typical of chronic "atrophic" pyelonephritis has been a matter of controversy for at least three decades. In the past, recurrent bacterial infection of the kidney was thought to be responsible for the pathologic entity of "chronic pyelonephritis." However, more recent studies suggest that recurrent bacteriuria, in the absence of some form of obstructive uropathy, rarely produces chronic pyelonephritis. The close association between vesicoureteral reflex and chronic pyelonephritis has also been firmly established and has been observed to occur frequently in the absence of urinary tract infection. However, the mechanism by which vesicoureteral reflux injures the kidney has not been firmly established. A number of observations have suggested that some normal component of urine, particularly Tamm-Horsfall protein, might serve as an antigenic determinant involved in the immunopathogenesis of renal scarring in vesicoureteral reflux. The present studies were designed to investigate the immunopathogenic role of Tamm-Horsfall protein in a rabbit model of tubulointerstitial nephritis, and in a swine model of reflux nephropathy. The immune responses to Tamm-Horsfall protein in patients with recurrent nephrolithiasis were also examined, as were the antigenic similarities between Tamm-Horsfall protein and protein-containing components of uropathic bacteria. The results of these studies indicate that autoimmune responses to Tamm-Horsfall protein may occur after exposure to Tamm-Horsfall protein by intravenous challenge in rabbits, and by urinary reflux in pigs, as well as in recurrent nephrolithiasis in man.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical study of tubeless cutaneous ureterostomy]

We constructed Toyoda cutaneous ureterostomy with fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. After the operation, the stent catheters were placed in the renal pelvis through the stoma, and exchanged every 4 weeks. The stent catheters were removed 3 months after the operation, because the stomal conditions were unstable and obstructive in the early phase after the operation. Fifteen patients (27 renal units) with at least 6 months of follow-up were enrolled in this study. The follow-up period was 6 to 33 months (average 14.0 +/- 7.9). Radical cystectomy was performed for bladder cancer in these patients. There were 12 men and 3 women with an average age of 73.3 +/- 7.2 years. At the operation, the ureters were intact in all 27 renal units. Six months after operation, 26 (96.3%) of 27 renal units achieved a tubeless condition, and 25 renal units (92.6%) had no hydronephrosis. Acute pyelonephritis had developed 2 (13.3%) of the 15 patients both within 3 months after the operation and after this period. In conclusion, our operative modification of cutaneous ureterostomy achieved a high catheter-free rate.

The prevalence of virulence genes of E. coli strains isolated from children with urinary tract infection

To evaluate the prevalence of virulence genes in E. coli strains isolated from urine samples of children with urinary tract infection(UTI) and their correlation with clinical data, we isolated E. coli strains from urine samples of children with UTI during the period of August 2005 - August 2006 and studied them for the presence of the virulence genes by PCR. A total of 96 E. coli strains were isolated. The prevalence of genes, pyelonephritis associated pili (pap genes), S-family adhesions (sfa gene), hemolysin (hly gene), and cytotoxic nercotizing factor type 1 (cnf-1-1 gene) among the isolated strains was 27.1%, 14.6%, 13.5% and 22.9 %, respectively. Pyelonephritis was more prevalent in the cases with positive virulence genes. The results showed significant correlation between age of the patient and the presence of the genes (P< 0.05). Cnf-1 gene was significantly more common in samples of patients with abnormal finding on the ultrasound of kidneys (P= 0.049). Our study demonstrated higher prevalence of pyelonephritis in the presence of E. coli virulence genes. Detection of the genes in urine samples may help in the management of UTI.

[Efficacy of photon therapy in combined postoperative treatment of children with congenital obstructive uropathy and secondary pyelonephritis]

A total of 110 children aged from 5 to 15 years with different forms of congenital obstructive uropathy and secondary pyelonephritis received standard combined treatment (n = 71) or standard treatment combination with photon therapy 3 months after discharge from hospital. Postoperative combined treatment including photon therapy promoted uneventful course of the postoperative period, normalized immunological indices, achievement of persistent remission.

Renal hemodynamics and blood pressure control in patients with pyelonephritic renal scarring

Pyelonephritic renal scarring is a common cause of renal failure and hypertension. We studied glomerular filtration rate (GFR), renal plasma flow (RPF), filtration fraction (FF), total renal area (TRA), systolic (SBP) and diastolic (DBP) blood pressure in 22 female patients with verified renal scarring and a history of febrile urinary tract infection (UTI) and in 9 healthy age-matched women with normal urograms and no history of symptomatic UTI. The patients with renal scarring had significantly lower GFR, smaller TRA and higher SBP than the healthy controls, but not significantly different RPF or FF. A decrease in GFR and RPF was associated with higher SBP and DBP in the patients with renal scarring. RPF/TRA, representing an approximation of the perfusion of renal tissue and GFR/TRA, were similar in patients with renal scarring and healthy controls. A reduction of renal parenchyma was accompanied by a proportional decrease in GFR and RPF, resulting in unchanged FF. These findings do not support the concept of hyperfiltration as a main cause of renal insufficiency in patients with pyelonephritis renal scarring. An increase in FF and a decrease in GFR/TRA and RPF/TRA was associated with higher DBP and a decrease in GFR/TRA and RPF/TRA with an increase in the urinary albumin excretion. We conclude that renal hemodynamics play an important part in the blood pressure control of patients with renal scarring and that in these patients with various degrees of renal failure there was no evidence of hyperfiltration or hyperperfusion by remnant glomeruli.

Renal disorders in haemophilia A and B

Although haematuria is a relatively common symptom of hemophilia A and B, renal disease seemed to be a rarity and it has usually been held that this symptom was benign in nature. However detailed studies of renal function in a series of such patients using radiological and biochemical tests of renal function show significant differences compared to normal. These abnormalities seem to be associated with recurrent haematuria but do not appear to be related directly to replacement therapy with plasma concentrate and do not occur more frequently in patients who have received long term fibrinolytic inhibitors. Other rare renal disorders associated with haemophilia include nephrotic syndrome, trauma, acute tubular necrosis, analgesic nephropathy and chronic pyelonephritis.

Failure of excessive doses of ampicillin to prevent bacterial relapse in the treatment of acute pyelonephritis

In order to evaluate whether very high doses of ampicillin might be more effective than conventional therapy in eradicating bacteria in patients with acute pyelonephritis, 34 affected patients were randomly assigned into two treatment groups. One group was given ampicillin in a daily dose of 30 g for three days and 20 g for four days without further treatment. The other group was given ampicillin in moderate doses for one month. Out of 13 patients treated with excessive doses for one week, only three were completely cured whereas conventional therapy cured 9 out of 21. Thus, excessive doses of ampicillin given for one week were not more effective but more expensive and possibly less beneficial than conventional therapy.

[Pyelonephritis with massive renal tissue necrosis in child with urinary tract malformation--a case report]

The aim of the case report is presentation of unusual and heavy clinical course of pyelonephritis with renal tissue necrosis in a child with urinary tract malformation. Nine month old girl was admitted to hospital in heavy clinical status due to pyelonephritis--urosepsis. It was complicated by acute renal insufficiency. Patient was treated by broad-spectrum antibiotics and parenteral nutrition. She was feverish for 14 days. Computed tomography done in order to exclude abdominal abscess showed massive renal tissue necrosis of on both sides. Antibiotic treatment was successful after 6 weeks. Urological evaluation revealed bilateral vesico-ureteral refluxes grade IV. Scintigraphy showed multiple scars. Patient was treated Deflux injections (twice). We noted 5 urinary tract recurrences despite antibiotic profilaxis. GFR of 75 ml/min/1.73 m2 was estimated at age of 16 m. Immunodeficiency or malignancy as background of clinical course were excluded. The case we describe presents severe clinical course of pyelonephritis due to complex urinary tract malformation that is to be considered despite based on modern publications "sparing" strategies of diagnosis and profilaxis in urinary tract malformations.

Renal transplant in patients with spinal cord injuries

OBJECTIVES

There is no knowledge on the outcome of renal transplant for end-stage renal disease secondary to neurogenic bladder caused by spinal cord injury. In this study, we evaluated the outcome of kidney allograft recipients with spinal cord injury.

MATERIALS AND METHODS

We evaluated graft survival, clinical course, laboratory findings, and imaging studies in 21 men (veterans) with spinal cord injury and renal failure secondary to neurogenic bladder. They underwent renal transplant between 1990 and 2006. Bladder dysfunction was appropriately managed before or with receiving the kidney allograft.

RESULTS

Mean (-/+ SD) age of patients was 43.8 -/+ 5.9 years. Mean glomerular filtration rate at the closing date of the study was 89.5 -/+ 33.6 mL/min. During follow-up (median: 6 years, range: 1-17 years), mean duration of graft survival was 15.4 -/+ 1.0 years (95% confidence interval, 13.2-17.5 years). Following renal transplant, mean nadir level of serum creatinine was 74.25 -/+ 16.79 micromol/L (0.84 -/+ 0.19 mg/dL). Six patients (28.6%) had kidney stones before renal transplant, and 2 patients (9.5%) after (1 patient with new kidney stones and 1 patient with kidney stones before and after transplant). Pyelonephritis occurred in 18 patients (85.7%) before transplant, and in 9 patients (42.9%) patients after (P = .07). Graft loss occurred in 2 patients (9.5%) 4 and 18 months after the transplant.

CONCLUSIONS

Spinal cord injury patients who receive allograft kidney transplants have acceptable outcomes, and transplantmay reduce urolithiasis and upper urinary tract infection.

Bilateral extensive emphysematous pyelonephritis. A case report

OBJECTIVE

We report a case involving a patient with bi- lateral emphysematous pyelonephritis (EPN) who was successfully treated with antibiotics and nephrostomy sparing nephrectomy.

CASE PRESENTATION AND INTERVENTION

A 54-year-old diabetic man presented with the chief complaint of progressive abdominal pain for 10 days. Blood tests indicated acute renal failure and hyperglycemic hyperosmolar state. An abdominal radiograph disclosed gas distributed over regions where the bilateral kidneys are located and the right para-lumbosacral area. Computed tomography revealed bilateral enlarged kidneys with the presence of gas in the renal parenchyma and renal pelvis, left peri-renal space, bilateral ureter, bladder, prostate gland and right scrotum. Cultures of urine and blood grew Escherichia coli. The patient was successfully treated with antibiotics coupled with nephrostomy.

CONCLUSION

Timely recognition and initiation of effective antibiotic therapy and nephrostomy may cure the patient with bilateral EPN, while sparing nephrectomy. Regarding clinical manifestations, EPN is nonspecific; hence, radiographs should be taken for diabetic patients with abdominal pain (especially those with poorly controlled blood sugar) to enable early diagnosis of potential EPN.

[Treatment of posttraumatic pyelonephritis and its complications in patients with trauma of the kidneys in combined injuries]

In 12-84% of patients with combined injuries of the kidneys renal complications were diagnosed which appeared at different periods of traumatic disease. Posttraumatic pyelonephritis which transformed in an independent disease at the late periods of traumatic disease was prevailing in the structure of infectious complications. The treatment of posttraumatic pyelonephritis was estimated in 124 patients and included both conservative and operative methods. Operative procedures were performed by minimally invasive (stenting the ureter and percussion methods), endovideosurgical (lumboscopy, sanation and drainage of paranephritis or abscess of the kidney) methods and traditional open operations.

[Type 1 and type 2 interferon inductor (cycloferon) in therapy of children with pyelonephritis associated with herpes viruses]

The clinical and laboratory efficacy of the treatment of children with pyelonephritis with addition of cycloferon, an inductor of early interferon of types 1 and 2, to the main therapy was studied. The mechanism of the cycloferon action was described. The clinical and laboratory remission within a year was observed in 64.3% of the patients treated with addition of cycloferon vs. 47.1% of the patients under the main therapy without the cycloferon addition. The number of the relapses lowered to 7.1% vs. 20.6% of the episodes in the control group. The minimal risk of the disease exacerbation (0.37) in the patients treated with cycloferon and the relative risk of the unfavourable outcomes among the patients under the therapy with addition of cycloferon (0.5967< or =1) were determined.

[Case report of inflammatory pseudotumor that occurred at the ureteropelvic junction]

A 60-year-old woman underwent detailed examinations for hepatic disorders and pancreatic tumor at the Department of Internal Medicine. A tumor mass in her left renal pelvis and a thickened wall in her left ureter were observed on computed tomography (CT) and magnetic resonance imaging (MRI) images. Retrograde ureteropyelography and drip infusion pyelography images showed a stenosis in 1 vertebral body from the left ureteropelvic junction. Urinary cytology finding was class III-a; however, malignancy could not be disregarded. Since the patient continued to experience severe dorsal pain, a left nephroureterectomy was subsequently performed at the patient's request. Pathological tests showed no malignant findings, and based on the chronic pyelonephritis, we diagnosed her condition as an inflammatory pseudotumor. Not many inflammatory pseudotumors are found in the urinary tract, and even fewer are manifest in the renal pelvis and ureter. Although inflammatory pseudotumors are generally benign, cases of repeated local recurrence exist. Therefore, a meticulous follow-up observation is required.

A prospective study of ceftriaxone treatment in acute pyelonephritis caused by extended-spectrum beta-lactamase-producing bacteria

BACKGROUND

Much controversy exists as to whether cephalosporin treatment is appropriate for infections caused by ESBL-producing organisms because no randomized controlled studies have been performed.

OBJECTIVE

Evaluate the therapeutic outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.

MATERIAL AND METHOD

The authors performed a prospective study in female patients hospitalized with acute pyelonephritis caused by ESBL-producing or ESBL-nonproducing E. coli, K. pneumoniae, or P. mirabilis in four hospitals in Thailand from 2004 to 2006. The clinical and microbiological outcomes were evaluated at 72 hours after empirical ceftriaxone treatment.

RESULTS

One hundred eleven patients with the mean age of 65.29 years participated in this study. There were no differences in demographic and clinical characteristics and laboratory data between the ESBL-producing and ESBL-nonproducing groups except the higher rates of previous antibiotic use and urinary tract infection; and the lower frequency of costovertebral angle tenderness in the ESBL-producing group. Both clinical (65% and 93%) and microbiological (67.5% and 100%) responses at 72 hours after ceftriaxone treatment were poorer in the ESBL-producing group than in the ESBL-nonproducing group (p < 0.0002).

CONCLUSION

To the authors' knowledge, this is the first prospective study to evaluate the outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Enterobacteriaceae. The present study confirms that acute pyelonephritis in the female patients caused by ESBL-producing strains could not be treated with ceftriaxone.

[Endoscopic treatment of complicated vesicoureteral reflux grades III-V in infants under the age of one year]

OBJECTIVES

Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritis and high grade (G) Vesicoureteral Reflux (VUR).

INCLUSION CRITERIA

infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibiotic prophylaxis (AP). N = 27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: G II (control without AP); Persistence: III-V Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings.

RESULTS

34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6%), Improved 1, OS 3 (33.3%). Overall results: Solved: 24 U (70.58%), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery.

CONCLUSIONS

ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.

[Case of fungal endophthalmitis from pyelonephritis caused by ureterolithiasis]

A 63-year-old woman presented with visual disturbance. A fever had been noted for 11 days. Right eye visual acuity was 20/50. Left eye visual acuity was 20/20. Inflammatory cclls wcrc present in the right aqueous and the vitreous humor. Tbc right retina was edematous. The left retina and left ocular humors were normal. Urinalysis showcd many white blood cells. Urine culture showed Candida albicans. KUB revealed many small ureteral calculi bilaterally. A diagnosis of fungal endophthalmitis due to pyeloncphritis caused by ureterolithiasis was rendered. The paticnt rcccivcd an intravenous course of fosfiuconazole and fluconazole.

[Immunological indices in urolithiasis patients with secondary pyelonephritis]

The immunological status was studied in 335 patients with urolithiasis and pyelonephritis. The techniques used for assessment of the immunological status provided a multifactorial control over immune system function in inflammation and urolithiasis: registered a significant rise of the level of proinflammatory and anti-inflammatory mediators of the immune response (IL-1beta, IL-4, IL-6, TNF), of neutrophil metabolic activity with parallel suppression of neutrophil phagocytic and absorbing functions, inhibition of bactericidal activity of the serum, a significant fall in the number of mature T-lymphocytes (CD3+) and T-helpers (CD4+). The immune status indices in urolithiasis patients with secondary pyelonephritis are closely linked with clinico-laboratory manifestations of the inflammatory process and renal function. Thus, the results of the study give grounds for developing indications for use of immunomodulating drugs in patients with secondary pyelonephritis associated with urolithiasis.

Emphysematous pyelonephritis in dialysis patient after embolization of failed allograft

Emphysematous pyelonephritis is an uncommon acute infection characterized by the presence of gas in the renal parenchyma. Diabetics account for most cases, and the mortality rate is high. We report a case of emphysematous pyelonephritis after therapeutic embolization of a nonfunctioning renal graft in a nondiabetic dialysis patient. Given the increasing popularity of therapeutic embolization to control graft intolerance syndrome associated with rejected kidneys, physicians should be aware of this potentially severe complication. We discuss the differential diagnosis from entities requiring different management strategies, such as postembolization syndrome, persistence of graft intolerance, and the presence of sterile intrarenal.

Does early treatment of urinary tract infection prevent renal damage?

OBJECTIVE

Therapeutic delay has been suggested as the most important factor that is likely to have an effect on the development of scarring after acute pyelonephritis. However, this opinion has not been supported by prospective studies, so we tested it.

METHODS

In a prospective clinical study, we evaluated whether the time interval between the onset of the renal infection and the start of therapy correlates with the development of acute inflammatory changes and the subsequent development of renal scars, documented by dimercaptosuccinic acid scintigraphy. A total of 278 infants (153 male and 125 female) aged 0.5 to 12.0 months with their first urinary tract infection were enrolled in the study.

RESULTS

The median time between the onset of infection and the institution of therapy was 2 days (range: 1-8 days). Renal inflammatory changes were documented in 57% of the infants. Renal defects were recorded in 41% of the patients treated within the first 24 hours since the onset of fever versus 75% of those treated on day 4 and onward. Renal scarring was developed in 51% of the infants with an abnormal scan in the acute phase of infection. The frequency of scarring in infants treated early and in those whose treatment was delayed did not differ, suggesting that once acute pyelonephritis has occurred, ultimate renal scarring is independent of the timing of therapy. Acute inflammatory changes and subsequent scarring were more frequent in the presence of vesicoureteral reflux, especially that which is high grade. However, the difference was not significant, which suggests that renal damage may be independent of the presence of reflux.

CONCLUSIONS

Early and appropriate treatment of urinary tract infection, especially during the first 24 hours after the onset of symptoms, diminishes the likelihood of renal involvement during the acute phase of the infection but does not prevent scar formation.

Part 1: Vesicoureteral reflux treatment: the past, present, and future

The purpose of this manuscript is to provide clinicians with highlights of key findings pertaining to our current understanding and treatment of the condition of vesicoureteral reflux (VUR). This includes a review of the disease, patient characteristics, current treatment options, challenges for managed care and patients, and opportunities for improvements in care. This is not intended as a comprehensive review of VUR. This manuscript does, however, serve to introduce three additional manuscripts contained within this supplement. The first article in this series is designed to provide the clinician with real-world data pertaining to treatment patterns and outcomes in patients with VUR (Examining pediatric vesicoureteral reflux: a real-world evaluation of treatment patterns and outcomes: Hensle TW, Hyun G, Grogg AL, Eaddy M). The second article considers the efficacy of prophylactic antibiotics in reducing the likelihood of urinary tract infections (UTIs) when compared with endoscopic injection with dextranomer/hyaluronic acid (Endoscopic injection versus antibiotic prophylaxis in the reduction of urinary tract infection in patients with vesicoureteral reflux: Elder JS, Shah MB, Batiste LR, et al.). The third article explores the role medication noncompliance plays in contributing to antibiotic resistance, the consequences associated with resistance (longer lasting illness and costs), and the difficulties with resistance specific to UTI pathogens in children (Considerations regarding the medical management of VUR: what have we really learned?: Koyle MA, Caldamone A). This supplement is intended to provide the clinician with valuable information regarding the treatment patterns, the role of compliance, and the efficacy of treatments for pediatric patients with VUR.

[Retroperitoneoscopic ureterolithotomy]

Ureterolithotomy has an alternative which is much less invasive --retroperitoneoscopic ureterolithotomy (RU). Nineteen cases of RU are reported (15 males, 4 females). Thirteen patients have undergone RU as monotherapy, 5 patients--after ineffective sessions of extracorporeal shock wave lithotripsy, 1 patient--after contact ureterolithotripsy. Mean size of the stones was 12.8 (9.5-30) mm. All the stones were eliminated for one procedure. Duration of surgery in the first 5 operations was 1.5-2 hours, in subsequent ones--65-70 min. The number of bed-days varied from 2 to 10 days (4.2 days). One male had a postoperative attack of pyelonephritis which was treated with antibacterial drugs. RU is a safe and effective operation, it is justified when previous surgery was ineffective, in large, longstanding concrements of the upper and middle third of the ureter, monohydrate-oxalate concrements.

[Transurethral endoscopic pyelolithotripsy in combined treatment of complex forms of nephrolithiasis]

The article presents results of retrograde endoscopic pyelolithotripsy (REP) in 75 patients with large and coral nephroliths. Retrograde contact pyelolithotripsy was made with application of Swiss Lithoclast unit, semirigid ureteroscopes R. Wolf with a cone 8-9 Ch and working channel 5.3 Ch. This enables maximal removal of the destroyed concrement by hydraulic litholapaxia with consequent insertion of the internal stent. Extracorporeal lithotripsy with low-energy shock-wave impulses was performed on demand (1-3 sessions). The stent was removed in 3-5 days in cases of complete one-stage sanation of the kidney and in 2-3 weeks in the presence of residual fragments of the nephrolith. One-stage complete sanation in coral nephrolithiasis (K1-K2) up to 5 cm3 and large concrements was achieved in 69.3% patients. Three months later residual fragments of the nephroliths were observed in 8% patients, 6 months later--in 5.3%. One year after treatment a complete sanation was achieved in 96%. Complications of the method consisted in exacerbation of chronic pyelonephritis observed in 12% cases. The control examination revealed improvement of renal function early and late after surgery. As shown by 6-year follow-up, recurrent nephroliths occurred in 6% patients. Endoscopic retrograde pyelolithotripsy can be used as a method of choice in the treatment of compound forms of nephrolithiasis in intrarenal type of the pelvis, the absence of marked extension of the caliceal-pelvic system of the kidney, in other stones resistant to extracorporeal lithotripsy.

The effects of methylene blue on renal scarring due to pyelonephritis in rats

The aim of this study was to evaluate the efficiency of methylene blue (MB) in preventing renal scar formation after the induction of pyelonephritis (PNP) in a rat model with delayed antimicrobial therapy. An inoculum of the K-12 strain of Escherichia coli was injected into both kidneys. Control groups received isotonic saline instead of bacterial solution. Four equal groups were then formed: the PNP group was untreated and the PNP ciprofloxacin (CIP) treated group was treated only with CIP intraperitoneally (i.p.) starting on the third day following bacterial inoculation. In the PNP (MB)-treated group, MB was given i.p., and in the PNP MB + CIP-treated group, MB + CIP were administered i.p.. In the sixth week following bacterial inoculation, all rats were sacrificed, and both kidneys of the rats in all groups were examined biochemically and histopathologically for renal scarring. Renal scar was significant in the groups treated with MB alone or MB + CIP combination compared with untreated or antibiotic only groups. Delayed treatment with antibiotics had no effect on scarring. These results suggest that the addition of MB to the delayed antibiotic therapy might be beneficial in preventing PNP-induced oxidative renal tissue damage.

Extensive emphysematous pyelonephritis

We report an unusually severe case of emphysematous pyelonephritis with very extensive kidney necrosis that led to unilateral nephrectomy. We discuss the diagnosis and treatment options in this very rare complication of pyelonephritis almost exclusively encoutered in diabetic patients.

[Laparoscopic cystectomy and transileal ureterostomy for neurogenic vesicosphincteric disorders. Evaluation of morbidity]

OBJECTIVES

To evaluate the morbidity and mortality of laparoscopic cystectomy combined with transileal ureterostomy to treat neurogenic vesicosphincteric disorders.

MATERIAL

Prospective study performed between february 2004 and april 2006 on 26 consecutive patients with a mean age of 55.0 +/- 12.7 years treated by laparoscopic cystectomy for neurogenic vesicosphincteric disorders. The underlying neurological disease was multiple sclerosis (MS) in 20 cases, spinal cord injury in 4 cases and transverse myelitis in 2 cases. The median preoperative ASA score was 3 (range: 2-3).

RESULTS

No open conversion was necessary. One intraoperative complication was observed (vascular injury). No perioperative death was observed. The nasogastric tube was maintained postoperatively for an average of 8.69 +/- 5.9 hours. The mean time to resumption of oral fluids was 1.4 +/- 0.7 days and mean time to resumption of solids was 2.6 +/- 1.0 days. The mean time to resumption of bowel movements was 3.8 +/- 3.2 days. The mean intensive care stay was 3.9 +/- 1.1 days. Two postoperative complications were observed in the same patient (ileus and bronchial congestion). Postoperative narcotic analgesics were necessary in 60% of cases. The mean hospital stay was 10.3 +/- 4.1 days. Two late postoperative complications were observed in the same patient (two episodes of pyelonephritis).

CONCLUSION

Laparoscopic cystectomy has a low morbidity in neurological patients, allowing early return of feeding and a moderate length of hospital stay.

A postoperative complication causing physician consternation

BACKGROUND

Postoperative ileus and urinary retention are relatively common complications after obstetric and gynecologic procedures. This case highlights an unusual cause of these common postoperative patient reports.

CASE

A 71-year-old woman underwent an uncomplicated total vaginal hysterectomy and pelvic reconstruction for stage III pelvic organ prolapse. She subsequently presented with and was hospitalized for labile blood pressures, ileus, urinary retention, and subjective sensory and motor complaints. The cause of the patient's reports was not clear until her disease became relatively severe.

CONCLUSION

When a postoperative patient has multiple symptoms that do not respond to standard intervention, rare causes outside of one's specialty should be considered.

Results of Percutaneous Endoscopic Ureterolithotomy Compared to that of Ureteroscopy

Percutaneous endoscopic ureterolithotomy is not a well-known method for the treatment of impacted ureteral stones. The authors performed a retrospective study to compare the effectiveness of this procedure to ureteroscopy for the treatment of ureteral calculi. Impacted ureteral stones were removed in 93 patients by percutaneous endoscopic ureterolithotomy (Group 1). In 142 patients, ureteroscopy was performed for the treatment of the ureteral stones (Group 2). The same instruments were used to carry out percutaneous endoscopic ureterolithotomy as were used for percutaneous nephrolithotomy. During these interventions, a direct percutaneous puncture and extraction of the stones was performed. The average diameter of the stones was 11 +/- 4 mm in Group 1 and 7 +/- 2 mm in Group 2. The average operating time was 32 +/- 11 minutes in Group 1 and 41 +/- 29 minutes in Group 2. The average duration of hospitalization following the operations was 7.2 +/- 3.1 days in Group 1 and 3.5 +/- 2.5 days in Group 2. In Group 1, the average time of the operations was significantly lower (p 0.006), and the duration of postoperative hospital stay was significantly higher (p < 0.001), compared to Group 2. In Group 1, retroperitoneal hematoma occurred in 1 patient and prolonged urine leakage was detected in 2 cases, whereas in Group 2, pyelonephritis occurred in 5 patients following the operation. In conclusion, the operating time of percutaneous endoscopic ureterolithotomy is shorter and the rate of complications comparable with that of ureteroscopy. Percutaneous endoscopic ureterolithotomy is suggested for the removal of impacted ureteral stones instead of open surgical ureterolithotomy.

Emphysematous pyelonephritis in a diabetic patient with pelvic-ureteric stone

Emphysematous pyelonephritis is a rare but life threatening infection of kidney that is characterized by gas formation within or around the kidney. We describe a case of emphysematous pyelonephritis as a consequence of inadequately treated pelvic-ureteric stone in a diabetic man and complement this with a brief review of the literature pertaining in particular to the management of this condition.