Gross Hematuria Does not Affect the Selection of Nephrectomy Types for Clinical Stage 1 Clear Cell Renal Cell Carcinoma: A Multicenter, Retrospective Cohort Study

PURPOSE

This study aimed to discuss the correlation between gross hematuria and postoperative upstaging (from T1 to T3a) in patients with cT1 clear cell renal cell carcinoma (ccRCC) and to compare oncologic outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in patients with gross hematuria.

METHODS

A total of 2145 patients who met the criteria were enrolled in the study (including 363 patients with gross hematuria). The least absolute selection and shrinkage operator logistic regression was used to evaluate the risk factor of postoperative pathological upstaging. The propensity score matching (PSM) and stable inverse probability of treatment weighting (IPTW) analysis were used to balance the confounding factors. The Kaplan-Meier analysis and multivariate Cox proportional risk regression model were used to assess the prognosis.

RESULTS

Gross hematuria was a risk factor of postoperative pathological upstaging (odds ratio [OR] = 3.96; 95% confidence interval [CI] 2.44-6.42; P < 0.001). After PSM and stable IPTW adjustment, the characteristics were similar in corresponding patients in the PN and RN groups. In the PSM cohort, PN did not have a statistically significant impact on recurrence-free survival (hazard ratio [HR] = 1.48; 95% CI 0.25-8.88; P = 0.67), metastasis-free survival (HR = 1.24; 95% CI 0.33-4.66; P = 0.75), and overall survival (HR = 1.46; 95% CI 0.31-6.73; P = 0.63) compared with RN. The results were confirmed in sensitivity analyses.

CONCLUSIONS

Although gross hematuria was associated with postoperative pathological upstaging in patients with cT1 ccRCC, PN should still be the preferred treatment for such patients.

Safety and efficacy of transcatheter arterial embolization in autosomal dominant polycystic kidney patients with gross hematuria: Six case reports

BACKGROUND

To retrospectively report the safety and efficacy of renal transcatheter arterial embolization for treating autosomal dominant polycystic kidney disease (ADPKD) patients with gross hematuria.

CASE SUMMARY

The purpose of this study is to retrospectively report the safety and efficacy of renal transcatheter arterial embolization for treating ADPKD patients with gross hematuria. Materials and methods: During the period from January 2018 to December 2019, renal transcatheter arterial embolization was carried out on 6 patients with polycystic kidneys and gross hematuria. Renal arteriography was performed first, and then we determined the location of the hemorrhage and performed embolization under digital subtraction angiography monitoring. Improvements in routine blood test results, routine urine test results, urine color and postoperative reactions were observed and analyzed. Results: Renal transcatheter arterial embolization was successfully conducted in 6 patients. The indices of 5 patients and the color of gross hematuria improved after surgery compared with before surgery. No severe complication reactions occurred.

CONCLUSION

For autosomal dominant polycystic kidney syndrome patients with gross hematuria, transcatheter arterial embolization was safe and effective.

C3 glomerulopathy in a patient with a history of post-infectious glomerulonephritis

Post-infectious glomerulonephritis (PIGN) is an immune complex mediated glomerular injury occurring because of an infection, most commonly with group A beta-hemolytic streptococcus in children. C3 glomerulopathy (C3G) is a distinct clinicopathological entity occurring secondary to dysregulation of alternate complement pathway encompassing both C3 glomerulonephritis (C3GN) and dense deposit disease (DDD). While most patients with PIGN attain complete remission with normalized complement levels by 6-8 weeks after presentation, patients with C3G continue to have hypocomplementemia with high rates of progressive kidney disease. Here, we report a patient diagnosed with dense deposit disease after his initial presentation with PIGN three years prior. While current literature continues to explore the overlapping and distinguishing features of PIGN and C3G, including how underlying defects in the alternate complement pathway may commonly contribute to both diseases, this case further exemplifies the importance of recognizing the clinico-pathogenic features of PIGN and C3G in pediatric patients with glomerulonephritis.

Contained rupture of a left renal artery aneurysm: Report of a case

Ruptured renal artery aneurysms are uncommon. Although the increased use of endovascular technologies, controversy persists over the management. Contained rupture may be more difficult to diagnose, hence delay the management. We report a case of contained rupture of renal artery aneurysm treated with selective embolization prior to nephrectomy.

Muscle-invasive angiosarcoma of the urinary bladder: Case report

A 71-year-old male with benign prostatic hyperplasia managed by self-catheterization presented with gross hematuria. A CT scan of abdomen and pelvis demonstrated abnormal bladder appearance with right sided mass and a diverticulum. Patient underwent transurethral resection of bladder tumor. Pathology was significant for high-grade muscle-invasive angiosarcoma. The malignant cells showed positive staining for vimentin and CD31. Given patient's underlying comorbidities and following multidisciplinary discussion, hospice care was pursued. The aim of this case report is to provide an overview on clinical presentation, diagnosis, and current management of this rare entity of genitourinary sarcoma.

Secondary immunoglobulin A nephropathy with gross hematuria leading to rapidly progressive glomerulonephritis following severe acute respiratory syndrome coronavirus 2 vaccination: a case report

BACKGROUND

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been followed by many reports of the development and relapse of autoimmune diseases associated with SARS-CoV-2 vaccination. Some of these reports have involved relapse or onset of immunoglobulin A (IgA) nephropathy following SARS-CoV-2 vaccination. Here, we report on a patient with IgA nephropathy who presented with gross hematuria and rapidly progressive glomerulonephritis following SARS-CoV-2 vaccination.

CASE PRESENTATION

A 63-year-old male patient with a history of habitual tonsillitis underwent bilateral tonsillectomy. He had a history of alcoholic cirrhosis of the liver and microscopic hematuria and proteinuria were indicated during a health checkup 2 years before hospital admission. He developed hematuria after the SARS-CoV-2 vaccination, which led to rapidly progressive glomerulonephritis, for which he was hospitalized. A renal biopsy led to the diagnosis of IgA nephropathy. Although pulse steroid therapy during his condition resulted in hepatic encephalopathy, three courses combined with mizoribine improved his renal function.

CONCLUSION

SARS-CoV-2 mRNA vaccines activate T cells, which are involved in the pathophysiology of IgA nephropathy. Therefore, this case suggests that the exacerbation of IgA nephropathy by the vaccine favors the vasculitis aspect of the disease.

IgA nephropathy after COVID-19 vaccination and analysis of reported cases

Background

Immunoglobin A nephropathy (IgAN) is one of the most common forms of chronic glomerulonephritis and has been shown to occur in association with vaccinations. While various vaccines against COVID-19 have become widely used, their side effects, especially on IgAN following COVID-19 vaccines are still unclear. In this report, we describe the clinical courses and histopathologic findings of a newly diagnosed case of IgAN after receiving the mRNA-1273 (Moderna) COVID-19 vaccination.

Methods

This study presents a case of new-onset IgAN following mRNA-1273 COVID-19 (Moderna) vaccination. In addition, we review and analyze similar cases previously reported in the literature up to October 2022.

Results

Of the 52 cases reviewed, including our own, the majority of patients were female, and 64% of patients had initial onset IgAN. The most common manifestation was gross hematuria (87%), other associated symptoms were fever (44%), myalgia (8%), arthralgia (4%), and edema (4%). Many of these cases occurred after receiving Pfizer products as the second vaccination. Oral corticosteroids were used to 16 cases, and steroid pulse therapy was used to treat 7 cases.

Conclusion

While this is not a controlled study, it is important for physicians to consider the possibility that COVID-19 vaccines may provoke a flare of IgAN. Several therapeutic agents may be useful for treating COVID-19 vaccine-induced IgAN, although a specific mechanism or pathophysiological association cannot be confirmed without further research.

Urinary catheterization prior to PCI worsens clinical outcomes in patients with acute myocardial infarction

BACKGROUND

Indwelling urethral catheters (IUCs) are used to measure urine volume, keep patients on bed rest, or keep the groin area clean in patients with acute myocardial infarction (AMI). However, the association between IUC use and in-hospital urinary-related complications is unknown.

METHODS

This was a single-center retrospective analysis of 303 patients admitted to our hospital in 2018-2020 who had AMI without cardiogenic shock. An IUC was inserted in the emergency room upon initiation of invasive catheter treatment and removed as soon as possible. The primary outcome was in-hospital adverse urinary event (IHAUE), which consisted of in-hospital urinary tract infection and in-hospital gross hematuria.

RESULTS

Of 303 patients, 243 patients (80.2 %) underwent IUC insertion. A lower proportion of patients with IUCs were male (72 % vs. 85 %, p = 0.044). A higher proportion had Killip classification 2 or 3 (13 % vs. 0 %, p = 0.003) or ST-elevation myocardial infarction (65 % vs. 32 %, p < 0.001). IHAUEs occurred significantly more commonly in patients with IUCs than without IUCs (11 % vs. 2 %, p = 0.023). Kaplan-Meier analysis showed that IHAUEs occurred more frequently in patients with IUCs than patients without IUCs (log-rank test p = 0.033). Furthermore, IUC use longer than the median of 2 days was associated with a higher odds ratio (OR) for IHAUE when compared with those without IUC use (OR, 3.65; 95 % confidence interval, 1.28-10.4; p = 0.015). There were no significant differences in in-hospital mortality by IUC status.

CONCLUSIONS

IUC use is associated with a higher risk of IHAUEs in patients with uncomplicated AMI. Routine IUC use might not be recommended.

Case report of avascular necrosis of the glans penis after PAE embolization

BACKGROUND

Prostate artery embolization (PAE) is a relatively safe and effective alternative method for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. The adverse events caused by PAE are primarily mild, including urinary tract infection, acute urinary retention, dysuria, fever, etc. Severe complications, such as nontarget organ embolism syndrome or penile glans ischemic necrosis, are rare. Here, we report a case of severe ischemic necrosis of the glans penis after PAE and review the literature.

CASE PRESENTATION

An 86-year-old male patient was admitted to the hospital due to progressive dysuria with gross hematuria. The patient underwent placement of a three-way urinary catheter to facilitate continuous bladder flushing, hemostasis, and rehydration. After admission, his hemoglobin decreased to 89 g/L. After an examination, the diagnosis was benign prostatic hyperplasia with bleeding. During communication with the patient regarding treatment, he requested prostate artery embolization due to his advanced age and concomitant disease status. He underwent bilateral prostate artery embolization under local anesthesia. His urine gradually turned clear. However, on the 6th day after embolization, the glans gradually showed ischemic changes. On the 10th day, there was partial necrosis and blackening of the glans. The glans completely healed, and the patient was able to urinate smoothly on the 60th day after local cleaning and debridement, the administration of pain relief, anti-inflammatory and anti-infection agents, and external application of burn ointment.

CONCLUSION

Penile glans ischemic necrosis after PAE is rare. The symptoms include pain, congestion, swelling, and cyanosis in the glans.

Gross hematuria as the presentation of ureteral paraganglioma: a case report and literature review

BACKGROUND

Paraganglioma of genitourinary tract is uncommon, and origin from ureter is even rarer. We aim to present a case of paraganglioma from ureter in a 48-year-old female patient, who presented with gross hematuria.

CASE PRESENTATION

We present a 48-year-old female who complained of gross hematuria for one week. A left ureteral tumor was found by image study. However, hypertension was unexpectedly recorded during diagnostic ureteroscopy survey. Due to persisted gross hematuria and bladder tamponade, she underwent left nephroureterectomy with bladder cuff resection. Blood pressure surged again when the tumor was surgically approached. Ureteral paraganglioma was confirmed according to pathological report. After the surgery, the patient recovered well, and no more gross hematuria was noted. She is now under regular follow-up at our outpatient clinic.

CONCLUSION

Ureteral paraganglioma should be kept in mind not only when blood pressure fluctuates during operation, but also before we manipulate the ureteral tumor when gross hematuria is the only sign. Whenever the presumption of paraganglioma is raised, laboratory evaluation and anatomical or even functional imaging should be considered. The concomitant anesthesia consultation before the surgery should not be deferred, either.

Easily misdiagnosed complex Klippel-Trenaunay syndrome: A case report

BACKGROUND

Klippel-Trenaunay syndrome (KTS) is a congenital vascular malformation with a complicated etiology. It is sporadic and clinically rare in occurrence. The typical characteristics are capillary malformation (also known as port-wine stain), varicose veins and malformations, and bony and/or soft tissue hypertrophy with or without lymphatic malformation, which are known as the “classic clinical triad”. Herein, a rare case of KTS characterized by crossed-bilateral limb hypertrophy accompanied by intermittent hematochezia and hematuria is reported.

CASE SUMMARY

We described a 37-year-old female with KTS. She was admitted to our hospital owing to the gradual enlargement of the left lower extremity along with intermittent hematochezia and hematuria. The patient was diagnosed to have hemorrhoid bleeding by other hospitals and treated with conventional hemostatic drugs, but continued to have intermittent gastrointestinal bleeding and hematuria. Therefore, she visited our hospital to seek further treatment. During hospitalization, relevant imaging and laboratory examinations and colonoscopy were performed. In combination with the patient’s history and relevant examinations, we considered that the patient had a complex form of KTS. We recommended a combined diagnosis and treatment from the vascular, interventional, anorectal, and other departments, although she declined any further treatment for financial reasons.

CONCLUSION

The clinical manifestations of KTS are extensive and diverse and chiefly include the typical triad. However, Vascular malformations of KTS can also involve several parts and systems such as digestive and urogenital systems. Therefore, the atypical manifestations and rare complications necessitate the clinician’s attention and are not to be ignored.

Operator Learning Curve for Prostatic Artery Embolization and Its Impact on Outcomes in 296 Patients

PURPOSE

To define operator learning curve inflection points for prostatic artery embolization (PAE) and their impact on technical efficiency, clinical outcomes, and adverse events.

MATERIALS AND METHODS

Between May 2013 and May 2021, 296 consecutive patients with moderate-to-severe lower urinary tract symptoms, urinary retention, or gross hematuria from benign prostatic hyperplasia underwent PAE by an interventional radiologist without prior PAE-specific experience. Operator learning curves plotted procedure time, fluoroscopy time, contrast volume, and embolic endpoint data against sequential procedure number. Multiple regression analysis evaluated for improvements in these parameters, with segmented linear regression to detect learning curve inflection points. Linear and logistic regression evaluated for learning curve impacts on 6-month clinical outcomes and 90-day adverse events.

RESULTS

No baseline patient characteristic varied over the series apart from decreasing pre-procedural gland volume (P < 0.01). Multiple regression analysis demonstrated experience-dependent improvements in procedure time, fluoroscopy time, and contrast volume (P < 0.01), with corresponding learning curve inflection points at 76 (P < 0.01), 78 (P < 0.01), and 73 (P = 0.10) procedures. Embolic endpoints did not vary with experience (P > 0.05). Post-procedure reductions in International Prostate Symptom Score (21.5 ± 6.2 to 6.7 ± 4.7), Quality of Life score (4.5 ± 1.2 to 1.3 ± 1.2), post-void residual (190 ± 203 to 97 ± 148 mL), and gland volume (142 ± 97 to 76 ± 47 mL) were substantial (P < 0.01) but did not vary with experience (P > 0.05), nor did adverse event frequency/severity (P > 0.05).

CONCLUSION

Operator technical efficiency plateaued after 73-78 PAE procedures. Clinical improvements were substantial and adverse event frequency/severity low, and neither varied with experience. Operators without prior PAE-specific experience may perform PAE safely and effectively from the outset.

LEVEL OF EVIDENCE

Level 2b, Cohort Study.

Comparison of renal histopathology in three patients with gross hematuria after SARS-CoV-2 vaccination

We present three cases of IgA nephropathy with gross hematuria following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) messenger RNA (mRNA) vaccination. Case 1 was a 60-year-old woman who has previously experienced transient proteinuria. Case 2 was a 22-year-old woman with no history of urinary abnormality. Finally, case 3 was a 66-year-old woman who has had microscopic hematuria since she was in her 50s. They were all diagnosed as IgA nephropathy with little histological active lesion. Their renal function and proteinuria improved without the use of corticosteroids. There were differences in the findings of vascular endothelial damage based on the time between the appearance of gross hematuria and renal biopsy. Glomerular endocapillary damage could be a part of the mechanism triggered by mRNA vaccination. When a patient presents with gross hematuria following vaccination, a comprehensive approach including renal biopsy should be considered.

A Review of Urinary Tract Endometriosis

PURPOSE OF REVIEW

To describe the presenting signs and symptoms of patients with urinary tract endometriosis (UTE), appropriate workup, and to review medical and surgical therapies for symptom palliation and definitive management.

RECENT FINDINGS

UTE is a condition that clinicians should maintain a high index of suspicion for, as symptoms can be easily misdiagnosed from other causes. Surgical resection of implants appears to offer safe and durable symptom relief. Urinary tract endometriosis may present with symptoms overlapping with interstitial cystitis, nephrolithiasis, bladder overactivity, or recurrent urinary tract infections, and may or may not be cyclical in nature. Cyclical gross hematuria is considered pathognomonic, though final diagnosis must be made after a pathologic review. Without proper diagnosis and treatment, consequences such as silent renal loss from asymptomatic obstruction may result. After the diagnosis is made, initial therapy can be undertaken with hormonal treatment to palliate symptoms (most commonly in the form of combined oral contraceptives), followed by surgical resection for a definitive treatment option.

Gross hematuria can be an impact of severe acute respiratory syndrome coronavirus 2 vaccination on immunoglobulin A nephropathy: a case report

BACKGROUND

Immunoglobulin A nephropathy is typically accelerated by upper respiratory tract infections and can relapse following vaccination. There have been reports of patients who presented with immunoglobulin A nephropathy flares with or without gross hematuria following coronavirus disease 2019 vaccination. However, this relationship remains to be elucidated.

CASE PRESENTATION

Herein, we present the case of a patient with newly diagnosed immunoglobulin A nephropathy who presented with gross hematuria following the second dose of coronavirus disease 2019 vaccine. A 21-year-old Japanese woman presented with fever and new-onset gross hematuria 1 day after receiving the second dose of the coronavirus disease 2019 vaccine (Pfizer). She had microhematuria without proteinuria for 2 years at the time of her medical check-up. Gross hematuria resolved 6 days after the second dose of the coronavirus disease 2019 vaccine; however, microhematuria (> 100 per high-power field) and mild proteinuria were observed. She was admitted to our hospital 4 weeks after the second vaccination because of persistent urinary abnormalities. She was well before the vaccination and did not have any pulmonary involvement on chest radiography or any symptoms suggestive of coronavirus disease 2019. Renal biopsy revealed an immunoglobulin A nephropathy. The Oxford MEST-C score was M0E0S0T0C0. Our patient's urinary abnormalities implied exacerbation of immunoglobulin A nephropathy after coronavirus disease 2019 vaccination.

CONCLUSIONS

In our case, gross hematuria served as a trigger for immunoglobulin A nephropathy diagnosis, suggesting that nephrologists should pay close attention to gross hematuria and urinalysis after coronavirus disease 2019 vaccination.

Sibling cases of gross hematuria and newly diagnosed IgA nephropathy following SARS-CoV-2 vaccination

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination has become a major part of the strategy to reduce Coronavirus disease 2019 (COVID-19) numbers worldwide. To date, vaccinations based on several mechanisms have been used clinically, although relapse of existent glomerulonephritis presenting as gross hematuria, and occurrence of de novo glomerulonephritis have been reported.

Case presentation

We report the first sibling cases newly diagnosed as immunoglobulin A (IgA) nephropathy after the second dose of SARS-CoV-2 vaccination. 15- and 18-year-old men presented with gross hematuria following the second dose of SARS-CoV-2 vaccine (Pfizer, BNT162b2) received on the same day. Pathological findings of each kidney biopsy specimen were consistent with IgA nephropathy. Gross hematuria in both cases spontaneously recovered within several days.

Conclusions

These cases indicate that SARS-CoV-2 vaccination might trigger de novo IgA nephropathy or stimulate its relapse, and also highlight the necessity of understanding the immunological responses to the novel mRNA vaccines in patients with kidney diseases.

Laparoscopic repair of sciatic ureteral hernia: A case report

We present a rare case of sciatic ureteral herniation with consecutive renal unit obstruction. 72 year old woman presented with gross hematuria associated with unilateral hydronephrosis. During work up IVP and MRI were performed, and the diagnosis of sciatic ureteral hernia was established. Condition was resolved by laparoscopic hernia repair.

Post traumatic internal iliac arteriovenous fistula presenting with persistent gross hematuria

Traumatic pelvic arteriovenous fistulas (AVFs) are exceedingly rare and can lead to significant morbidity. Herein, we describe the case of a 31 year-old male who presented with two months of recurrent gross hematuria following a gluteal gun-shot wound and was found to have a right internal iliac AVF. To our knowledge, this is the first reported case of a post traumatic pelvic AVF presenting with gross hematuria.

Gross hematuria after SARS-CoV-2 vaccination: questionnaire survey in Japan

Background

Recent clinical reports indicate a correlation between gross hematuria after the coronavirus 2019 (COVID-19) vaccination in patients with glomerulonephritis, especially immunoglobulin A nephropathy (IgAN). Furthermore, healthcare workers in Japan were initially vaccinated with an mRNA vaccine from February 17, 2021, and some of them experienced gross hematuria after receiving the vaccination.

Methods

We conducted a web-based survey of the councilor members of the Japanese Society of Nephrology (581 members, 382 facilities) to elucidate the relationship between gross hematuria and COVID-19 vaccination.

Results

In the first survey, 27 cases (female: 22, 81.5%) of gross hematuria were reported after receiving a COVID-19 vaccination. Of them, 19 (70.4%) patients were already diagnosed with IgAN at the occurrence of gross hematuria. Proteinuria appeared in eight of the 14 (57.1%) cases with no proteinuria before vaccination and hematuria in five of the seven (71.4%) cases with no hematuria before vaccination. The second survey revealed that a renal biopsy was performed after vaccination in four cases, all of whom were diagnosed with IgAN. Only one case showed a slightly increased serum creatinine level, and no patients progressed to severe renal dysfunction.

Conclusion

This study clarified the clinical features of gross hematuria after a COVID-19 vaccination. Because there was no obvious progression to severe renal dysfunction, safety of the COVID-19 vaccination is warranted at least in the protocol of inoculation twice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10157-021-02157-x.

Gross hematuria: An unusual presenting symptom of systemic wild-type transthyretinamyloidosis

Amyloidosis of the urinary bladder is a rare cause of gross hematuria. In patients with systemic amyloidosis, identification is nearly always related to cardiac complaints; urologic presenting symptoms are extremely uncommon. We present a 77-year-old male patient with painless gross hematuria ultimately found to be secondary to systemic wild-type transthyretin amyloidosis. He underwent transurethral resection of the bladder lesion and was initiated on transthyretin stabilizing medication. In the 6 months since starting treatment, the patient has had no further episodes of gross hematuria, but will require cystoscopic surveillance for evidence of recurrence or concomittment urothelial carcinoma.

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Systemic transthyretin amyloidosis diagnosed after an episode of painless gross hematuria.

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Extremely uncommon presenting symptom; only the second documented patient.

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No evidence of recurrent disease at 6 months status post transurethral resection.

ACR Appropriateness Criteria® Hematuria

Hematuria is a common reason for patients to be referred for imaging of the urinary tract. All patients diagnosed with hematuria should undergo a thorough history and physical examination, urinalysis, and serologic testing prior to any initial imaging. Ultrasound, CT, and MRI are the most common imaging modalities used to evaluate hematuria. This document discusses the following clinical scenarios for hematuria: initial imaging of microhematuria without risk factors or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation; initial imaging of microhematuria in patients with known risk factors and no history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation or renal parenchymal disease; initial imaging of microhematuria in the pregnant patient and initial imaging of gross hematuria. Follow-up of normal or abnormal findings is beyond the scope of this review. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Non-penetrating traumatic psoas muscle hematoma presenting with gross hematuria: a case report

Psoas muscle hematoma is defined as a spontaneous or traumatic retroperitoneal collection of blood involving the psoas muscle. Early symptoms of an iliopsoas hematoma include lower abdominal or severe groin pain. Although psoas hematoma is a known complication of coagulopathy, psoas hematoma caused by non-penetrating trauma is the subject of only scattered reports and its significance has not been well described in the literature, so the aim of this study was to report a case of blunt traumatic psoas hematoma with the fracture of vertebral transverse process with the presentation of gross hematuria. A 65-year-old Iranian man slipped backward to the ground, and the patient complaint of gross hematuria and difficulty in walking. There was severe left costo-vertebral angle (CVA) tenderness, and mild groin tenderness, and the lower back area was painful, and he had some pain with the flexion of the vertebral column, and there was tenderness on lumbar spine, but there was no tingling, paresthesia, and weakness in left lower extremity. Hip flexion was 3/5 in the left lower. We used some diagnostic modalities as x-ray radiography, ultrasonography, computed tomography (CT) scan with intravenous (IV) contrast, CT cystography, and intravenous pyelogram (IVP) IVP to differentiate the diagnoses and also find skeletal and other organ injuries associated with this kind of injury. We can conclude that post-traumatic psoas hematoma is a rare condition. The diagnostic modality of choice is CT scan which allows rapid identification and measurement of the hematoma. The lesion usually treated with non-operative conservative management.

Gross hematuria: A rare presentation of disseminated tuberculosis

Tuberculosis (TB) is a multi-systemic disease instigated by Mycobacterium tuberculosis that can involve any organ. In any child presenting with clinical features involving multiple organ systems, TB forms an important differential. This holds particularly for endemic countries like India. Genitourinary TB (GUTB) comprises up to 27% of all extrapulmonary TB cases. We present an unusual presentation of disseminated TB involving kidneys and presenting as gross hematuria. 12-year-old girl, presented with recurrent episodes of gross hematuria of one-month duration. She received multiple packed cell transfusions for the same. She had chronic malnutrition. USG KUB with renal doppler was normal. Given persistent hematuria, CT urography was done which showed features suggestive of papillary necrosis with cystitis. Tubercular workup showed multiple opacities predominantly involving perihilar regions bilaterally on chest x-ray along with positive Mantoux test. Sputum for AFB was positive for tubercular bacilli. Urine samples were also sent for CBNAAT which showed TB bacilli sensitive to rifampicin. With a diagnosis of disseminated TB, antitubercular therapy (ATT) was started followed by cystoscopic resection of inflamed bladder wall tissue. Bladder mucosal biopsy confirmed caseating granulomas suggestive of tuberculous cystitis. The patient is doing well and symptom-free after completion of ATT.

[Arterioureteral fistulas in the last 10 years at the University of Lübeck]

INTRODUCTION

Arterioureteral fistulas are rare, life-threatening, and difficult to diagnose. Risk factors are medical interventions in the lesser pelvis (general, urological, gynecological, and vascular surgery), radiation therapy of the lesser pelvis, permanent double J catheters, and previous vessel malformations.

MATERIALS AND METHODS

We retrospectively evaluated all cases of arterioureteral fistulas registered over the last 10 years in the clinic's documentation system. For all cases, clinical symptoms, diagnostics, therapies as well as clinical outcome were evaluated.

RESULTS

Four of the 5 patients were women. The most common initial symptom was a gross hematuria (4/5). All patients had a permanent double J catheter after extensive surgery of the lesser pelvis. In one case the initial diagnosis was done by retrograde ureterography, in 2 patients by provocative angiography and in the other 2 cases with a laparotomy due to cardiovascular problems. Three patients were treated by open surgery and 2 patients were treated by stenting of the iliac artery. One patient died, 2 patients had a permanent kidney fistula, and 2 patients continued treatment with a permanent double J catheter.

CONCLUSION

Based on the more aggressive therapy regimens, we expect that the number of patients presenting with arterioureteral fistulas will continue to rise. The identification of these patients based on their risk profile is essential.

Hematuria

Hematuria is common in the primary care setting. It is classified as either gross or microscopic. Hematuria warrants a thorough history and physical to determine potential causes and assess risk factors for malignancy. Risk of malignancy with gross hematuria is greater than 10%, and prompt urologic referral is recommended. Microscopic hematuria most commonly has benign causes, such as urinary tract infection, benign prostatic hyperplasia, and urinary calculi. If no benign cause for microscopic hematuria is found, the work-up includes laboratory tests to rule out intrinsic renal disease, imaging of the urinary tract, and referral to nephrology and urology subspecialists.

Approach to the Child with Hematuria

The causes of macroscopic and microscopic hematuria overlap; both are often caused by urinary tract infections or urethral/bladder irritation. Coexistent hypertension and proteinuria should prompt investigation for glomerular disease. The most common glomerulonephritis in children is postinfectious glomerulonephritis. In most patients, and especially with isolated microscopic hematuria, the diagnostic workup reveals no clear underlying cause. In those cases whereby a diagnosis is made, the most common causes of persistent microscopic hematuria are thin basement membrane nephropathy, immunoglobulin A nephropathy, or idiopathic hypercalciuria. Treatment and long-term prognosis varies with the underlying disease.

A special case of recurrent gross hematuria: Answers

Wilson's disease (WD) is an autosomal recessive disorder, and has a variety of presentations. We reported a case of 9-year-old girl who presented with a history of recurrent gross hematuria, renal histological changes of IgA nephropathy, and finally had been confirmed to be Wilson's disease-associated IgA nephropathy.

Ct2 Bladder Cancer

The patient is an 80-year-old man who presented with gross hematuria. His past medical history indicates he was a cigarette smoker with 50 pack/years. He was successfully treated for carcinoma of the lung 7 years ago. He received chemotherapy, radiation, and surgery. He has mild COPD but has a good performance status. His laboratory studies do not indicate any abnormalities in terms of renal function. He does not have any significant cardiac disease. He has a medium build. He had prostate cancer and underwent a successful radical prostatectomy 10 years ago. His PSA is undetectable. He has some urinary incontinence and wears two pads/day. He underwent the appropriate investigations for gross hematuria. A CT scan of the abdomen and pelvis was normal with the exception of a 4-cm posterior mass in the bladder. There was no hydronephrosis and no enlarged lymph nodes. He underwent a transurethral resection of a solitary bladder tumor performed by another urologist. The tumor was described as large and sessile. It was located on the posterior wall and was approximately 4 cm. The bimanual examination did not reveal a mass. The pathology report stated that the tumor was a high-grade urothelial carcinoma with invasion into the muscularis propria. There was no lymphovascular invasion. I performed a reTURBT, and at that procedure, I did not identify any obvious tumor but the prior resection site was evident. I resected the prior tumor site quite extensively both in depth and width. The pathology revealed only focal carcinoma in situ. There was ample muscle in the specimen and there was some fat as well. As stated, they were free of any cancer. The patient is receptive to any treatment approach.

Spontaneous rupture of a renal artery aneurysm presenting as gross hematuria

Renal artery aneurysms (RAAs) are localized dilations of the renal artery and/or its branches. They are being found with increasing frequency as a result of unrelated abdominal imaging or on workup for hypertension. They are rarely symptomatic; however, they can be a cause of life-threatening hematuria. Discussed is the case of a previously healthy 46-year-old man presenting with flank pain and gross hematuria. It is imperative for the practicing urologist to be aware of the appropriate evaluation and management of RAAs.

Renal involvement by chronic myelomonocytic leukemia requiring nephroureterectomy

Chronic monomyelocytic leukemia (CMML) is a relatively rare clonal hematologic disorder with features of myelodysplastic syndrome and myeloproliferative disease. Renal impairment from CMML is infrequent and can result from both direct (ie, infiltrative) and indirect (eg, vasculitis, infarction) mechanisms. This case report describes a patient with refractory gross hematuria requiring nephroureterectomy with diffuse involvement of the upper tract by CMML and accompanying extramedullary hematopoiesis. Underscored are the need to maintain a broad differential diagnosis for upper tract lesions in the setting of gross hematuria, and the potential need for drastic measures to control upper tract bleeding if conservative measures fail.