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.

Antimicrobial prophylaxis protocol based on rectal swab culture before prostate biopsy to prevent infectious complications: a prospective randomized comparative study

PURPOSE

To evaluate the benefit of targeted antibiotic prophylaxis (TAP) based on rectal swab culture in comparison with standard empiric antimicrobial prophylaxis in patients undergoing transrectal ultrasound-guided needle biopsy of the prostate (TRUS-BP), as well as to assess rate of fecal carriage of Fluoroquinolone-resistant Enterobacterales FQRE.

PATIENTS AND METHODS

We prospectively analyzed data that randomized 157 patients within two groups: (G1) TAP according to rectal swab performed 10 days before PB; (G2): empirical antibiotic prophylaxis with ciprofloxacin. Prevalence of FQRE digestive carriage and risk factors were investigated. Incidence of infectious complications after (TRUS-BP) in each group was compared.

RESULTS

G2 included 80 patients versus 77 in G1. There was no difference between the two groups regarding age, diabetes, prostate volume, PSA, number of biopsy cores, and risk factors for FQRE. In G2, the prevalence of FQRE digestive carriage was 56.3% all related to E. coli species. In the case of digestive carriage of FQRE, TAP according to the rectal swab culture with third-generation cephalosporins was performed in 73.3%. Patients with FQRE had history of FQ use within the last 6 months in 17.8% (p = 0.03). Rate of febrile urinary tract infection after PB was 13% in G1 and 3.8% in G2 (p = 0.02).

CONCLUSIONS

Incidence of FQ resistance in the intestinal flora of our local population was prevalent. Risk factor for resistance was the use of FQ within the last 6 months. TAP adapted to rectal swab, mainly with third-generation cephalosporins, significantly reduced the rate of infectious complications after (TRUS-BP).

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.

Risk factors for sepsis and mortality in patients with emphysematous pyelonephritis : a series of 68 cases (case series)

Background

Emphysematous pyelonephritis (EPN) is a rare and severe necrotizing infection of the kidney with a high rate of complications and mortality. Our aim was to investigate risk factors of urosepsis and mortality in case of EPN.

Materials and methods

Between January 2010 and December 2022 the charts of patients diagnosed with EPN were retrospectively reviewed. Patients medical records were collected and data including demographics, BMI, EPN type, the organism causing the infection and biochemical variables were registered. The authors performed an univariate and multivariate logistic regression analysis for sepsis, septic shock, and mortality. Statistical significance was defined as a P-value of <0.05.

Results

Our study included 68 patients (63% females, mean age 58.6 years old). Forty-eight patients (70.6%) had diabetes. Half of the patients (50%) presented with sepsis and 11 patients (16.2%) developed a septic shock. The following factors were associated with sepsis by univariate analysis: diabetes (P=0.01), higher blood sugar on admission (P=0.01), higher leukocytic count (P<0.001), higher lymphocytic count (P<0.001), and lower platelet to leukocytes ratio (P<0.001). Multivariate regression analysis revealed that the main risk factors of urosepsis were the leukocytic (OR: 85.7; 95% CI: 9.177-800.486; P<0.001) and lymphocytic count (OR: 6.65; 95% CI: 1.228-36.050; P=0.028). Neither of the variables was significantly associated with a higher risk of mortality.

Conclusion

Leukocytic and lymphocytic count on admission are independent simple predictors for sepsis in patients with EPN.

Isolated ureteral injury from multiple stab wounds: A case report

This is a case report about a 44-year-old woman who sustained multiple stab wounds, resulting in an isolated right ureteral injury. Despite a precise diagnosis from an urgent CT scan showing contrast material extravasation, the patient's stable vital signs allowed for a thorough surgical exploration, leading to an accurate diagnosis. Immediate surgical repair of the right ureter using an end-to-end anastomosis following precise surgical principles achieved complete restoration of the initial injuries. The case highlights the accuracy of CT scan assessment, the unreliability of hematuria in diagnosing ureteral injuries, and the need for a high index of suspicion during surgical exploration to avoid overlooking such cases.

Squamous and glandular metaplasia related to a renal pelvis stone leading to secondary pyeloureteral junction syndrome

Keratinizing squamous metaplasia of the renal pelvis is a rare lesion of the upper urinary tract that can occur in the context of chronic aggression to the urothelium, potentially leading to a secondary pyeloureteral junction syndrome. We report the case of a 43-year-old patient discovered intraoperatively in relation to a renal pelvis stone causing a pyeloureteral junction syndrome. The extemporaneous histological examination ruled out a malignant process, and we performed a pyeloplasty according to KUSS-ANDERSON technique. This pathology should be recognized by the urologist for appropriate management. Treatment is conservative, with extended follow-up to detect recurrences or carcinomatous degenerations.

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.

Retroperitoneal ganglioneuroma: A five-case series from a single Tunisian center

INTRODUCTION AND IMPORTANCE

Retroperitoneal ganglioneuroma is an infrequent, benign tumor originating from the sympathetic nervous system. The diagnosis predominantly relies on histological assessment, often as an incidental discovery. Surgical removal stands as the primary treatment modality, and the overall prognosis tends to be favorable.

CASE PRESENTATION

Objective: In order to comprehensively examine the diagnostic, therapeutic, and progressive aspects of retroperitoneal ganglioneuroma, this study aims to analyze five cases of retroperitoneal ganglioneuroma that were surgically managed between 1993 and 2013.

PATIENTS AND METHODS

We present a series of five cases involving retroperitoneal ganglioneuromas that underwent surgical intervention in the urology department of Charles Nicolle Teaching Hospital of Tunis between the years 1993 and 2013. The study cohort comprised three females and two males, with an average age of 36.4 years (ranging from 10 to 88 years). Among these cases, four instances showcased incidental tumor detection, while one case manifested with cruralgia due to nerve compression. Complete tumor excision was achieved in all cases, with a single instance necessitating concurrent nephrectomy. Accurate diagnosis was ascertained through meticulous histological examination.

CLINICAL DISCUSSION

Results: The case series encompassed three women and two men, with an average age of 36.4 years (ranging from 10 to 88 years). The majority of cases (four out of five) unveiled tumors incidentally, whereas one case presented with cruralgia. Surgical removal resulted in complete resection of all tumors, although nephrectomy was necessary in one instance. Postoperative complications were minimal, and effective anticoagulant treatment addressed one thrombotic event. While recurrence was noted in a solitary case, subsequent imaging confirmed its stability. The average follow-up duration extended to 23.2 months (ranging from 6 to 72 months).

CONCLUSION

Retroperitoneal ganglioneuroma, being a rare and benign neoplasm, mandates meticulous pathological assessment and precise imaging for precise localization. Unquestionably, complete surgical resection remains paramount to forestall recurrence and mitigate the likelihood of malignant transformation. Overall, the prognosis associated with retroperitoneal ganglioneuroma tends to be favorable.

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.

A juxtaglomerular cell tumor revealed by a hemorrhagic stroke. A case report

With about 110 cases reported in literature, juxtaglomerular cell tumors are rare. We report a 25 years old patient who was admitted in neurology for a hemorrhagic stroke secondary to a cerebral aneurysm rupture due to high blood pressure. Etiological investigations showed a solid mass of the left kidney. A radical nephrectomy was realized and pathological examination and immunohistochemical profile concluded to juxtaglomerular cell tumor. The originality of this observation is based on the mode of presentation of a rare renal tumor by a malignant high blood pressure.

Inflammatory suppurated tumor of urachus mimicking a malignant urachus adenocarcinoma

This is a case report about a patient presenting with a urachal mass mimicking a urachus adenocarcinoma. Cystoscopy showed a vesicourachal patent diverticulum. Histological findings after the removal of the umbilicus, urachus, urachal tumor, as well as a bladder cuff, consisted of a nonspecific polymorphous suppurative inflammatory infiltrate. Urachal adenocarcinoma is an aggressive tumor with poor prognosis if not treated while it is still localized. Surgical excision is the only recommended treatment that offers the best chances of survival. As no preoperative procedure has been proven accurate enough to rule out the diagnosis of adenocarcinoma, surgery appears to be inevitable.

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.

Predictors of successful outcome after adrenalectomy for unilateral primary aldosteronism

Introduction

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. The cause of resistant hypertension after surgery is still a matter of debate. Our aim was to investigate cure rates after surgery and to evaluate preoperative factors that might influence the surgical outcome.

Methods

Between 2000 and 2021, the charts of 71 Tunisian patients who underwent laparoscopic adrenalectomy for UPA were retrospectively reviewed. Preoperative medical records were collected and follow-up data (1-158 months) were registered. Antihypertensive medication doses were calculated using defined daily doses (DDD) and postoperative outcomes were assessed using the Primary Aldosteronism Surgical Outcome (PASO) criterion.

Results

Of 91 enrolled patients, 71 (59% women, mean age 46 years, median length of follow-up 21 months) were suitable for evaluation. Thirty-four patients (48%) had complete clinical success according to the PASO criteria. The most relevant factors associated with complete clinical success on univariate analysis were: absence of diabetes (p= 0.007), low body mass index (BMI) (p= 0.001), lower preoperative DDD (p= 0.01), preoperatively controlled blood pressure (p= 0.024), higher plasma aldosterone to renin ratio (ARR) (p= 0.001), adenoma subtyping (p <0.001) and aldosteronoma resolution score (ARS) (p= 0.002). Multivariate regression analysis showed that the major predictors of complete clinical success were absence of diabetes (OR: 5.205), a BMI < 30 (OR: 4.930), a plasma ARR > 332 (OR: 4.554) and an ARS ≥ 3 (OR: 2.056).

Conclusion

Complete and partial clinical response rates were achieved in respectively 48 and 43% of cases. The main predictors of complete resolution of hypertension were absence of diabetes, low BMI, high plasma ARR and high ARS. Taking these factors into account may help identify patients at risk of persistent postoperative hypertension who may require long-term surveillance and medication.

Management strategies and root causes of missed iatrogenic intraoperative ureteral injuries with delayed diagnosis: a retrospective cohort study of 40 cases

BACKGROUND

Intraoperative iatrogenic ureteral injuries represent rare technical surgical complications with the potential for adverse patient outcomes, particularly when the diagnosis is delayed. Ideally, these technical complications are recognized and repaired intraoperatively. This study was designed to investigate the root causes and outcomes of missed intraoperative ureteral injuries at a tertiary urology referral centre in Tunisia.

METHODS

This is a retrospective cohort study in a tertiary urology referral centre in Tunis from January 1^st, 2015, to December 31^st, 2020, including all patients with iatrogenic ureteral injury, not diagnosed intraoperatively. The factors associated with the success of endoscopic treatment and those associated with the unfavourable evolution were investigated.

RESULTS

A total of 40 iatrogenic ureteral injuries were included. Gynaecological surgery was responsible for 85% of ureteral injuries, mainly during hysterectomies (55%). The symptoms were dominated by low back pain (37.5%) and pyelonephritis (25%). Endoscopic treatment was attempted in 22 cases, it was sufficient in 12 cases. Ureteral injury required surgical treatment in 24 cases, and ureteroneocystostomy was performed in 16 cases. Nephrectomy was performed in eight cases, representing 20% of injuries, including three cases as the first treatment for late-diagnosed cases with a destroyed kidney. In the analytical study, endoscopic treatment was sufficient in 50% in case of ureteral fistula versus 27% in case of ureteral stenosis (p = 0.04). Nephrectomy was performed in 10% of cases when ureteral injury was diagnosed within the first month postoperatively compared to 60% of cases when this delay exceeded one month (p = 0.004).

CONCLUSION

Iatrogenic ureteral injuries discovered postoperatively are mostly secondary to gynaecologic surgery. Although endoscopic treatment is usually performed as a first treatment, a more aggressive surgical is often necessary, with a nephrectomy rate of 20%.

Management of blunt renal trauma on pre-existing diseased kidneys: a cross-sectional study

Pathological kidney trauma is a special entity. Congenital or acquired lesions may interfere with clinical presentation, radiological imaging, and the therapeutic approach.

Objective

Our objective was to determine the clinical, radiological, and therapeutic features of this entity.

Materials and methods

The medical records of 37 observations were retrospectively collected from January 1992 to February 2022. All cases were explored by a kidney ultrasound and/or a computed tomography scan, and classified according to the American Association of Surgery of Trauma. Pre-existing renal abnormalities were found in 37 patients among 203 (18.2%). The most common underlying lesion were urolithiasis (37.8%) followed by pyelo-ureteral junction syndrome (32.4%). Surgical abstention was decided in 11 cases, four nephrectomies were performed as a matter of urgency, and seven nephrectomies were performed remotely. The cure of uropathy was performed after an average delay of 3 months.

Conclusion

Kidneys with underlying pathology are habitually more susceptible to trauma. Contusions are often benign contrasting with a high nephrectomy rate.

Coexistence of multiple clear cell papillary renal cell carcinoma with renal oncocytoma: a case report

Clear cell papillary renal cell carcinoma (CCPRCC) is a new entity, previously known as unclassified renal cell carcinoma, and initiallly identified in patients suffering of end-stage kidney failure. It is extremely rare to see this new entity associated with others renal malignant lesions.

Case presentation

The authors report a case of a female 65-year-old suffering from end-stage kidney failure for 10 years, who presented with a double left renal tumor, composed by an oncocytoma associated to multiple CCPRCC, a very rare entity. A radical left nephrectomy was realized by lumbotomy, with an uneventful postoperative course. Histological examination was challenging. Immunohistological examination showed diffuse positivity of cytokertain 7. No local recurrence nor metastatic progression were found during the 12 months of follow-up.

Clinical discussion

CCPRCC, is a new entity, previously known as the unclassified rena cell carcinoma, is a malignant renal tumor, initially reported in patients at end-stage kidney failure. Oncocytoma is a well-known rare benign renal tumor. The association of both is rare, and should be kept in mind, especially when scanoguided diagnosis biopsy is realized. Histopathological confirmation may be challenging, given the recent identification of CCPRCC. The nuclei disposal toward the luminal surface is a characteristic pathological landmark of CCPRCC. Immunohistopathological examination is of great help, showing a distinctive profile: diffuse staining for cytokertain 7 and carbonic anhydrase IX.

Conclusion

CCPRCC is a new malignant pathological entity in renal tumors. It can be associated with other benign renal lesions. This should be taken into consideration while histopathological examination, mainly of scanoguided biopsy cores.

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.

Retrovesical hydatid cyst: an unusual location of hydatid disease about a case series

Hydatid disease is an endemic zoonosis in regions with temperate climates where pastoral farming is common. Retrovesical localization is rare. Given the rarity of this entity, the lack of personal clinical experience, and the difficulty with detecting early symptoms, the diagnosis remains elusive for years.

Methods

This is a 30-year retrospective, descriptive and analytic study of seven patients who were hospitalized and operated on in the Department of Urology during 30 years (1990-2019).

Outcomes

The average patient age was 54 years (range: 28-76). Signs of bladder irritation were the predominant presenting complaint. No cases of hydaturia were noted. Preoperative diagnosis was based on ultrasonography and serology tests. Hydatid serology was positive for three patients. In three cases, a hydatid cyst of the liver was associated. A partial cystopericystectomy was performed for five patients, it was total for one patient. The resection of the prominent dome was realized once. No cystovesical fistula was found. The mean postoperative stay was 16 days. The postoperative course was uneventful for five patients. Urinary fistula occurred in one patient. One case of infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation.

Conclusion

The preoperative diagnosis of retrovesical hydatid cysts is based mainly on ultrasonography. Open surgery is the treatment of choice. Different approaches are possible. Given the rarity of this entity, management should be guided by experienced experts.

Oncocytoma with a vascular extension, associated with a papillary carcinoma: A case report

This is a case report about a patient which presents with two right renal tumors, one of them being an oncocytoma with typical histopathological features and renal vein extension. Recent studies show that despite renal vein thrombus being a histological sign of malignancy; when associated with renal oncocytoma, it should not alter the benign prognosis of oncocytoma, and a simple follow-up may be carried. Further explorations should be done when easily available, and when the histopathologic diagnosis of oncocytoma is uncertain, to rule out the differential diagnosis of a chromophobe renal cell carcinoma, oncocytic variant.

Paratesticular leiomyoma: A case report of a rare entity

Paratesticular leiomyoma is an extremely rare benign tumour. It is often asymptomatic. It is sometimes difficult to distinguish leiomyomas from malignant testicular tumours, which leads to radical orchidectomy, despite its benign nature. Magnetic resonance imaging can be helpful to make conservative management of this lesion.

Air gun accident: A case report of a penile injury

Air rifle, although considered as a toy, can cause injuries ranging from trivial to very grievous. The severity of injuries depends on the type of air rifle, the distance of firing, and the anatomic site at which the bullet hits. We present a case involving a young boy, who was accidently hit by an air rifle while playing. The Bullet penetrated the penis through the glans to be lodged in between the distal extremities of the corpus cavernosum behind the urethra. The surgical treatment was performed and the results were good.

Prostate adenocarcinoma metastasis to the testis: A new case report

Prostate cancer (PCa) in the second most common cancer in men worldwide. It commonly metastasizes to the bone, lymph nodes, liver and lungs. Synchronous or metachronous testicular metastasis is a rare finding, generally diagnosed incidentally after bilateral orchidectomy for hormonal management in patients with advanced PCa, or at autopsy. We report a case of a 55-year-old male, presenting a PCa and who developed a single testicular metastasis treated by radical orchidectomy, while he was under hormonotherapy.

Two brothers with congenital bulbar urethral stricture: case report of a very rare condition

Congenital urethral stricture is rare. It has been reported in only four sets of brothers. We report the fifth set of brothers. Cases of two brothers aged 23 and 18 years old diagnosed with low urinary tract symptoms are presented. We diagnosed an apparently congenital urethral stricture in both brothers. Internal urethrotomy was performed in both cases. Both are asymptomatic after 24 and 20 months of follow-up. Congenital urethral strictures are probably more frequent than we think. We suggest that a congenital origin should be considered if there is no history of infections or trauma.

An insight into the diagnostic and prognostic value of HOX A13 ’s expression in non‐muscle invasive bladder cancer

Background

Several studies have interrogated the molecular pathways and their interacting genes underlying bladder cancer (BCa) tumorigenesis, yet, the role of homeobox genes is still poorly understood. Specifically, HOXA13, which plays an important role as a major actor in the urogenital tract's development.

Methods

Immunohistochemical (IHC) staining was performed to inspect the differential expression of HOXA13 protein in non‐muscle‐invasive bladder cancer (NMIBC) and non‐tumoral tissues. A semiquantitative scoring system was adopted to evaluate the IHC labeling. Correlation to clinical parameters was performed by descriptive statistics. Overall survival was estimated by the Kaplan–Meier method and Cox regression model. The functional HOX A13 protein association networks (PPI) were obtained using String 11.0 database.

Results

HOX A13 exhibited cytoplasmic and nuclear staining. Its expression levels were lower in high‐grade NMIBC (HG NMIBC) compared to low‐grade ones (LG NMIBC). The expression of HOX A13 was correlated to tumor grade (LG/HG) (p = 0.036) and stage (TA/T1) (p = 0.036). Nevertheless, its expression was not correlated to clinical parameters and was not able to predict the overall survival of patients with HG NMIBC. Finally, PPI analysis revealed that HOX A13 seems to be a part of a molecular network holding mainly PBX1, MEIS, ALDH1A2, HOX A10, and HOX A11.

Conclusion

The deregulation of HOX A13 is not associated with the prognosis of BCa. It seems to be rather implicated in the early initiation of urothelial tumorigenesis and thus may serve as a diagnostic marker in patients with NMIBC. Further experimentations on larger validation sets are mandatory.

Upper urinary tract urothelial carcinoma diagnosis by biopsy of a vaginal metastasis

Upper tract urothelial carcinoma presents 5% of urothelial cancers. The most frequent revealing symptom gross haematuria. Vaginal metastasis is rare revealing condition. The combination on these two symptoms should recall the diagnosis of this neoplasm. Biopsy of the vaginal mass can make the histologic diagnosis easily.

The brain in oral clefting: preliminary results of a systematic review with meta-analyses

Introduction

Previous neuroimaging studies of individuals with nonsyndromic oral clefts have revealed subtle brain structural differences compared to matched controls. Additional studies strongly suggest that the higher incidence of neuropsychiatric issues observed in these individuals may be explained by these neuroanatomical differences. Currently there are no studies that have assessed the overall empirical evidence of the effect of oral clefts on the brain.

Objectives

Our aim was to summarize available evidence on potential brain structure differences in individuals with nonsyndromic oral clefts and their matched controls. In the current presentation, we discuss the results of regional brain structural differences.

Methods

Five databases were systematically searched in September 2020 for case-control studies that reported neuroimaging in healthy individuals and individuals with nonsyndromic oral clefts. Duplicate study selection, data extraction, random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals were performed in order to compare regional brain MRI volumes.

Results

We have identified 245 records following the database searches, from which 12 records met the inclusion criteria. Quantitative data on brain structure were available in three studies.The cerebellum, occipital and temporal lobes were significantly smaller in the cleft group compared to controls (MD: -12.46, 95% CI: -18.26, -6.67, n=3 studies; MD:-7.39, 95% CI: -12.80, -1.99, n=2 studies; MD: -10.53, 95% CI: -18.23, -2.82, n=2 studies, respectively).

Conclusions

There may be structural brain differences between individuals with nonsyndromic oral clefts and their controls based on the available evidence.

Disclosure

No significant relationships.

MO967: Lymphocele After Renal Transplantation: Management, Risk Factors and Impact on Transplant Survival

BACKGROUND AND AIMS

Lymphocele after renal transplantation remains a common complication, despite all the technical precautions taken, in particular the ligation of lymphatic vessels. Its incidence varies according to the series, depending on the diagnostic methodology, and whether or not it is systematically screened.

This study aims to investigate the risk factors for lymphocele and its impact on transplant survival.

METHOD

We performed a retrospective longitudinal descriptive study including all patients who had a kidney transplant in a Urology department from 1986 to 2017. Clinical presentation and management of lymphocele were studied. Then, the characteristics of patients who presented a lymphocele were compared with those of the rest of the population including characteristics related to the recipient, the donor, the transplant and the procedure to identify risk factors. The impact of lymphocele on patient and transplant survival was then studied.

RESULTS

A total of 720 patients were included with a mean age of 32.7 years. The transplant was from a living donor in 79% and a brain-dead donor in 21%. Lymphocele occurred in 51 patients (7.1%). The lymphocele was asymptomatic in 80%, and clinical manifestations were related to the compression of the transplant or its important size, requiring active treatment, most often percutaneous (13.7%). The lymphocele did not require treatment in 42 cases (82.4%) with disappearance in 90.5%. Revision surgery for a lymphocele was necessary in two cases.

The risk factors for lymphocele were a cadaveric donor (P = 0.003) and an advanced age of the recipient (P  &lt; 0.001). No predictive factors related to the transplant (vascular anatomy), or procedure (location and type of anastomoses, ischemia time) were identified.

Transplant survival was 77.9% at 5 years, with a median survival of 15.9 years. The occurrence of a lymphocele did not influence the survival of the transplant (P = 0.25) (Figure 1).

CONCLUSION

Our study showed that lymphocele is usually asymptomatic, not requiring a specific treatment in most cases with a high rate of spontaneous disappearance with no impact on transplant survival. Risk factors were a cadaveric donor which may reflect the absence of careful ligation of the transplant's lymphatic vessels in the context of urgent, sometimes multi-organ, cadaveric procurement and advanced recipient age.

MO968: Vascular Complications of Renal Transplantation: Risk Factors and Impact on Graft Survival

BACKGROUND AND AIMS

Despite the progress made in renal transplantation, vascular complications can occur, jeopardizing the prognosis of the transplant.

This study aims to investigate the risk factors of vascular complications and their impact on transplant survival.

METHOD

We performed a retrospective longitudinal descriptive study including all patients who had a kidney transplant in a Urology department from 1986 to 2017. Transplant Vascular complications included: Arterial thrombosis (AT), Venous thrombosis (VT), hemorrhagic complications (hemorrhage and hematoma) and arterial stenosis (AS). The potential risk factors for vascular complications that were investigated included characteristics related to the recipient, the donor, the transplant and the procedure. The impact of vascular complications on transplant survival was then studied.

RESULTS

A total of 720 patients were included with a mean age of 32.7 years. The transplant was from a living donor in 79% and a brain-dead donor in 21%.

AT occurred in 15 patients (2.1%) and VT occurred in 10 patients (1.4%). Risk factors for vascular thrombosis were recipient age &gt;35 years (P = 0.001; OR = 10.78), recipient smoking (P = 0.005; OR = 1.8), multiple arteries (P  &lt; 0.001; OR = 1.45) and prolonged warm ischemia (P = 0.02). Perirenal hematoma occurred in 11 patients (1.5%) and hemorrhage occurred in six patients (0.8%). The risk factors for bleeding complications were a prolonged pre-transplantation dialysis time (P = 0.03; OR = 1.35), and prolonged warm ischemia (P = 0.02; OR = 1.26). AS was the most frequent vascular complication, occurring in 20 cases (2.8%) and no risk factors were identified.

Transplant survival was 77.9% at 5 years, with a median survival of 15.9 years. Vascular thrombosis led to the loss of the transplant in all cases, and externalized hemorrhage significantly reduced transplant survival (P  &lt; 0.001). Perirenal hematoma (P = 0.42) and transplant artery stenosis (P = 0.25) had no impact on transplant survival (Figure 1).

CONCLUSION

Our study showed that the vascular complications impacted the survival of the transplant and that they were related to factors related to the recipient, the transplant and the procedure insisting on a multidisciplinary and personalized management for each case.

Bladder exstrophy in adulthood: About a case report

Bladder exstrophy is a severe malformation characterized by the lack of the anterior sub-umbilical abdominal wall, and the front wall of the bladder. We present a rare case of a 26-year-old woman without any previous medical or surgical history, that we treated for bladder exstrophy. We performed an iliac osteotomy, bladder enlargement using the ileum and a Monti-type continent urinary derivation and a Promentofixation. A vesico-cutaneous fistula was diagnosed after surgery and we failed to manage it after two surgical revision. Therefore, we performed a cystectomy and a non-continent Bricker external urinary derivation.

Ejaculatory duct reflux revealed by chronic scrotal swelling in an adult

Ejaculatory duct reflux is rare and few investigations have focused on this entity, which is usually described in children. This study reports a new case of unilateral ejaculatory reflux in a 32-year-old patient, with a history of urethroplasty at the age of 5 for hypospadias, who presented for right chronic scrotal swelling. Urethrocystscopy showed an anterior urethral stricture and a gaping opening of the right ejaculatory duct. CT scan with opacification through the right ejaculatory duct, showed a dilated right seminal vesicle, associated to a reflux in the right deferent vas and epididymis, which was dilated explaining the scrotal swelling.

A cadaveric anatomical study: anatomy and anatomical variations of left adrenal vein

PURPOSE

Control of adrenal vein is the key of adrenal surgery. Its anatomy can present variations. Our aim was to study the anatomy of the main left adrenal vein (LAV) and its anatomical variations.

METHODS

Our work is based on dissection of 40 cadavers. We studied the number of LAV and the drainage of the main adrenal vein as well as its level of termination. We measured its length, its width and the distance between its termination level and the termination level of the gonadal vein (GV).

RESULTS

The average length of the LAV was 21 mm its mean width was 5 mm. It ended in 100% of cases at the upper edge of the left renal vein after an anastomosis with the lower phrenic vein in 36 cases (90%) and without anastomosis with the lower phrenic vein in four cases (10%). The left adrenal vein ended at the upper edge of the left renal vein either at the same level as the termination of the left GV in 14 cases (35%) or within the termination of the left GV in 26 cases (65%) by an average of 8 mm. The LAV was unique central vein in 22 cases (55%) and in 12 cases (30%), a major central adrenal vein with several small veins was found.

CONCLUSIONS

The LAV is usually unique but there are variations in number. There are also variations in the level of its termination in the left renal vein as well as its anastomosis. During surgery, in case of difficulty, the left GV and the adrenal-diaphragmatic venous trunk could be used as benchmarks.

Management and prognosis of liposarcomas of the spermatic cord: an experience with six cases

Liposarcoma of the spermatic cord (LSC) is a rare tumor with no consensus on therapeutic management. This study reports six new cases of LSC. The patients’ age ranged from 56 to 80 years. All patients presented with a scrotal mass, and it was ultrasound that oriented the diagnosis. The initial treatment consisted of an inguinal orchiectomy. Anatomopathological study coupled with immunohistochemistry using the anti-MDM2 antibody confirmed that the tumors were well-differentiated LSC in four cases and dedifferentiated LSC in the other two cases. Adjuvant radiotherapy was performed in two patients. No recurrence was noted in these two patients at 14 and 34 months of follow-up. The only recurrence we had was local and occurred at 44 months of follow-up in a patient who had a dedifferentiated form ofLSC.

The diagnostic applicability of A-type Lamin in non-muscle invasive bladder cancer

PURPOSE

Lamin A is a major component of the nuclear lamina maintaining nuclear integrity, regulation of gene expression, cell proliferation, and apoptosis. Its deregulation in cancer has been recently reported to be associated with its prognosis. However, its clinical significance in non-muscle invasive bladder cancer (NMIBC) remains to be defined.

MATERIAL/METHODS

Immunohistochemical staining and RT-qPCR were performed to screen the expression patterns of Lamin A/C protein and Lamin A mRNA respectively in 58 high and low grade NMIBC specimens.

RESULTS

Lamin A/C protein was expressed only in the nucleus and less exhibited in NMIBC tissues compared to non-tumoral ones. On the other side, Lamin A mRNA was up-regulated in NMIBC compared to controls. Nevertheless, both expression patterns (protein and mRNA) were not correlated to clinical prognosis factors and were not able to predict the overall survival of patients with high-grade NMIBC.

CONCLUSIONS

The deregulation of A-type Lamin is not associated with the prognosis of NMIBC, but it could serve as a diagnostic biomarker distinguishing NMIBC patients from healthy subjects suggesting its involvement as an initiator event of tumorigenesis in our cohort.

Isolated bladder metastasis from lung adenocarcinoma: a case report

Cancers of extra bladder origin represent between 2 and 12% of bladder neoplasms and are most often secondary to contiguous bladder invasion. Metastasis from distant organs is exceptional, especially from pulmonary adenocarcinoma with <10 cases identified over the last 20 years. We report here a new case of a 55-year-old patient with a recently diagnosed pulmonary adenocarcinoma referred to the urology department for macroscopic hematuria. Computed tomography scan showed, in addition to the lung mass of the right lower lobe with a right mediastinal adenopathy, a thickening of the right lateral bladder wall. Cystoscopy showed inflammatory lesions on the bladder mucosa, which biopsy with immunohistochemical examination revealed to be tumoral proliferation in the lamina propria realizing the same immunohistochemical profile of the primary lung tumor (CK7+/TTF1+/CK20-/PSA-). The patient was treated with palliative platinum-based chemotherapy and unfortunately died 5 months after diagnosis.

Partial open tumorectomy for a renal tumor in a horseshoe kidney with a close contact with the vena cava: A case report

Introduction and importance

Horseshoe kidney has unique anatomical features, such as a complex blood supply. We report a patient with renal tumor in a horseshoe kidney in close contact with the vena cava, who underwent open tumorectomy.

Case presentation

A 72-year-old woman was referred to our hospital with a 4-cm enhancing mid-pole mass in the right moiety of a horseshoe kidney. Open tumorectomy was performed with parenchymal clamping. The warm ischemia time was 18 min. Pathologic examination confirmed a diagnosis of pT1a clear cell renal cell carcinoma with negative surgical margins. At 3 months postoperatively, computed tomography showed no local recurrence or metastasis and renal function was intact.

Clinical discussion

Horseshoe kidney is a rare congenital abnormality. Renal cell carcinoma is the most frequent tumor in adults having this anomaly and treatment in localised tumors if usually tumorectomy. Surgery may be challenging in some cases because of its difficulty.

Conclusion

Open surgery remains the standard treatment for horseshoe kidney tumors because of anatomic complexity and especially in cases where the tumor is difficult to extirpate.

•

Renal cell carcinoma tumors in horseshoe kidneys are a very rare entity.

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Management of localised tumors in horseshoe kidney is surgical and surgery is challenging due to anatomical difficulties.

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Open surgery is usually the best option for tumors having a posterior development in the horseshoe kidney.

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 28^th to April the 3^rd. 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.

State of the art: Open prostatectomy for benign prostate hyperplasia: Should we avoid it in all cases?

Surgical procedures for benign prostate hyperplasia (BPH) had considerably evolved during last decades. New techniques can nowadays treat prostate big in size, which are classically treated by open prostatectomy (OP). Therefore, the place of this procedure that has been used for over 150 years is nowadays questioned. Is it outdated? Is there emerging techniques that are more efficient, safer and cost effective? This state of the art based on literature review will assess the place of OP in BPH surgery from efficacy on functional outcomes, security, competitiveness with modern and minimally invasive techniques and socio-economic perspectives. Currently, OP has excellent functional outcomes, with low rate of retreatment after surgery, low morbidity and affordable cost in our country. It remains competitive with new surgery techniques for BPH, even if the latter offer the advantages of a minimally invasive surgery, especially in hospitalization length. Taking in consideration the social and economic context in Tunisia, it remains the most accessible and affordable surgical technique. Besides, OP is a procedure that has to be handled by every urologist given the theoretical risk of conversion during endoscopic surgery of BPH, and its use under certain circumstances (In case of bladder lithiasis ou diverticle or impossibility of lithotomy position).

Management of perianal abscesses in infants without general anaesthesia: a systematic review of the literature

Perianal abscesses are a common surgical presentation in infants. Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA). This review aims to assess outcomes following management of perianal abscesses without GA in infants less than 24 months old. We aim to identify the success of management without GA. Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE and PubMed. Studies including infants less than 24 months with perianal abscesses managed without GA were reviewed. The primary outcome was the number of patients requiring GA following initial management without GA. Secondary outcomes included rates of recurrent perianal abscesses, rates of progression to FIA and time to cure. Nine studies, involving 1049 infants less than 24 months old met inclusion criteria. A total of 1039 (99.0%) were males. Study design consisted of one prospective case series of 18 patients, and eight retrospective cohort studies. There were no randomized control trials. A total of 1037 (98.9%) patients were initially managed without GA. Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic. Treatment modalities included antibiotics, regular baths, needle aspiration, incision and drainage under local anaesthesia, hainosankyuto and fibroblast growth factor. A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA. All patients who required a subsequent general anaesthetic had progressed to FIA. Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants, with more than 75% healing completely. Further research aimed at standardizing care and confirming the safety and efficacy of initial non-operative management are warranted, and may potentially reduce the number of unnecessary initial and subsequent clinical interventions.