Nephro-Urology Monthly
Volume:14 Issue: 4, Nov 2022

 Renal cell carcinoma (RCC) is an invasive malignancy of kidney origin. The programmed death-1 ligand (PD-L1) with its receptor (PD-1) on T-cells can inactivate antitumor response and possibly lead to poor outcomes in patients with RCC.

 Our study assessed the expression of PD-L1 by immunohistochemical staining on 86 radical or partial nephrectomy samples with RCC diagnoses with diverse types, tumor grades, and stages. Tumor specimens were collected from the pathology archive of 2014 - 2017 in Sina Hospital, Tehran, Iran.

 Out of 86 studied RCC samples, 68 cases (79.1%) were clear cell types. PD-L1 expression was observed more in non-clear cell carcinoma samples than in clear cell carcinoma (P = 0.008). PD-L1 expression had significant relationships with nuclear grade and tumor necrosis (P = 0.025 and 0.010, respectively). However, PD-L1 expression was not correlated with tumor size, lymphovascular invasion, and sarcomatoid differentiation. The disease-free survival rate in patients with PD-L1 expression was significantly less than in patients with PD-L1 negative staining (P = 0.032).

 According to our findings, PD-L1 could be regarded as an important biomarker with worse prognosis and aggressive clinicopathologic findings in patients with RCC.

 Chronic kidney disease, a global health problem, leads to end-stage kidney disease, whose treatment requires long-term renal replacement therapy. The incidence of hemodialysis patients with end-stage kidney disease is increasing worldwide. The survival rate of hemodialysis patients is crucial for decision-making and planning.

 This study aimed to determine the survival rate of hemodialysis patients and its related factors using the competing risk analysis approach to acquire more precise estimations of survival and mortality of the patients.

 This study was primarily based on medical records of hemodialysis patients who started dialysis from January 2011 to December 2017. The end of the study follow-up period was December 2021. The study included 214 eligible patients. Death was regarded as the event of interest, kidney transplantation as the competing risk, and other consequences as censored. We analyzed the data by cumulative incidence functions, Gray’s test, and Fine-Gray regression model using R version 4.1.2 and Stata v.16 at a significance level of 0.05.

 The median age at the initiation of hemodialysis was 60 years. The risks of death in the first, second, third, fourth, and fifth years were 18.3%, 31.7%, 41.6%, 49.9%, and 60.9%, respectively. In the regression model, age at the initiation of hemodialysis (P-value = 0.000) and education (P-value = 0.000) were associated with mortality.

 Competing risk estimates of survival analysis of hemodialysis patients are more reliable than conventional approaches (e.g., Kaplan–Meier estimator) for planning and improving interventions and allocating resources. Detection of patients at a younger age and increasing patients' knowledge plays a significant role in improving their survival.

 Primary retroperitoneal mature cystic teratomas (PRPMCT) are uncommon in adults. They typically occur in infants under six months old and young females. So far, some limited case reports have been documented in the literature. This case report presents a rare case of an adult patient with PRPMCT aged over 30 years.

 The patient was a 34-year-old female with PRPMCT in the site of the left adrenal gland and abdominal discomfort. Computed tomography (CT) scan revealed a 66 mm hypodense lesion with fat attenuation and calcification in the left retroperitoneum. Laparotomy with resection of the retroperitoneal (RP) lesion was done. Gross examination showed a solid multicystic mass measuring 8x6.5x6 cm. Histopathologic examination revealed a neoplastic tissue composed of mature osseous and cartilaginous tissue associated with stratified squamous epithelium and lumens lined by ciliated columnar epithelium, and the diagnosis was mature cystic teratoma. The patient had an uncomplicated postoperative course without recurrence after seven months of follow-up.

 PRPMCT in adults is extremely rare. RP metastasis of primary gonadal teratoma and non-functioning adrenal tumors should be excluded first. Due to the diagnostic difficulty of posterior peritoneal teratoma with radiological imaging and its risk of malignancy, surgical resection would be the most effective diagnostic and therapeutic option. Complete resection of the mass is important to judge the existence of immature and solid components that require a long-time follow-up because of the increased risk of malignancy.

 Suprapubic catheter (SPC) and bladder indwelling catheter (BIC) placement are among the most common urological procedures. Inadvertent misplacement of the catheter tip into the ureteral orifice is an infrequent event with potentially critical complications.

 We describe two cases of inadvertent intraureteral misplacement of an SPC and a BIC. A 66-year-old man with chronic kidney disease (CKD) stage G3b, urethral stenosis, long-term SPC who attended the emergency room (ER) 6 hours after the last catheter replacement due to low back pain, fever, deterioration of the general condition, anuria, acute kidney injury (AKI); CT-scan revealed a left uretero-hydronephrosis secondary to obstruction of the catheter balloon misplaced inside the distal ureter. A 59-year-old woman with CKD stage G3b, post-radiotherapy cystitis, and small capacity bladder, long-term BIC who attended the ER a few hours after the last BIC replacement due to abdominal pain, anuria, AKI; CT-scan revealed left hydronephrosis secondary to catheter obstruction within the distal ureter. In both patients, management was conservative, consisting of removing the catheter and repositioning it inside the bladder, in addition to hydration and antibiotherapy.

 These cases illustrate that awareness of this rare complication can be prevented by confirming the correct positioning of SPC or BIC after its replacement. Early detection and management of this complication can prevent a serious clinical setting.

 There has been a rise in the reappearance of multidrug-resistant Gram-negative bacteria in recent years. Using polymyxins, such as colistin, as a last-line treatment for these infections has led to renewed interest in the toxic effects of this drug.

 In this case report, we present neurological signs and symptoms developed in a patient with a history of cervical cancer four to five hours after receiving colistin for treating a urinary tract infection caused by MDR Pseudomonas aeruginosa with a colony count of > 100,000/L. These signs and symptoms included lower limb hemiparesis, facial paresthesia, decreased deep tendon reflexes, and tinnitus, which were resolved on their own 24 hours after discontinuation of the drug. Antibiotic therapy was continued with pipractate and ciprofloxacin instead. The patient got discharged in stable condition after negative urine culture results.

 In general surgery, the acute scrotum is equivalent to the acute abdomen, and any delay in treatment may be risky for testis functions, especially in children. Among acute scrotal etiologies, spermatic cord cyst or hydrocele could be misleading. Spermatic cord cysts can evoke long-term scrotal pain with acute exacerbation.

 Here we report a boy aged 14 years old referring to the emergency clinic with the complaint of high riding testis, acute scrotal pain, and decreased testicular perfusion in Doppler ultrasound, which all warranted immediate scrotal exploration. According to exploration, a cyst was found twisting around the testis, lacking any sign of ischemia. The cyst was marsupialized, and the contained serum liquid was drained.

 Management of torsion of the spermatic cord cyst can be conservative if it is confirmed with absolute certainty. Hence, spermatic cord cyst torsion possibly is a source of confusion requiring further research to improve the precision of diagnoses. A spermatic cord cyst or hydrocele torsion is a rare cause of acute scrotum with a good prognosis. However, every suspicion must be confirmed by scrotal exploration.

 Due to the occurrence of hemodialysis, the life expectancy of end-stage renal disease (ESRD) patients is lengthening. However, their quality of life (QoL) is decreasing. The QoL of ESRD patients is composed of physical component score (PCS), mental component score (MCS), and kidney-related component score (KDCS) components. Nutritional status is one of the influencing factors of QoL. It is unclear whether free fat mass (FFM) or fat mass contributes to the increase of QoL in ESRD patients.

 This study aimed to identify the correlation between FFM percentage and the QoL of ESRD patients.

 This cross-sectional study was conducted in Hemodialysis Unit, Division of Kidney and Hypertension, Dr. Cipto Mangunkusumo General Hospital, Jakarta from June to July 2018. In this study, 102 subjects were included. Blood samples were collected for laboratory examination. FFM percentage was measured using bioimpedance analysis (BIA). Meanwhile, QoL was evaluated using KDQOL SF-36 version 1.3. Statistical analysis was done using Pearson correlation test. Analysis of QoL was done based on fat percentage using ANOVA test.

 In this study, the overall KDQOL score was 47.86 ± 6.56 with PCS 40.97 ± 9.66, MCS 46.6 (22.05 - 59.95), and KDCS 55.98 ± 9.02. FFM percentage was 74.21 ± 1% with mean mass of 43.06 ± 8.16 kg. Statistical analysis showed no correlation between FFM percentage and overall KDQOL score (r 0.032, P 0.750). However, there was a significant correlation between PCS and FFM (r 0.223, P 0.024).

 There is a weak positive correlation between FFM in kg and the physical quality of end-stage kidney disease (ESKD) patients.

 Chronic itch (CI) in hemodialysis (HD), also called uremic pruritus (UP), is a common, distressing, and unpleasant symptom. Fibroblast growth factor 23 (FGF23) is a bone-secreted phosphaturic factor. Several bone diseases can accompany kidney diseases. It is unclear whether the common disturbance of calcium/phosphate homeostasis can cause CI in chronic kidney disease.

 This study investigated the association between FGF23 and UP among HD patients in northern Iran.

 Patients undergoing maintenance HD at four referral medical centers were recruited in this cross-sectional survey. The enzyme-linked immunosorbent assay was used to evaluate serum FGF23 levels. An interview questionnaire was used to analyze the various aspects of pruritus.

 Of 237 subjects, 54.01% had UP. There was no difference in serum FGF23 levels between patients with and without UP (413.17 ± 416.97 vs. 410.81 ± 444.49, P = 0.85). Those with UP required dialysis for a longer period (P = 0.02). FGF23 was shown to be associated with parathyroid hormone in UP (P = 0.02, r = 0.41).

 There was no linear correlation between FGF23 and UP in this study.

 Chronic renal failure (CRF) is a major public health problem affecting individuals’ quality of life (QOL). Hemodialysis is one of the most common treatments for CRF. Although hemodialysis increases the life expectancy of CRF patients, it also arouses several problems affecting these patients’ QOL.

 This study aimed to detect factors affecting QOL in hemodialysis patients in the East Azerbaijan province, Iran.

 This cross-sectional study was conducted in the East Azerbaijan Province in 2021. Data collection instruments were the SF-36 Quality of Life Questionnaire and a demographic information checklist. The collected data were analyzed with SPSS software version 25 using Spearman’s rank correlation, Kruskal-Wallis, and Mann-Whitney U tests.

 The mean score of QOL was 42.6 ± 7.6, and the mean scores of the physical and psychological dimensions of QOL were 40.7 ± 9.9 and 43.4 ± 7.4, respectively. The highest mean score of QOL was 44.6 ± 6.2 for men, 42.7 ± 5.8 for the married, and 41.2 ± 6.9 for those with high levels of education. The mean score of QOL was not significantly correlated with any of the individual characteristics and clinical factors, except for age (P = 0.03), level of education (P = 0.03), and duration of each dialysis session (P = 0.05). From the QOL dimensions, physical dimension had a significant relationship with marital status (P = 0.03), age (P = 0.04), and duration of each dialysis session (P = 0.02). Moreover, psychological dimension was significantly correlated with marital status (P = 0.01).

 Patients undergoing hemodialysis have low QOL and need further attention from the authorities in terms of care and social support.

Context: 

Pituitary adenomas are amongst the most common tumors with a low mortality rate compared to other intracranial malignancies. Delayed hyponatremia (DH) is a common finding after transsphenoidal resection (TSS), which is the basis for the management of these tumors. Although DH is one of the leading causes of readmission after TSS, no unified guidelines exist with regard to the prevention of this electrolyte disturbance.

 This study aims to evaluate and compare existing preventive protocols for DH in order to identify and signify their common grounds.

 After a search in electronic databases, including PubMed (NCBI), Embase, Scopus, and Google Scholar with the keywords of “pituitary adenoma,” “hyponatremia,” “transsphenoid surgery”, “water electrolyte balance,” “patient readmission", six original articles were included in the study.

 We found that a protocol that both identifies groups susceptible to DH (males, older individuals, and those with a lower BMI) and consists of fluid restriction, sodium supplementation, and regular serum sodium monitoring could be utilized to prevent DH in patients with pituitary adenomas after TSS.

 Further studies with a larger sample size must be conducted to compare existing protocols for preventing DH and also investigate post-surgery optimal fluid-restricted diets and corticosteroid therapy in these patients.

 Nowadays, because of remarkable advancements in retrograde intrarenal surgery (RIRS), modest attention toward this procedure as the second or alternative choice for renal stones treatment has been drawn.

 In the present study, we compared RIRS and percutaneous nephrolithotomy (PCNL) outcomes in treating obese patients with 2 - 4 cm renal stones.

 Eighty-two patients who underwent PCNL (n = 40) and RIRS (n = 42) between June 2015 and December 2018 at the Department of Urology of Sina Hospital were enrolled in our retrospective cohort study.

 After the first surgery session, stone-free rates for the RIRS group were 92.9% and for the PCNL group was 95% (P value = 0.52). The mean operation time for the RIRS and PCNL groups were 71.6 ± 11 and 93.3 ± 12.2, respectively (P < 0.001). The hospitalization stay for all of the PCNL group was more than 1 day (mean = 2.5 days); however, that for the majority of the RIRS group was less than 1 day (P < 0.001). The analgesic use in the RIRS group was significantly lower than in the PCNL group (9.0 ± 5.5, 61.8 ± 13.6, respectively; P < 0.001). The overall complication rates were higher in the RIRS group. However, none of them were statically significant (P > 0.05).

 According to satisfactory outcomes obtained in the RIRS groups, it can be concluded that RIRS can be applied as an alternative or even the first choice in obese patients with 2 - 4 cm renal stones.

 Renal papillary necrosis (RPN) is a multifactorial complication that occurs under the following conditions: Pyelonephritis, obstruction of the urogenital tract, non-steroidal anti-inflammatory drugs (NSAIDs) abuse, diabetes mellitus (DM2), and coronavirus disease 2019 (COVID-19). The present report presented a case of right ureteral obstruction due to RPN.

 The patient was a 68-year-old woman referred to the hospital due to flank pain, fever, vomiting/nausea, frequency, and nocturia. She also had a history of DM2, hypertension, dialysis, COVID-19, and the use of NSAIDs and antihypertensive. The results of computed tomography (CT) scan suspected a clot, bladder fungus or RPN, and COVID-19. After performing the ultrasound, mild hydroureteronephrosis and two echogenic foci were seen in the right kidney, suggesting a possible RPN. The patient was transferred to the urology service. After cystoscopy and urethroscopy, a severe stenosis was seen in the distal right ureter. As soon as inserting double J, lots of pus came out. The definitive diagnosis was RPN, ureteral obstruction, and pyelonephritis.

 It is important to pay enough attention to the disorders related to the urinary system, especially in the elderly with a history of NSAIDs abuse, DM2, hypertension, COVID-19, and renal diseases. Additionally, the underlying diseases, blood glucose, infection, dehydration, and use of NSAIDs must be well-controlled to protect nephro-ureteral structures.

 Closing the fascia after surgery should be quick, easy, and strong but comfortable for the patient. Polydioxanone thread is not available in Iran. Thus, we used Vicryl sutures for almost all patients.

 This study was conducted at Imam Reza and Imam Khomeini Medical Centers in Ardabil from January 2018 to January 2020. The fascia was continuously sutured with size 0 or 1 of Vicryl in a double layer for all patients in the Urology Department.

 Here, 642 patients were evaluated in two years. The fascia suturing was at the site of the inguinal, midline Gibson, and flank areas. The data showed that incisional hernia and infection were more prevalent in obese and diabetic patients. We had no incisional complications in radical cystectomy or even kidney transplantation, which are complicated and time-consuming surgeries. Overall, the surgical site complication rate (including incisional hernia and surgical site infection) was 0.9%, which could be negligible.

 The fascia repair could be treated with Vicryl suture in a continuous form in all urologic surgeries, with a very low rate of wound infection and hernia at the operation site, sinus formation, and long-term surgical site discomfort. However, we suggest more research to confirm the Vicryl suture safety in urologic fascia repairs.