Anthony Kodzo-Grey Venyo

Tuberculosis of the kidney and the genitourinary tract – a review of the literature

The incidence of human tuberculosis (TB) is increasing worldwide, mainly because of the spread of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and the emergence of drug resistance. Pulmonary TB occurs more commonly than genitourinary TB (GUTB). Symptoms of GUTB are vague and are frequently go undetected. This review serves as a reminder that GUTB exists and, if undiagnosed, may cause unnecessary morbidity. GUTB occurs in 4–20% of patients with pulmonary TB. Onset of GUTB is insidious, and with pyuria and microscopic haematuria in 90% of patients. Diagnosis is achieved by the demonstration of tubercle bacilli in urine. Imaging features include calcifications, calyceal distortion and infundibular and ureteral strictures. Early changes include erosion and blunting of the calyces, narrowing of collecting system infundibula, overt papillary necrosis and parenchymal scarring/calcification. Prostatic involvement is nodular and non-tender. Genital TB presents with superficial ulcers in both males and females. Obstruction of the vas deferens causes infertility. Tuberculous orchitis may mimic other testicular mass lesions. Treatment is with antituberculous therapy. Early endourological decompression of ureteric strictures improves the salvage rate of the kidney.

Leprosy in pregnancy – a review of the literature

Leprosy, or Hansens disease, is one of the worlds oldest infectious diseases. It affects the skin and nerves and, if left untreated, leads to deformity. Every 2 minutes someone is diagnosed with leprosy, but, because of the lack of education and the stigma surrounding the disease, some people are diagnosed too late and develop life-changing disabilities. Through a simple course of medication, leprosy is an entirely curable disease. Literature, such as reported cases and review papers, on leprosy in pregnancy was obtained using various internet search engines. Leprosy in pregnancy is a rarely reported event, but nine countries in Africa, Asia and Latin America have considered it a public health problem. An effective cure for leprosy is available in the form of multidrug therapy, taken for some months, but if treatment is delayed until a later stage, there is a high risk of disability. Pregnancy is hazardous for women with leprosy. It is most dangerous during the third trimester when infection can lead to adverse obstetric and fetal outcomes, such as low birthweight, prematurity, exfoliative dermatitis in the newborn and erythema nodosum in the pregnant mother. Documentation on leprosy in pregnancy indicates that pregnancy is not only a trigger for leprosy but also an ideal in vivo model for research. Leprosy in pregnancy can be treated safely and effectively by combined drug therapy. However, early detection, well-planned health education for leprosy patients and the highest standard of clinical supervision during pregnancy are key strategies in reducing problems associated with the disease and are also the best way to prevent disability.

Brucellosis associated with kidney injury and any form of nephropathy – a review of the literature

Systemic brucellosis may be associated with acute kidney injury (AKI), haemolytic–uraemic syndrome, nephrotic syndrome or various types of nephropathy. Presentation depends on the type of renal disease the patient develops. A diagnosis of brucellosis as a cause of nephropathy would require the following: isolation of Brucella in blood culture; positive serological test for brucellosis; renal biopsy evidence of the type of nephropathy; culture of Brucella from perinephric abscess or renal abscess aspirate; culture of Brucella from nephrectomy specimen; and finding a specific type of nephropathy during histological examination. Ultrasonographic and computerized tomographic findings are not specific for brucellosis; however, the scans may show an abnormal area in the kidney from which renal biopsies can be taken for pathological examination and culturing, and if there is an abscess it can be aspirated for culture. A high index of suspicion is required to diagnose the disease. The most commonly used antibiotic regimen for the treatment for brucellosis is doxycycline 100mg twice a day for 45 days in combination with streptomycin 1g/day for 15 days. The main alternative treatment is doxycycline 100mg twice a day for 45 days in combination with rifampicin 15mg/kg/day (600–900mg) for 45 days. Experience suggests that streptomycin may be replaced by gentamicin 5mg/kg/day for 7–10 days. The optimal treatment for neonates and children under 8 years old with acute brucellosis has not yet been determined but there is some experience with trimethoprim/sulfamethoxazole (cotrimoxazole) in combination with an aminoglycoside (streptomycin, gentamicin) or rifampicin. In general, other combinations of antibiotics have also been used to treat brucellosis. In cases of kidney injury and dehydration, in addition to antibiotic treatment, rehydration and clinical monitoring is required, as is monitoring urine output, repeated urinalysis and repeated serum biochemical tests for renal function estimation to assess the patients progress. Most renal complications due to brucellosis resolve/improve after combined antibiotic treatment and rehydration, which is also most often associated with return of normal renal function or improvement in renal function. However, relapses can occur, and careful patient follow-up is required to further assess the patient clinically by regularly repeating urinalysis, renal function tests, liver function tests and full blood count and coagulation tests, as well as repeating blood and urine cultures and Brucella serology tests. Patients should be educated to avoid contact with and ingestion of unpasteurized dairy products. Pasteurization of all dairy products should be advised, encouraged and monitored. Veterinary surgeons in endemic areas should be informed and assist when a new diagnosis is made in order to help identify and treat or kill affected animals harbouring Brucella.

Primary and metastatic lymphoma of the testis – a review of the literature

Primary lymphoma of the testis is rare. The commonest type of lymphoma of the testis is diffuse large B-cell lymphoma, but other types of primary and metastatic lymphoma of the testis also occur. Diffuse large B-cell lymphoma usually manifests as a painless unilateral mass in older men. Children can also develop lymphoma of the testis. Constitutional symptoms may be experienced. Specimens for histological confirmation of this type of lymphoma are obtained through orchiectomy. Chemotherapy and radiotherapy are used to avoid or reduce recurrences. Intrathecal chemotherapy is also used to reduce recurrence in the central nervous system, but despite this central nervous system recurrences do occur. There is no consensus on the best chemotherapy regimen. It is important that a correct diagnosis is made based upon the microscopic and immunohistochemical characteristics of the tumour, because differentiation of diffuse large B-cell lymphoma from other types of lymphoma is helpful in selecting the correct chemotherapeutic regimen, and the appropriate regimen differs depending upon the specific type of lymphoma. There is a need for a global multicentre trial to identify the best treatment option for improving the long-term survival of patients and reducing central nervous system, extranodal and contralateral testis recurrences.

Endometriosis of the colon – a review of the literature

Endometriosis is an oestrogen-dependent clinical condition that manifests with functional endometrial tissue at sites outside the uterus or elsewhere than in the normal endometrial lining. Endometriosis of the colon is not common and its presentation is non-specific. In view of this, its diagnosis may be difficult. The aim of this review is to gather information from the available literature on endometriosis. Various internet databases were searched, including PubMed, Un-bound MEDLINE, DeepDyve, Google, Google Scholar, Educus and Yahoo. Colonic endometriosis is not uncommon and has a myriad of presentations. It affects Caucasians and the sigmoid colon predominantly. The risk of perforations, malignancy and mucosal involvement increases with gravidity, post-menopausal status and rectosigmoid sites, respectively. Clinicians should maintain a high index of suspicion when managing women of child-bearing age who present with gastrointestinal symptoms or pelvic pain.

Primary well-differentiated neuroendocrine tumour (carcinoid tumour) of the urinary bladder

Primary well-differentiated neuroendocrine tumour (NET) (carcinoid tumour) of the urinary bladder is extremely rare and most clinicians would be unfamiliar with its presentation, investigation, pathological classification, management and treatment outcomes. The aim of this article is to review the literature on reported cases of primary well-differentiated NETs of the urinary bladder. Bladder NETs due to metastasis from other sites and mixed-bladder NETs were excluded from the literature search. Fewer than 20 cases of primary well-differentiated NETs of the urinary bladder have been reported in the literature. A total of 18 cases were reviewed, with 28% of the cases discovered as an incidental finding. The mean age of the patients at presentation was 56 years (range: 30–73 years). There was no sex predilection. The size of the tumour ranged from 2 to 50 mm. The mean follow-up was 24 months. This tumour tends to present with haematuria, with transurethral resection as a modality of treatment with good results. Histological examination of reported cases of well-differentiated NETs of the urinary bladder have exhibited histological characteristics similar to primary well-differentiated NETs that are found in sites outside the urinary bladder. Primary well-differentiated NETs (carcinoid) of the urinary bladder are very rare and have similar histological characteristics to those of carcinoid tumours in other sites of the body. They predominantly present with haematuria, appear to have excellent prognosis and are amenable to transurethral resection.

Micropapillary variant of urothelial carcinoma – a review of the literature

The micropapillary variant of urothelial carcinoma is one of the variants of urothelial carcinoma that was added to the World Health Organization (WHO) classification in 2004. This variant of urothelial carcinoma is uncommon and, therefore, a number of practitioners have not yet encountered the tumour in their clinical practice. In view of this, the diagnostic features and the biological behaviour of this tumour are not well known by practitioners. This review documents the diagnostic features, management and outcome of the micropapillary variant of urothelial carcinoma. Various internet search engines were used to identify literature on the micropapillary variant of urothelial carcinoma, including case reports and case series, which formed the basis of the literature review. At least 500 cases of the micropapillary variant of urothelial carcinoma have been reported since it was first described in 1994. The gross morphology is variable and there are no special features to differentiate this variant from other variants or from conventional urothelial carcinoma. The micropapillary variant may be sessile, papillary, ulcerative or polypoid or may manifest as an infiltrative mass of variable size, ranging from microscopic to >10cm. The microscopic features of this variant of urothelial carcinoma exhibit an architecture that is reminiscent of the papillary configuration of ovarian papillary serous tumours. The nuclei of the micropapillary variant cells are commonly of high grade and show reverse polarity to the external surface of the tumour nests. A minority of the tumour-containing spaces represent actual lymphovascular invasion, which is supported by their characteristic immunohistochemical staining with endothelial markers. Lymphovascular invasion can be found in most cases of the invasive micropapillary variant of urothelial carcinoma if the specimens are adequately sampled, but a majority of the tumour-containing lacunae do not have endothelial lining and, therefore, do not represent true lymphovascular invasion. Psammoma bodies, which are common in ovarian papillary serous tumours, are rare in the micropapillary variant of urothelial carcinoma, and most of these tumours exhibit deep muscle invasion. Urine cytology exhibits papillary/spheroid clusters of tumour cells that have a high nuclear grade. The micropapillary variant of urothelial carcinoma is a rare and aggressive variant and may be under-reported as some pathologists may not be aware of its diagnostic features. Reports so far would indicate that this variant is associated with poor prognosis and adjuvant chemotherapy may have a questionable efficacy. Because of the rarity of this variant of urothelial carcinoma, there is no consensus opinion regarding the optimal treatment. Therefore, there is a need for urologists and oncologists throughout the world to report cases of the micropapillary variant of urothelial carcinoma so that the biological behaviour of the tumour can be ascertained. There is also a need for multicentre trials of treatment of this variant of urothelial carcinoma so that lessons can be learnt regarding the biological behaviour of the tumour and a consensus opinion can be established regarding the best treatment modality for such an apparently aggressive tumour.

Inverted papilloma of the urinary tract – a review of the literature

Inverted papilloma of the genitourinary tract is an uncommon neoplasm. Some urothelial carcinomas exhibit prominent inverted growth patterns that may pose a diagnostic dilemma. The presence of multiple inverted papillomas, their frequent recurrence and association with transitional cell carcinoma may lead to conflicting clinical conclusions regarding their biological behaviour and hence there is a need to review the literature. Internet databases including PubMed, Google Scholar, Google and Educus were searched to identify publications on inverted papilloma. Thirty-four publications formed the foundation for this review of the literature. The results revealed that inverted papilloma is a rare endophytic urothelial neoplasm that is most commonly found in the urinary bladder and less commonly in the upper urinary tract and urethra. Inverted papillomas are more common in men than in women and may present with obstructive or irritating voiding symptoms or haematuria. Inverted papilloma of the prostatic urethra may present with perineal pain whereas inverted papilloma of the upper renal tract may present with haematuria and loin pain. Inverted papillomas may be difficult to differentiate from inverted urothelial carcinomas but exhibit an absence of, or only few, atypical cells whereas inverted urothelial carcinomas exhibit atypia. Immunohistochemistry can be of assistance as urothelial carcinomas are positive for Ki-67 and p53, fluorescence in situ hybridization (FISH) and cytokeratin 20; however, inverted papillomas generally do not express these markers. FISH analysis can often detect chromosomal anomalies in urothelial carcinomas, but chromosomal abnormalities are absent in inverted papillomas. Inverted papillomas are endophytic and, when they are completely resected or excised, they do not initially recur; however, urothelial carcinomas recur and may progress. Inverted papillomas rarely coexist with urothelial carcinomas and malignant transformation has rarely been reported in inverted papillomas. Microscopic examination may enable inverted papillomas to be classified as the more common classic trabecular subtype or the glandular subtype.

Percutaneous transcatheter super-selective embolization of a tributary of an accessory renal artery to control traumatic haematuria from a horseshoe kidney-a case report

Objectives: The most experienced clinicians could easily miss serious renal injury at surgery. We report a case of a recently diagnosed bleeding from a lacerated horseshoe kidney with a review of the literature. Methods: The clinical and imaging records and laboratory results of a patient with blunt abdominal trauma were reviewed who initially underwent splenectomy for splenic injury, but a renal injury was missed at laparotomy. We also carried out a review of published reports of renal artery injuries. Results: A thirty-year-old man was admitted as an emergency to a hospital after he had sustained blunt abdominal trauma in a go-carting accident. He underwent splenectomy for splenic injury following which he was discharged. A few days later, he was seen in another hospital complaining of left loin pain where, a provisional diagnosis of urinary tract infection and possible haematoma around his splenic bed was made. He discharged himself against medical advice before further imaging could be undertaken. He presented to a third hospital with abdominal pain and then developed haematuria severe enough for him to be transfused. Ultra-sound scan and CT-scan of the abdomen and pelvis showed injury to a horseshoe kidney with haematoma which was initially drained percutaneously. Post contrast axial CT scans showing the transacted kidney and active renal bleeding are shown in Figures 1 & 2. A selective renal artery angiogram confirmed bleeding from a tributary of an accessory descending left renal artery that was successfully treated by super-selective embolization (Figures 3, 4, 5 and post embolization CT Figure 6). Conclusions: Ultrasonography and Computed Tomography are instrumental in the diagnosis of a horseshoe kidney. Both ultrasound and CT scans confirm a renal/peri-renal haematoma resulting from renal trauma. Selective renal artery angiography not only confirms the source of bleeding but also allows superselective arterial embolization as a definite or stopgap treatment.Super-selective embolization of renal haemorrhage is comparatively non-invasive and preferred to open surgery.