Antony Devasia

Emphysematous Pyelonephritis: Outcome of Conservative Management

OBJECTIVES To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis. METHODS Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics. RESULTS Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%. CONCLUSIONS A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

Retroperitoneal lymphatics on CT and MR

We report the CT and MRI appearances of dilated retroperitoneal lymphatic channels in six patients. In two patients, these dilated channels resembled a mass of confluent low-density lymph nodes on CT. On MR urography the lymphatic channels in all six patients were seen as a meshwork of multiple tubular, tortuous, fluid-filled structures in the retroperitoneum of the abdomen and pelvis. On axial T1W images, these channels were seen as numerous, interconnected small, nodular and streaky intensities and as a cloak of diffuse homogenous hyperintensity on T2W axial images. The lymphatic nature of these abnormalities was confirmed at surgery in one patient. In another patient, the calibre and number of the dilated retroperitoneal channels reduced following anti-filarial therapy. The remaining four patients presented with chyluria.

Extramedullary hematopoiesis in the adrenal: Case report and review of literature

Extramedullary haematopoiesis (EMH) is common in the spleen, liver and lymph nodes, or in para osseus sites. EMH in the adrenal is rare, with fewer than 10 cases reported. We report the case of a 40-year-old male who underwent laparoscopic adrenalectomy for an incidentally detected adrenal mass. The histology showed extramedullary hematopoesis. In patients with a known history of haemolytic anaemia, an enlarged adrenal gland in an asymptomatic individual could represent extramedullary haematopoesis. A confirmatory biopsy would be all that is necessary to avoid adrenalectomy.

Second transurethral resection in T1G3 bladder tumors - Selectively avoidable?

Aim: To assess the need of a second transurethral resection (TUR) in select T1G3 bladder tumor patients. Materials and Methods: All the pT1G3 bladder tumors diagnosed during the period between January 2005 and December 2008 were included. Second TUR was routinely performed in all the pT1G3 bladder tumors within 4–6 weeks. Fifty out of the 68 patients with T1G3 underwent a second TUR and were retrospectively reviewed. The primary bladder lesions were grouped as solitary papillary, multiple papillary and sessile lesions. Statistical analysis was performed using STATA version 11 (STATA Corp., Texas, USA). Results: Forty percent (n = 20) of the lesions were solitary papillary, 48% (n = 24) were multiple papillary and 12% (n = 6) were sessile lesions. All our resections had muscularis propria sampled at the end of the resection and separately sent for histopathological examination (HPE), which showed them to be tumor free. Thirty-six percent of patients had residual disease at the second resection and 4% were upstaged. Ninety-five percent of the patients (n = 19) with solitary papillary lesions did not have any residual disease and 50% (n = 12) of the multiple papillary and 83.3% (n = 5) of the sessile group had residual disease at the second TUR. Conclusions: Patients with T1G3 tumors do not represent a homogenous group. Second TUR is recommended in patients with high-grade T1 urothelial bladder carcinoma as it identifies residual disease and invasive disease. Solitary papillary lesions may be the only group where the need for the second TUR is questionable.

Bladder Varices—Rare Cause of Painless Hematuria in Idiopathic Retroperitoneal Fibrosis

A patient presented to the urology outpatient department with complaints of recurrent episodes of painless hematuria. A contrast-enhanced computed tomography scan of the abdomen revealed vesical varices that had developed secondary to obstruction of the inferior vena cava. Additional investigation revealed idiopathic retroperitoneal fibrosis. Steroid therapy was started and tapered during a 6-week period. No recurrence of the hematuria was noted on follow-up. We have described a unique presentation of hematuria due to vesical varices in a patient with idiopathic retroperitoneal fibrosis.

Trichosporon Surgical Wound Infection in a Renal Allograft Recipient Successfully Treated With Voriconazole

A 39-year-old chronic kidney disease patient underwent a preemptive renal transplantation in November 2009. His native kidney disease was unknown (biopsy performed in 2006 showed diffuse global sclerosis). He reached end stage in 2009 and after that he was worked up for transplantation. He was not a diabetic and did not have any other comorbidity. He did not receive any immunosuppression before renal transplantation. His wife donated the kidney. His immunosuppression included Basiliximab (two doses) for induction along with prednisolone, tacrolimus, and mycophenolate sodium for maintenance. He had a prolonged warm ischemia time because of difficulty in donor nephrectomy. After surgery, he had a slow recovery in renal function for which a graft biopsy was performed on 4th postoperative day. It showed acute tubular necrosis. Tacrolimus levels were found to be high (13 ng/mL), and hence the dose was reduced. Because renal recovery continued to be slow, a second renal biopsy was performed after a week, which showed cortical necrosis at the upper pole. Without any specific intervention, renal function slowly improved to attain a nadir creatinine of 1.4 mg/dL. Dose titration of tacrolimus and mycophenolate sodium was performed in this period with therapeutic drug monitoring. In the postoperative period, he had received ciprofloxacin as treatment for lower respiratory infection and there were no other infective episodes. After suture removal, he was found to have pus discharge from the surgical wound site. A pus swab for culture grew Trichosporon species. It was confirmed by a second culture. An ultrasonogram revealed a small subcutaneous collection. Surgeons considered exploration to be unnecessary and wanted daily dressings only. A small noncompressing lymphocele was also noted near the lower pole of the graft kidney. Imaging studies excluded involvement of other organs. He did not have neutropenia. Antifungal therapy in voriconazole was begun at standard doses (400 mg twice daily on day 1 followed by 200 mg twice daily). Tacrolimus dose was decreased based on new trough levels. Mycophenolate area under the curve was found to be high, and the dose was dropped. He showed response to the treatment with clearing of the discharge. The wound healed within 2 weeks and the subcutaneous collection resolved. Voriconazole was continued for 4 weeks and stopped. His renal function remains stable and the wound is healthy.

Hematuria, renal mass and amenorrhea: indicators of a rare diagnosis.

Metastatic choriocarcinoma of the kidney is a rare entity, and its primary presentation with hematuria and renal mass is even less common. Two cases are presented with a review of the literature.

Exstrophy-epispadias Complex Presenting in Adulthood: A Single-center Review of Presentation, Management, and Outcomes

OBJECTIVE To study the presentation, management, and outcome of patients with exstrophy-epispadias complex, who present in adulthood (aged >18 years). MATERIALS AND METHODS A retrospective review of the electronic medical records of patients with exstrophy-epispadias complex managed from January 2001 to December 2010 was undertaken. Patients aged >18 years at presentation, with detailed medical records were selected. They were classified into 2 groups: group A (previously untreated) and group B (residual defects or complications after childhood surgery). RESULTS Thirty-nine patients with exstrophy-epispadias complex presented to our institution over this 10-year period. Of these 26 were adults (aged >18 years; range, 18-48 years). Detailed medical records could be obtained for 21 of them and they were included. Group A consisted of 4 patients--2 male and 2 female. All underwent cystectomy; 2 had an ileal conduit and 2 had ureterosigmoidostomy (Mainz II). All had improved quality of life and a stable renal function at follow-up. Group B consisted of 17 patients. Mean number of surgeries attempted previously was 4.4 (range, 2-13). Presentation was varied but primarily involved incontinence of urine (n = 12). Four patients were lost to follow-up, 2 were managed conservatively, and 11 underwent a surgical procedure. All patients returned to normal activity with an improvement in the quality of life postoperatively. CONCLUSION Exstrophy-epispadias complex is difficult to manage in resource-poor settings associated with illiteracy and poverty. However, successful rehabilitation and an improved quality of life are possible even in cases presenting in adults.

Mutations seen among patients with pheochromocytoma and paraganglioma at a referral center from India.

Determining the mutational status of susceptibility genes including RET, VHL, SDHx (SDHB, SDHC, SDHD) among patients with pheochromocytoma/paraganglioma (PCC/PGL) is gaining importance. These genes have not been systematically characterized among patients with PCC/PGL from India. The aim of the work was to screen the most frequently mutated genes among patients with PCC/PGL to determine the frequency and spectrum of mutations seen in this region. Fifty patients with PCC/PGL treated at our tertiary care hospital between January 2010 and June 2012 were screened for mutations in susceptibility genes using an algorithmic approach. Thirty-two percent (16/50) of patients were found to be positive for mutations including mutations among RET (n=4), VHL (n=6), SDHB (n=3), and SDHD (n=3) genes. None of these patients were positive for SDHC mutations. A significant association was found between young patients with bilateral tumors and VHL mutations (p=0.002). Two of the 3 patients with extra-adrenal SDHB associated tumors, had unique mutations, viz., c.436delT (exon 5) and c.788_857del (exon 8), one of which was malignant. High frequency of mutations seen among patients in this study emphasizes the need to consider mutational analysis among Indian patients with PCC/PGL.

Emphysematous pyelonephritis in a renal transplant recipient – Is it possible to salvage the graft?

BACKGROUND Emphysematous pyelonephritis (EPN) is a rare but potentially devastating complication after renal transplantation. It carries the risk of graft loss and is associated with a high mortality. The majority of cases reported thus far have undergone graft nephrectomy. CASE REPORT We report the case of a live-related renal transplant recipient who presented 10 years later with fever, graft tenderness and worsening serum creatinine. Computed tomography (CT) revealed emphysematous pyelonephritis, with a large perinephric collection. The case was managed successfully by percutaneous drainage. CONCLUSIONS Percutaneous drainage is a safe and effective therapeutic modality in cases of EPN in transplant recipients, and allows salvage of the renal allograft in most cases.