Testicular Necrosis Post Kidney Transplantation: Lessons Learned

There is a paucity of literature on testicular complications after kidney transplant. Testicular necrosis after kidney transplantation has only been reported twice before. We present a 60- year-old man with end-stage renal disease who underwent uneventful deceased-donor kidney transplant. The patient's postoperative course was complicated by delayed graft function, urinary tract infection, epididymo-orchitis, and a necrotic testis necessitating radical orchiectomy on postoperative day 15. With their complex comorbidities compounded by a high burden of genitourinary complications, kidney transplant recipients may face testicular complications post-transplant due to the inherent risk posed by intraoperative manipulation of spermatic cord and ligation of lymphovascular structures.     

Urologic manifestations of hematologic disease sickle cell,leukemia, and thromboembolic disease

Advances in medicine are allowing patients with hematologic disease to live longer and healthier lives than ever before. As these patients age, however, manifestations of their disease processes may develop as complications in other organ systems. We discussed the major genitourinary complications of sickle cell anemia, leukemia, and thromboembolic disease. These range from the benign inability to concentrate urine that is seen in sickle cell disease to renal infarction that results from nephrotic syndrome. Our ability to treat and prevent these complications will improve as our understanding of these disease processes and their pathophysiology grows. Additionally, it is important for urologists to understand the underlying pathophysiology of hematologic disease to best serve the patients. For example, it may be the urologist who makes the diagnosis of ovarian vein thrombosis in a pregnant woman with right lower quadrant pain and fever. This diagnosis, with the proper treatment of antibiotics and anticoagulation, could prevent the potential development of septic thrombophlebitis. Urologists will increasingly be called upon to deal with the manifestations of these complex diseases as these patients are living longer. It is our duty to educate ourselves about these disease processes so that we can make the best clinical decisions for our patients.     

Sickle cell nephropathy: challenging the conventional wisdom

This review explores the current model of sickle cell nephropathy and the limitations of the model. Renal abnormalities are common complications of sickle cell disease (SCD). Beginning in childhood, patients with SCD develop a urinary concentrating defect resulting in polyuria and a predisposition to nocturnal enuresis and dehydration. The current model of sickle cell nephropathy suggests that destruction of the renal medulla induces production of renal vasodilating substances that feedback to the glomerulus causing hyperfiltration. Hyperfiltration leads to glomerulosclerosis and proteinuria, with eventual reduction in kidney function. The crucial steps of vasodilating substance production and hyperfiltration in children with SCD have not been proven. Treatment of sickle cell nephropathy is aimed at the reduction of proteinuria with angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Hydroxyurea and chronic transfusion therapy may also alter the progression of sickle cell nephropathy in children. Further studies are needed to identify an accurate model and effective treatments for sickle cell nephropathy.     

Role of prophylaxis in vesicoureteral reflux

PURPOSE OF REVIEW: Traditional management of vesicoureteral reflux focuses on preventing renal complications associated with ascending urinary tract infection by either providing continuous antibiotic prophylaxis to sterilize the urine and thus prevent recurrent infection, or abolishing reflux via surgical intervention. This review will consider the rationale for antibiotic prophylaxis in light of contemporary data regarding the natural history of vesicoureteral reflux, urinary tract infection and renal scarring, as well as the efficacy of various treatment strategies. RECENT FINDINGS: Recent studies have shown that in grades I-IV vesicoureteral reflux, open surgical intervention compared with antibiotic prophylaxis is no better at preventing renal complications. Endoscopic subureteral injection of biomaterials has been proposed as a cost-effective, minimally invasive alternative to surgical or medical intervention; however, given the variety of materials and techniques, the literature has yet to achieve consensus on its efficacy. The first study to compare antibiotic prophylaxis with increased surveillance and prompt treatment of urinary tract infection shows no difference between the two approaches in low-grade (grades I-II) vesicoureteral reflux. SUMMARY: Recent studies have challenged the traditional paradigm of aggressive vesicoureteral reflux management with surgery or antibiotic prophylaxis. In light of these findings, pediatric urologists will need to reexamine treatment modalities for vesicoureteral reflux.     

Guideline on the peri-operative management of patients with sickle cell disease

Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso-occlusive crises and acute and chronic end-organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri-operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non-sickle-related. Complications may be reduced by meticulous peri-operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo-immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID-19 infection but may have a relatively mild clinical course. Outcomes are determined by pre-existing comorbidities, as for the general population.     

Etiology and pathophysiology of pyelonephritis.

Escherichia coli is the most frequent cause of pyelonephritis. Its possible virulence factors include the ability to adhere and colonize the urinary tract, an important initiating factor in all urinary tract infections (UTIs). The importance of P fimbriae in this adhesion is stressed and the evidence for its importance in pyelonephritis is presented in epidemiologic studies of patients, as well as in animal studies. It appears that both host receptor density and the nonsecretor state is responsible for susceptibility to urinary tract infection. Vesicoureteral reflux can be responsible for ascending upper tract infection, but infection with P-fimbriated E coli may lead to ascending pyelonephritis without reflux because of the paralytic effect of lipid A on ureteral peristaltic activity. Renal ischemia leads to renal damage following infection by reperfusion damage due to the release of superoxide. Experimentally, this ischemic damage can be prevented by allopurinol, a xanthine oxidase inhibitor. The acute inflammatory response can produce renal damage because of the respiratory burst of phagocytosis, which while killing phagocytosed bacteria also damages renal tubules. An amelioration of the inflammatory response by treatment with superoxide dismutase or corticosteroids has been shown to modulate renal damage. Vaccination with P fimbriae has been shown experimentally to prevent the initiation of the disease. However, since vaccines are not clinically available, the clinical and animal studies on therapy of acute disease are stressed. Acute pyelonephritis during the first 3 years of life more often produced the renal damage that could lead to end-stage renal disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

儿童髓质海绵肾的合并症分析及与预后关系探讨

目的 髓质海绵肾（Medullary sponge kidney,MSK）多在成年发病,儿童期发病者罕见且病情多较严重,导致肾功能不全者较多,这可能与同时存在影响肾脏的一些合并症有关.本文分析儿童期发病的MSK的合并症发生情况并探讨合并症与预后的关系.方法 收集20例MSK患儿的临床资料,分析其合并症发生率并探讨合并症与预后的关系.结果 20例儿童MSK患儿,其中男13例,女7例,年龄10个月～13岁,平均年龄（7.95±11.49）岁.所有病例均有特征性多发性双肾结石表现,15例（占75%） 例并发尿路感染.此外,15例合并症中有14例为远端肾小管酸中毒（dRTA）,4例为胱氨酸尿症,1例为Carolis病,1例为肝豆状核变性.慢性肾功能不全的发生与结石关系不大,而与合并症有无以及泌尿道感染发生有关,差异有统计学意义（P〈0.05）.结论 儿童期发病的MSK合并症发生率高,对于儿童MSK,应积极治疗合并症,及时控制尿路感染,以减少慢性肾衰的发生.     

Urologische Betreuung von Patienten vor und nach Nierentransplantation

Patients with end-stage renal disease awaiting kidney transplantation require regular urological evaluation. The urologist's main task is early diagnosis and treatment of genitourinary malignancies and evaluation of the lower urinary tract. Furthermore, urologists are often confronted with the question of whether or not to perform pretransplant urological surgery, i.e., native nephrectomy for polycystic kidney disease. Urological care after kidney transplantation involves diagnosis and treatment of ureteral complications, malignancies, lower urinary tract symptoms, and last but not least erectile dysfunction, which has a prevalence of 20-50% among kidney transplant recipients.For the evaluation and follow-up of the living kidney donor, international guidelines have been developed in recent years to also help the urologist to perform a correct evaluation and follow-up of the kidney donor.     

Nephrogenic adenoma of the ureter: Case report

Nephrogenic adenoma is a rare metaplastic benign lesion of urothelium in response to genitourinary tract procedures, chronic infection, trauma, urinary calculi and immunosuppressive therapy after renal transplantation. It has been reported to occur throughout the urinary tract especially, in the urinary bladder. We report a case of nephrogenic adenoma arising from the lower end of the right ureter with clinical and radiological features suspicious of carcinoma.     

Nephrogenic adenoma of bladder after ibuprofen abuse

Nephrogenic adenoma is an infrequent benign lesion of the urinary system that occurs in patients with a history of genitourinary surgery, stone disease, trauma, chronic urinary tract infection, or renal transplantation. We report the first case of nephrogenic adenoma of the bladder in a 53-year-old man with a 5-year history of ibuprofen abuse for chronic arthritis. We stress the importance of investigating the analgesic abuser for nephrogenic adenoma if microhematuria and/or irritative lower urinary tract symptoms are present.     

The role of magnetic resonance imaging in pediatric urology

PURPOSE OF REVIEW: Magnetic resonance imaging has emerged as a powerful diagnostic tool for the imaging of the pediatric genitourinary tract. The aim of this review is to familiarize the reader with the current applications and basic techniques utilizing magnetic resonance imaging in pediatric uroradiology. RECENT FINDINGS: Magnetic resonance imaging can provide both a detailed anatomic and functional assessment of the pediatric genitourinary tract in a single study without the use of ionizing radiation. Magnetic resonance urography combines static and dynamic evaluation of the urinary tract following contrast administration and has been most often applied to the evaluation of hydronephrosis. In addition to unparalleled anatomic assessment, it allows for the evaluation of glomerular filtration rate, renal transit time, and differential renal function. It also provides unique insights into a wide range of obstructive uropathies and has been demonstrated to be useful in the evaluation of complex genitourinary anomalies. Magnetic resonance voiding cystourethrography has been used to rule out vesicoureteral reflux. Magnetic resonance imaging has also been demonstrated to be superior to nuclear scintigraphy for the diagnosis of pyelonephritis and renal scarring. SUMMARY: Magnetic resonance imaging has emerged as a powerful tool for the diagnosis of pediatric genitourinary anomalies. It provides functional and anatomic assessment with a single procedure that in most cases is superior to conventional procedures. Magnetic resonance imaging will probably become the modality of choice for the imaging of pediatric genitourinary tract anomalies.     

Is suprapubic cystostomy an optimal urinary management in high quadriplegics?. A comparative study of suprapubic cystostomy and clean intermittent catheterization

INTRODUCTION: Long-term outcome of spinal cord injury (SCI) patients was compared between those managed by suprapubic cystostomy (SPC) and clean intermittent catheterization (CIC) with particular emphasis on an incidence of urinary tract complications and patients perception for urinary management. MATERIALS AND METHODS: The study comprised 61 SCI patients; 34 patients managed with SPC (group A), while 27 with CIC (group B). After stabilization of their condition, all were followed annually on an outpatient basis with clinical history, urinalysis, urinary imaging and renal function studies. Mean follow-up periods were 8.6 and 9.9 years for groups A and B, respectively. Between groups, a comparative study was performed on the incidence of urinary complications such as renal dysfunction, hydronephrosis, vesicoureteral reflux, symptomatic genitourinary infection and urinary stone. Satisfaction with urinary management was also estimated using the questionnaires during follow-up. RESULTS: Renal dysfunction, hydronephrosis and vesicoureteral reflux were not found in either group. Symptomatic genitourinary infection was seen in 4 (12%) of group A and 7 (26%) of group B, respectively. The incidence of renal stone was 3 (9%) in group A and 1 (4%) in group B. A significant difference was not found between two groups in these urinary complications. On the contrary, bladder stone was seen more frequently in group A (65%) than in group B (30%) with a significant difference (p<0.001). The degrees of incontinence, bother score of daily activities, and overall satisfaction showed no significant difference between the two groups. CONCLUSION: Except for bladder stones, SPC is a valuable option of urinary management for quadriplegic patients, the results of which were comparable to paraplegic SCI patients managed with CIC.     

Malacoplakia of the urinary tract

Malacoplakia is a granulomatous disease that most frequently involves the genitourinary tract. Because of the great variability of symptoms and lack of typical radiologic findings, this disease is usually not considered preoperatively. Generally of benign nature in the lower urinary tract, it leads to destruction and loss of renal function when affecting ureter and kidney. Progression of the latter can only be prevented by surgical intervention. Malacoplakia of the lower urinary tract requires long-term treatment with intracellularly active antibiotics in combination with drugs enhancing phagocytosis.     

Urological manifestations of Down syndrome

PURPOSE: We identified the urological anomalies seen in patients with Down syndrome. MATERIALS AND METHODS: We reviewed the literature on Down syndrome and its associated genitourinary pathology. RESULTS: Associated defects have been reported throughout the genitourinary tract. The most common renal anomalies seen are renal hypoplasia, obstructive uropathy and glomerular microcysts. Decreased creatinine clearance has also been noted. Developmental anomalies, such as megaureter and vesicoureteral reflux, have been reported. Dysfunctional voiding and urinary retention have been found in these patients. Posterior urethral valves and hypospadias have also been seen. The testicular abnormalities most frequently reported are cryptorchidism, testicular cancer and infertility. CONCLUSIONS: Improved understanding and identification of the various urological anomalies associated with Down syndrome will aid in the care of these patients. In addition, an awareness of perioperative issues will further facilitate a smooth clinical course.     

Primary vesicoureteral reflux: review of current concepts

The well-known association between vesicoureteral reflux and urinary tract infection is the basis for pathophysiological and therapeutic implications which have dominated the literature on the subject for the last 2 decades. We critically review the following issues: (1) does urinary tract infection cause reflux? (2) does reflux predispose to infection? (3) does reflux predispose to pyelonephritis? (4) does reflux predispose to a renal parenchymal scar? (5) does long-term urinary antibiotic prophylaxis prevent renal damage in patients with reflux? We conclude that none of the reviewed issues have been rigorously proven or validated and that the role of vesicoureteral reflux in urinary tract infections needs to be redefined through well-designed, multicenter, prospective, randomized, controlled studies using state of the art renal imaging techniques. Received May 9, 1997; received in revised form December 3, 1997; accepted December 4, 1997     

Experience with schistosomiasis in renal transplantation.

Schistosomiasis involving the urinary tract has only occasionally been reported in North American literature and rarely from American hospital experience. Chronic infection may result in numerous abnormalities of the urinary tract which may interfere with the function of a transplanted kidney. Our institution has performed a number of renal transplants in patients who are from countries where schistosomiasis is endemic. Six patients in our group had evidence of schistosomal disease during their pretransplant evaluation and were appropriately treated. None of these patients had postoperative complications attributable to the schistosomal disease. We recommend that all patients who are from areas where urinary schistosomiasis is endemic undergo a cystoscopic examination and bladder biopsies in addition to the routine pretransplant urologic evaluation.     

High dose zinc increases hospital admissions due to genitourinary complications

PURPOSE: Zinc is a common dietary supplement that is widely believed to have beneficial health effects. To assess the impact of high dose supplemental zinc on genitourinary diseases we analyzed a recent randomized trial comparing zinc, antioxidants and their combination to placebo for complications related to the genitourinary tract. MATERIALS AND METHODS: In a further analysis of the recent Age-related Eye Disease Study we examined the data pool for primary International Classification of Diseases, 9th revision codes given for hospital admissions related to urological problems. The Age-Related Eye Disease Study randomized 3,640 patients with age related macular degeneration to 1 of 4 study arms, including placebo, antioxidants (500 mg vitamin C, 400 IU vitamin E and 15 mg beta-carotene), 80 mg zinc and antioxidant plus zinc. Statistical analyses using Fisher's exact test were performed. RESULTS: We found a significant increase in hospital admissions due to genitourinary causes in patients on zinc vs nonzinc formulations (11.1% vs 7.6%, p = 0.0003). The risk was greatest in male patients (RR 1.26, 95% CI 1.07-1.50, p = 0.008). In the study group of 343 patients requiring hospital admission the most common primary International Classification of Diseases, 9th revision codes included benign prostatic hyperplasia/urinary retention (benign prostatic hyperplasia), urinary tract infection, urinary lithiasis and renal failure. When comparing zinc to placebo, significant increases in urinary tract infections were found (p = 0.004), especially in females (2.3% vs 0.4%, RR 5.77, 95% CI 1.30-25.66, p = 0.013). Admissions for urinary lithiasis approached significance in men on zinc compared to placebo (2.0% vs 0.5%, RR = 4.08, 95% CI 0.87-19.10). There was no increase in prostate or other cancers with zinc supplementation. A significant decrease in prostate cancer diagnoses was seen in patients receiving antioxidants vs placebo (RR = 0.6, 95% CI 0.49-0.86, p = 0.049). Subgroup analysis revealed that this finding was significant in men who smoked but not in nonsmokers. CONCLUSIONS: Zinc supplementation at high levels results in increased hospitalizations for urinary complications compared to placebo. These data support the hypothesis that high dose zinc supplementation has a negative effect on select aspects of urinary physiology.     

An update on lower urinary tract tuberculosis

Tuberculosis of the genitourinary tract presents with atypical manifestations. Only 20% to 30% of patients with genitourinary tuberculosis have a history of pulmonary infection. Tuberculosis often affects the lower genitourinary system rather than the kidney. Tuberculosis of the lower genitourinary tract most commonly affects the epididymis and the testis, followed by bladder, ureter, prostate, and penis. Use of bacillus Calmette-Guérin therapy for bladder cancer can cause symptomatic tubercular infections of the lower genitourinary tract. Tuberculosis of the lower genitourinary tract can present with irritative voiding symptoms, hematuria, epididymo-orchitis, prostatitis, and fistulas. Tuberculosis of the seminal vesicles, vas, fallopian tubes, and the uterus can cause infertility. Urinalysis may demonstrate sterile pyuria, hematuria, or albuminuria. Identification of acid-fast bacilli in culture or tissue or by polymerase chain reaction studies is diagnostic. Medical treatment may not result in resolution of symptoms. Surgical intervention and reconstruction of the urinary tract are frequently indicated.     

Unusual clinical presentation of Klebsiella pneumoniae induced endogenous endophthalmitis and xanthogranulomatous pyelonephritis in a non-nephrolithiasis and non-obstructive urinary tract

The genitourinary tract is well recognized as a route through which bacteria could gain access to the blood circulation. Under some circumstances, metastatic infections may occur in distant organs, including endogenous endophthalmitis. Xanthogranulomatous pyelonephritis (XGP) is an unusual variant of chronic pyelonephritis. It most often occurs in middle-aged women who frequently have a history of recurrent urinary tract infections combined with obstruction and a kidney of poor function. We reported an unusual case of urinary tract infection in a non-nephrolithiasis and non-obstructive urinary tract complicated by Klebsiella pneumoniae endogenous endophthalmitis and developed XGP in two months.