The nutcracker phenomenon refers to compression of the left renal vein at the origin of the superior mesenteric artery and is often underdiagnosed. This can cause symptoms of pelvic venous congestion with retrograde venous flow and a dilated gonadal vein. Here we describe a case in a 39-year-old female, who following imaging investigations to confirm the diagnosis, underwent transperitoneal laparoscopic ligation of the left gonadal vein. Laparoscopic sterilization was also performed with the aid of the gynecologists. Multiparous women, who are more likely to develop pelvic congestion symptoms, more commonly request sterilization and thus we propose that a dual laparoscopic procedure in these cases could be the treatment of choice.
To evaluate the long-term oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU) and the impact of diagnostic ureteroscopy (URS) on survival outcomes. Materials and MethodsA retrospective analysis of all consecutive patients undergoing RNU for suspected UTUC at a UK tertiary referral centre from a prospectively maintained database was conducted. The primary outcome measures were 5-and 10-year cancerspecific survival (CSS). The secondary outcomes were: overall survival (OS), recurrence-free survival (RFS), impact of prior diagnostic URS on OS, CSS and intravesical RFS (intravesical-RFS), and predictors of intravesical recurrence. Statistical analysis was performed in R using the 'survminer' and 'survival' packages. The Kaplan-Meier method was used to calculate survival functions and these were expressed in graphical form. Uni-/multivariate survival analyses were performed using the Cox proportional hazard regression model. Statistical significance in this study was set at P < 0.05. ResultsA total of 422 patients underwent RNU with confirmed UTUC. The median (interquartile range) follow-up of patients with confirmed UTUC was 9.2 (5.6-12.7) years. The 5-and 10-year CSS rates were 70.5% (95% confidence interval [CI] 65.9-74.9) and 67.1% (95% CI 62.4-71.6), respectively. OS (HR 1.04 [95% CI 0.78-1.38]; P = 0.46) and CSS (HR 0.96 [95% CI 0.68-1.34]; P = 0.81) were similar in the diagnostic URS and the direct RNU cohorts. intravesical RFS was superior for the direct RNU cohort ; P = 0.008). In multivariate analysis, prior URS, T2 stage, proximal ureter tumour and bladder cancer history were predictors of metachronous bladder recurrence. ConclusionThis single-centre retrospective cohort study reports the long-term oncological outcomes of RNU with a median follow-up of 9.2 years, serving as a reference standard in counselling patients undergoing RNU. Stage and grade of the RNU specimen were the only two studied factors that appeared to adversely impact long-term CSS and OS. Our results suggest that the risk of intravesical recurrence is increased nearly twofold in patients who have undergone diagnostic URS prior to RNU. Prior URS, however, does not appear to adversely impact long-term CSS and OS. The authors suggest that a risk-stratified approach be adopted, wherein diagnostic URS is offered only in equivocal cases.
Introduction: With the rise in the use of ureteroscopy and laser stone lithotripsy (URSL), a proportionate increase in the risk of post-procedural urosepsis has also been observed. The aims of our paper were to analyse the predictors for severe urosepsis using a machine learning model (ML) in patients that needed intensive care unit (ICU) admission and to make comparisons with a matched cohort. Methods: A retrospective study was conducted across nine high-volume endourology European centres for all patients who underwent URSL and subsequently needed ICU admission for urosepsis (Group A). This was matched by patients with URSL without urosepsis (Group B). Statistical analysis was performed with ‘R statistical software’ using the ‘randomforests’ package. The data were segregated at random into a 70% training set and a 30% test set using the ‘sample’ command. A random forests ML model was then built with n = 300 trees, with the test set used for internal validation. Diagnostic accuracy statistics were generated using the ‘caret’ package. Results: A total of 114 patients were included (57 in each group) with a mean age of 60 ± 16 years and a male:female ratio of 1:1.19. The ML model correctly predicted risk of sepsis in 14/17 (82%) cases (Group A) and predicted those without urosepsis for 12/15 (80%) controls (Group B), whilst overall it also discriminated between the two groups predicting both those with and without sepsis. Our model accuracy was 81.3% (95%, CI: 63.7–92.8%), sensitivity = 0.80, specificity = 0.82 and area under the curve = 0.89. Predictive values most commonly accounting for nodal points in the trees were a large proximal stone location, long stent time, large stone size and long operative time. Conclusion: Urosepsis after endourological procedures remains one of the main reasons for ICU admission. Risk factors for urosepsis are reasonably accurately predicted by our innovative ML model. Focusing on these risk factors can allow one to create predictive strategies to minimise post-operative morbidity.
Study Type – Therapy (prospective cohort) Level of Evidence 2a What's known on the subject? and What does the study add? In the West, transitional cell carcinoma (TCC) in renal transplant patients is uncommon, but aggressive. Conversely, it appears to be frequent in the Far East, necessitating aggressive surgical approaches such as prophylactic nephroureterectomy. There are few European case series to date. TCC in the present population was predominantly low‐grade and superficial, with no progression in patients with those tumours. Endoscopic management was sufficient for most patients. The behaviour of TCC in the present population was much less aggressive than that described in the Far East. Altering immunosuppression regimes may have a role to play in managing bladder cancer in renal transplant patients. OBJECTIVE To examine the clinical characteristics, management and long‐term outcomes of patients with transitional cell carcinoma (TCC) who also have had renal transplantation. PATIENTS AND METHODS A retrospective case note review was performed for the 15‐year period 1995–2009. Searches from three different urological centres in the UK, using multiple sources, yielded 1647 patients with renal transplants, 12 of whom had TCC. Eight cases were identified who developed de novo TCC after transplantation (0.48%). Four patients had pre‐existing TCC who then had renal transplantation. The current literature was reviewed. RESULTS In the eight de novo TCC cases, the bladder was the site in all with no upper tract TCC; seven were superficial (pTa/T1) and five were low grade (G1/2). The mean time to development of TCC after transplant was 5 years, with a mean follow‐up of 11 years. There was no progression in low‐grade superficial disease that was managed endoscopically. The 5‐ and 10‐year overall survival was 83% and 72%, respectively. In patients with pre‐existing TCC prophylactic bilateral nephroureterectomy before transplantation was performed once. There was progression of superficial disease whilst on immunosuppression in one patient. Sirolimus was used in patients with TCC and reports suggest this may have a role to play in modifying malignancy in this setting. The number of patients involved in studies particularly focusing on TCC in renal transplantation is small (136 patients), with 60% from China/Taiwan where there is a high incidence of upper tract TCC and high‐grade muscle‐invasive disease. CONCLUSIONS Although this is one of the largest European case series of renal transplant patients with TCC, the numbers are small making clear conclusions difficult. The frequency of TCC in our renal transplant population is low, consistent with previous studies. However, contrary to prior studies, TCC after renal transplantation in this European population was predominantly superficial, low‐grade, non‐progressive and confined to the bladder. Altering immunosuppression regimes in patients with TCC may have a role to play, although further work is required to clarify and substantiate this.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.