Diffuse alveolar hemorrhage (DAH) is a rare but fatal complication in patients with systemic lupus erythematosus (SLE). We describe a case of a 74-year-old woman who presented with DAH as an initial presentation of SLE. She also had microscopic polyangiitis clinically manifesting as crescentic glomerulonephritis and purpura with positive myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCA). The patient transiently improved when treated with plasma exchange and methylprednisolone pulse therapy; however, she died of recurrent pulmonary hemorrhage and concurrent cryptococcal pneumonia. This case indicates that MPO-ANCA is associated with severe organ involvement such as pulmonary hemorrhage and crescentic glomerulonephritis in SLE.

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A 66-year-old man with a history of multiple transurethral resections for recurrent bladder tumors, staged as Ta according to the International Union Against Cancer staging guidelines, presented with a complaint of dry cough. A round nodule with a diameter of 7.5 cm was detected in the lung by chest computed tomography, and a video-assisted thoracoscopic lobectomy was performed. Pulmonary metastasis of recurrent bladder cancer was diagnosed by immunohistochemistry staining for the urothelium-specific protein uroplakin Ia. Subsequently, 2 cycles of systemic chemotherapy were administered. Two and a half years after treatment, no recurrence of pulmonary lesions has been detected. A combination of complete resection of pulmonary lesions and systemic chemotherapy may result in a good prognosis for patients with non-muscle-invasive bladder cancer.

Abbreviations & AcronymsAbstract: The objective of the present study was to assess the efficacy of posterior reconstruction of Denonvilliers' musculofascial plate for restoring urinary continence after laparoscopic radical prostatectomy. A total of 48 consecutive patients who underwent laparoscopic radical prostatectomy were retrospectively reviewed. Of them, 23 underwent laparoscopic radical prostatectomy without posterior reconstruction of Denonvilliers' musculofascial plate (group 1) and 25 underwent laparoscopic radical prostatectomy with posterior reconstruction of Denonvilliers' musculofascial plate (group 2). Patients' demographics were analyzed and continence rates between the two groups at 1, 3, 6 and 12 months after surgery were compared. Patients in group 2 had significantly larger prostates than in group 1. There were no significant differences between the two groups in terms of the other patient characteristics. The urinary continence rates were significantly higher in group 2 than in group 1 at 1, 3 and 12 months after surgery, and the rates of severe incontinence were significantly lower in group 2 at all time-points considered. These findings suggest that posterior reconstruction of Denonvilliers' musculofascial plate helps in restoring early continence and decreasing severe incontinence in patients undergoing laparoscopic radical prostatectomy.

Objective To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications. Methods The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone‐free rate. The predictors of postoperative complications were evaluated using logistic regression models. Results A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone‐free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035). Conclusion Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

INTRODUCTION AND OBJECTIVE: Small renal masses (SRM) represent a diagnostic challenge despite advances in imaging and renal biopsy. Approximately 20% of SRM removed at surgery are found to be benign post-operatively. DNA methylation is an early and stable event in tumorigenesis, which reveals cell ontology. We developed and validated a machine learning model, leveraging DNA methylation analysis in >1500 patient samples, to classify pathological subtypes of renal tumours and provide a platform to improve diagnosis.METHODS: Methylation was evaluated in gDNA from fresh frozen nephrectomy specimens, using the Illumina 450k microarray and EPIC Methyl Capture sequencing platforms. We combined our own dataset and TCGA data (N[approx 158000 markers). This dataset was divided into training and testing sets, using 4-fold cross validation, and used to train an XGBoost model to classify samples into one of five pathological subtypes. External validation was carried out on two independent publicly available datasets, from fresh frozen nephrectomy tissue (Brennan et al) and ex-vivo tissue biopsies (Chopra et al).RESULTS: The integrated training and testing set consisted of 1268 samples, including: 465 ccRCC, 303 pRCC, 101 chRCC, 73 oncocytomas and 329 adjacent normal kidney. The prediction accuracy in the testing set was 0.954; with high class-wise Area Under the Receiver Operating Characteristic Curves (ROC AUCs): 0.994 (ccRCC), 0.995 (pRCC), 0.982 (chRCC), 0.999 (oncocytoma), 1 (adjacent normal). The model was externally validated on 245 ex-vivo tissue biopsies from 100 renal tumours. The accuracy was 0.824 and average class-wise ROC AUCs were: 0.978 (ccRCC), 0.946 (pRCC), 0.994 (chRCC), 0.892 (oncocytoma), 0.969 (adjacent normal). Furthermore, an independent external validation was performed on 34 tissue samples, achieving average class-wise ROC AUCs: 1 (ccRCC), 0.904 (chRCC), 0.946 (oncocytoma), 0.976 (adjacent normal). In order to assess the impact of methylation heterogeneity on our classifier, the model was evaluated in 97 multi-region samples from 18 ccRCC patients.CONCLUSIONS: A machine learning model based on DNA methylation data can differentiate pathological subtypes of renal tumours with excellent accuracy, including external validation. The model may be applied to renal biopsy samples to improve the diagnostic pathway for renal tumours. This has the potential to reduce overtreatment by preventing unnecessary surgery, enhance patient QoL and minimize healthcare costs.

IntroductionThis study aimed to identify preoperative risk factors and create a risk classification for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy in a multi‐institutional cohort.MethodsWe retrospectively analyzed 283 patients who had undergone laparoscopic radical nephroureterectomy for nonmetastatic upper tract urothelial cancer between March 2002 and March 2020. The cumulative incidence of intravesical recurrence for 224 patients without previous or concomitant bladder cancer was examined using multivariate Fine‐Gray competing risks proportional hazards models. A risk stratification model was created to predict subsequent patient outcomes based on the results.ResultsThe median follow‐up duration was 33.3 months, and 71 (31.7%) patients experienced intravesical recurrence. The estimated cumulative incidence of intravesical recurrence at one and 5 years was 23.5% and 36.4%, respectively. In multivariate analysis, the presence of ureter tumors and multiple tumors were shown to be independently significant predictive factors for intravesical recurrence. Based on the results, we classified patients into three risk groups. The cumulative incidence rates of intravesical recurrence within 5 years after surgery were 24.4%, 42.5%, and 66.7% in the low‐, intermediate‐, and high‐risk groups, respectively.ConclusionsWe identified risk factors and created a risk classification model for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy. Based on this model, an individualized surveillance protocol or adjuvant therapy could be provided.

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