Kidney , Ureter And Bladder Research Articles

Acute Post-streptococcal Glomerulonephritis in a Pediatric Population: A Five-Year Retrospective Study.

Post-streptococcal glomerulonephritis is a kidney disease that occurs after infection with a certain strain of streptococcal bacteria. It has a high hospitalization rate, especially in developing countries. It is characterized by the sudden appearance of edema, hematuria, proteinuria, and hypertension. The objective of this retrospective descriptive study conducted at James L. Gordon Memorial Hospital in Olongapo, Zambales, Philippines, is to analyze the demographic distribution, clinical presentation, complication, and outcome of acute post-streptococcal glomerulonephritis (APSGN) in a pediatric population. Methods: A retrospective descriptive study was done in patients (below 18 years of age) admitted with the diagnosis of post-streptococcal glomerulonephritis during a five-year period in the pediatric ward of a tertiary hospital in the Philippines. All patients underwent detailed clinical history and examination and were closely monitored during treatment. The course of disease progression was closely monitored and recorded. Seventy-seven children were treated for APSGN with a mean age of 7.8 years and with standard deviation of 3.85. Edema and gross hematuria were noted in 53 (68.8%) and 24 (31.1%) cases, respectively. Hypertension was present in 54 patients (70.1%). Among those 54 patients, 49 (63.6%) patients developed acute renal injury (based on normal creatinine for age), three cases (3.8%) had pleural effusion, and two patients (2.5%) developed hypertensive encephalopathy. All patients underwent KUB (kidneys, ureters, and bladder) ultrasound, among which 13 (16.88%) had diffuse parenchymal swelling which improved and eventually were discharged. Increased blood urea nitrogen (BUN) was noted in 60-65% of patients. Hypoalbuminemia and lower hemoglobin were also quite common. There was no mortality during treatment and hospital stay. APSGN remains one of the most common causes of glomerulonephritis in the region. Edema, hypertension, and hematuria were the most common presenting features. Early identification and comprehensive monitoring and management are required to prevent morbidity and mortality. The prognosis is generally good if early treatment is done.

SFM Fetal Therapy Practice Guidelines: Fetal Cystoscopic Laser Ablation

AbstractFetal lower urinary tract obstruction (LUTO) in a male fetus could cause detrimental effects to the KUB (kidney, ureter, and bladder) system from back-pressure changes as well as to the lungs from reduced amniotic fluid. In a carefully selected case where the obstruction causes progressive damage, a therapeutic intervention could be lifesaving. In utero vesico-amniotic shunting has been shown to improve perinatal pulmonary survival, but evidence on improvement of renal outcomes with this procedure is lacking. More recently, fetal cystoscopic laser fulguration has been shown to be beneficial in longer-term survival and renal outcomes. These interventions carry significant risk, and therefore patient selection and optimal timing are key. This guideline lists the intricacies of patient selection, relevant counseling points and procedural details.

Evaluating Unenhanced Multidetector Computed Tomography of Kidneys, Ureters and Bladder (CT KUB) as the Initial Imaging Service in Suspected Acute Renal Colic Patients

Objective: To assess the role of unenhanced multidetector computed tomography (CT) of kidneys, ureters and bladder (KUB) in the initial imaging of suspected acute renal colic.
 Study Design: Retrospective longitudinal study.
 Place and Duration of Study: Combined Military Hospital, Kharian Pakistan, from Jan 2020 to Jan 2021.
 Methodology: One hundred and thirty-eight cases of suspected acute renal colic underwent CT-KUB. The demographic,radiological, clinical, and follow-up data were recorded for each patient. 
 Results: There were 88(51.8%) males and 82(48.2%) females in the present study, with a mean age of 50.86±18.57 years. Out of 170 patients, only 138(81.17%) were indicated with acute findings, whereas 32(18.82%) individuals showed no acute findings.The mean stone size was found to be 4.77±0.98mm. Most of the stones had a location near the pelvic brim (n=47; 34.15%).
 Conclusion: The use of CT KUB should be encouraged for the evaluation of renal colic.Keywords: Acute renal colic, Computed tomography (CT), Computed tomography of Kidneys, ureter and bladder (CT-KUB).

Evaluation of Renal/Ureteric Calculus Composition using Dual-Energy Computed Tomography: A Cross-sectional Study

Introduction: Urolithiasis is a commonly encountered health problem, and knowledge of the chemical composition of stones is crucial in deciding the management approach and preventing recurrence. Pre-operative assessment of stone composition has become possible after the introduction of Dual-Energy Computed Tomography (DECT). Aim: To compare the accuracy of DECT with biochemical analysis of postoperative stone samples. Materials and Methods: A cross-sectional study was conducted in the Department of Radiodiagnosis, Mysore Medical College and Research Institute, Mysore, Karnataka, India, between January 2020 to June 2021 on 35 patients who met the inclusion and exclusion criteria. All the patients underwent a non contrast DECT scan of the Kidneys, Ureters and Bladder (KUB) on a 128-slice twin beam single-source DECT scanner. The stone composition was determined using pre-programmed software and was correlated with biochemical analysis. Proportions were compared using chi-square test of significance. The sensitivity and specificity of DECT was determined. Results: Amongst the total 35 patients (mean age of 45.7±14.89 years, 23 patients males and 12 patients females) and 36 calculi analysed, The most frequently encountered calculus in the urinary tract was calcium oxalate n=24 (66.7%). The second most common calculus was Uric Acid (UA) n=5 (13.9%). The DECT findings regarding chemical composition of calculus were confirmed by Fourier Transformation Infrared Spectroscopy (FTIRS). The mean Dual-Energy (DE) ratio for oxalate, UA, hydroxyapatite, cystine and mixed stones was found to be 1.18, 1.01, 1.39, 1.09 and 1.11, respectively. DECT was found to be highly sensitive and specific in the diagnosis of calculi composition based on their DE ratio. It was found to be 95.8% sensitive and 100% specific for differentiating calcium oxalate stones from non oxalate stones and 100% sensitive and 96.8% specific for differentiating UA stones from non UA stones. Conclusion: DECT has high diagnostic accuracy in the pre- operative determination of urinary calculus composition which will guide in management, as UA stones are open to medical therapy while most of the non UA stones need surgical intervention.

Management of encrusted ureteral stents: Two center experience.

We present our experience of the endourological management of encrusted ureteral stents (EUS) and a literature review on forgotten encrusted ureteral stents. A total of 13 encrusted ureteral stents from 12 patients were removed in two hospitals. The medical records were retrospectively analyzed for stent indication, indwelling time, clinical presentation, investigations, type and the number of surgical procedures, operative time, complications, duration of hospital stay, and the follow-up. Five ureteral stents (US) inserted before ESWL (extracorporeal shockwave lithotripsy) for renal stones, seven US for ureteric stones with ureteric colic, and one ureteral stent for post ureteroscopy procedure. The mean indwelling time was 15.07 ± 7.34 months with a range from 6 to 24 months. The mean Kidney,Ureter and Bladder (KUB) score of encrusta-tion grading was 11.84 ± 2.07 with a range from 9 to 15. The encrusted stents were removed by a combination of cystolithotripsy, semi-rigid ureteroscopy (URS), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and ESWL. The average total number of procedures to remove one EUS was 3 ± 1.08 with a range of 2 to 5 proce-dures. Six encrusted stents were removed in one, five stents required two, one stent required three and one stent required four hospital admissions. The median operative time was 210 minutes with a range of 60 to 660 minutes per EUS removal and the mean hospital stay was 2.69 ± 1.43 days with a range of 1 to 6 days. All patients had successful removal of encrusted stent and complete stone clearance with no major complica-tions. In the follow-up, one patient had recurrent ureteric stone, one patient on regular stent exchange due to poor renal function and one patient developed significant ureteric stricture referred for reconstruction. Removal of forgotten encrusted impacted ureteral stents is challenging and requires a multimodal surgical approach. It adds significant costs to the health care system and in addition it affects patient safety and quality of life. Patient education, avoiding unnecessary ureteral stent place-ment and a computerized stent monitoring system reduces the incidence of forgotten ureteral stents and their complications.

Survey on Untethering of the Spinal Cord and Urological Manifestations among Spina Bifida Patients in Malaysia.

The incidence and severity of urinary tract infections (UTIs) due to spina bifida is poorly understood in Malaysia. Tethering of the spinal cord is a pathological fixation of the cord in the vertebral column that can result in neurogenic bladder dysfunction and other neurological problems. It occurs in patients with spina bifida, and the authors of this study sought to investigate the impact of untethering on the urological manifestations of children with a tethered cord, thereby consolidating a previously known understanding that untethering improves bladder and bowel function. Demographic and clinical data were collected via an online questionnaire and convenient sampling techniques were used. A total of 49 individuals affected by spina bifida participated in this study. UTIs were reported based on patients’ observation of cloudy and smelly urine (67%) as well as urine validation (60%). UTI is defined as the combination of symptoms and factoring in urine culture results that eventually affects the UTI diagnosis in spina bifida individuals irrespective of CISC status. Furthermore, 18% of the respondents reported being prescribed antibiotics even though they had no history of UTI. Therefore, indiscriminate prescription of antibiotics by healthcare workers further compounds the severity of future UTIs. Employing CISC (73%) including stringent usage of sterile catheters (71%) did not prevent patients from getting UTI. Overall, 33% of our respondents reported manageable control of UTI (0–35 years of age). All individuals below the age of 5 (100%, n = 14) were seen to have improved urologically after the untethering surgery under the guidance of the Malaysia NTD support group. Improvement was scored and observed using KUB (Kidneys, Ureters and Bladder) ultrasound surveillance before untethering and continued thereafter. Spina bifida individuals may procure healthy bladder and bowel continence for the rest of their lives provided that neurosurgical and urological treatments were sought soon after birth and continues into adulthood.

Is percutaneous nephrolithotomy effective and safe for children with solitary kidney?

To evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) in pediatric patients with solitary kidneys and kidney stones. Thirty-nine patients (group A) with solitary kidney under 18years of age who underwent PCNL between January 2015 and December 2021 were evaluated and analyzed. Forty-two patients (group B) with bilateral kidneys who underwent PCNL were determined as the control group and included in the analysis. Intraoperative and postoperative data such as demographic data, stone localization, bleeding and transfusion rates, operation time, complications, hospital stay, stone-free rates (SFR) and kidney function (glomerular filtration rate (eGFR)) were compared between the two groups. PCNL was performed with all patients in the prone position. Only a laser was used to fragment the stone in all cases. Stone-free was defined as the absence of residual stone fragments ≥ 2mm in maximum diameter at 3months on kidney, ureter and bladder (KUB) graphy, ultrasonography (US) or non-contrast tomography (NCCT). The mean ages of the patients in Group A and B were 7.5 ± 2.6 and 8.5 ± 3.1years, respectively. The mean stone size was 16.5 ± 4.1 and 17.0 ± 3.2mm in group A and group B, respectively (p = 0.49). SFR rates in Groups A and B were 97.4% and 95.2% (p = 1.00). There was no statistically significant difference in terms of the operation time, perioperative blood transfusion, hemoglobin decrease and Clavien grade 1 complication rates (p > 0.05). However, double-J (JJ) stent placement, duration of nephrostomy and hospital stay were longer in the solitary kidney group (p < 0.05). There was a significant improvement in creatinine and eGFR levels in both groups at the postoperative sixth month (p < 0.05). Our results show that PCNL is a safe and effective method in pediatric patients with solitary kidneys.

The putty kidney: a classic sign from past in genitourinary radiology.

A 56-year-old woman with known genitourinary tuberculosis (GUTB) presented for follow-up evaluation with Computed Tomography (CT). Her urine referred acidic with few pus cells, but sterile on culture. Other laboratory tests were normal. A pigtail catheter is also referred to the left kidney. X-ray (actually CT-topogram) kidney, ureter and bladder (KUB) show multiple lobulated calcifications in the right renal region conglomerated into the shape of the kidney. This imaging finding were suggestive of the classical “putty kidney sign” of an end stage renal tuberculosis (TB). Radiological findings in renal TB depend on the extent of the disease process and are best demonstrated both on intravenous urogram and CT scan. Describing the condition, it is an extensive parenchymal calcification in a non-functioning kidney, forming its cast. The “putty kidney” or “autonephrectomy” is the end result of scarring, obstruction, and atrophy of the kidney due to TB which is complicated by dystrophic calcification with time. Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and peritubular capillary bed from primary pulmonary infection. Disease´s physiopathology and/or progression includes granuloma formation which causes necrosis with cavitation within the renal parenchyma, fibrosis, calcium deposition and stricture formation. Diagnosis of GUTB based on biochemical workup is often delayed and high index of suspicion required to avoid misdiagnosis. Thus, imaging has an important role in diagnosis. The present X-ray KUB and CT is a classic example of such “putty kidney” which first described in 1906 by Dr. F.Tilden Brown, a genitourinary surgeon (Figure 1).

English

BACKGROUND Dual energy computed tomography (DECT) is a new method of computed tomography (CT) imaging which allows to determine stone composition in addition to assessing stone morphology. The purpose of this study was to evaluate the role of dual energy CT (DECT) preoperatively to assess the composition of urinary stones and to compare it with post-operative in vitro qualitative chemical analysis as reference standard. METHODS Forty patients (18 male and 22 female) who presented with symptoms of renal stones in the department of urology were included in the study. All 40 patients who were diagnosed to have renal stones clinically and by ultrasonography (USG) kidney, ureter and bladder (KUB) region were subjected to dual energy CT. The stone composition assessed in vivo using DECT preoperatively and in vitro by chemical analysis post operatively after stone extraction by surgical procedure. The results were compared by statistical analysis. Sensitivity, specificity and positive predictive value (PPV) were calculated and descriptive study done using Statistical Package for Social Sciences (SPSS) 20.00 version. Data was analysed by comparing it with correlative qualitative chemical analysis. RESULTS In our study, in vivo analysis using DECT showed most common type of stone was calcium oxalate seen in 20 cases compromising 50 % of total cases. Next common stone type was uric acid stone (22.5 %) followed by cysteine (17.5 %) and calcium hydroxyapatite (10 %) respectively. When the same stones were subjected to ex vivo chemical analysis, one of the calcium oxalate stone came out to be calcium phosphate and one of the cysteine stone came out to be mixed stone. Thus, out of 40 stones, 38 stones were found to have the same result in ex vivo chemical analysis as that of in vivo analysis by dual energy CT. Hence, accuracy of dual energy CT in diagnosis of renal stones was found to be 100 % with CI 91.19 % - 100 %. CONCLUSIONS With dual energy CT, it is possible to determine the composition of renal calculi in vivo non-invasively (with specificity of 100 % in our present study). Therefore, this helps in deciding the modality of treatment pre-operatively whether the stone is amenable to medical management (e.g., Uric acid stones) or requires extracorporeal shock wave lithotripsy (ESWL) or surgical intervention can be determined preoperatively. This helps to reduce the unnecessary financial burden and is found to be time saving. KEYWORDS Renal Calculus, Dual Energy CT, Stone Composition, Uric Acid Stones, Non-Uric Acid Stones, Attenuation, Hounsfield Units HU, Chemical Analysis of Stones.

Renal function estimation done by contrast enhanced computed tomography volume percentage: a better cost-effective alternate for renogram values

Background: For optimal management of obstructive uropathy the function of each renoureteral unit needs to be assessed precisely. Usage of nuclear scan for estimation of split renal function has been standard technique till now. Renal parenchymal volume percentage, which is calculated through multislice CT, used as a surrogate marker of split renal function. The aim of the study was to correlate the renal volume percentage calculated from contrast enhanced computed tomography (CECT) of kidney, ureter and bladder (KUB) with split renal function estimated by the gold standard 99mTc-DTPA (diethylene triamine pentaacetic acid) among obstructive uropathy patients.Methods: Patients who have been diagnosed as chronic unilateral renal obstruction and were requiring 99mTC-DTPA nuclear scan for functional assessment of kidneys were included as our study subjects. A total of 46 patients were taken as our study sample and for all these patients CECT KUB was done and the reports were collected and the renal volume percentage was obtained through those images. Correlation was made between the measurements made by nuclear scan and CECT images in unilateral renal obstruction patients.Results: A positive linear correlation was obtained between DTPA nuclear scan and CECT images in the detection of renal volume/renal function with r value 0.904 (p&lt;0.05) in obstructive renal units and similarly among non-obstructive renal units the r value was 0.889 (p&lt;0.001).Conclusions: Though 99mTc-DTPA renal scan is a safest choice by considering its less radiation exposure and no contrast requirement still cost and its universal availability make us to consider CECT as a better alternative.

Pen cap in the urinary bladder: A rare type foreign body in the urinary bladder in a 16 years old female

Foreign body in the urinary bladder is a rare urological presentation and in most cases are due to self-insertion usually for autoerotic stimulation. We presented a case of 16 years old female who presented with history recurrent urinary tract infection for 6 months. After thoroughly work up she was diagnosed to have a pen cap in her urinary bladder. The foreign body in the urinary bladder was detected by abdominal ultrasound, Kidney, Ureter and Bladder (KUB) X-ray did not detect any abnormal radiopaque material in the area of the urinary bladder or upper tract. At cystoscopy, one pen cap was identified and removed successful.

Focal Segmental Glomerulosclerosis in Paediatric Population of South Punjab Pakistan: A Tertiary Care Hospital Experience.

Objectives:To find out frequency, clinicopathological features, response of treatment and outcome among children with primary focal segmental glomerulosclerosis (FSGS).Methods:This retrospective, non-interventional medical charts review study was conducted from a period of January 2011 to January 2020 at Pediatric Department of Nishtar Medical University Hospital, Multan, Pakistan. During the nine years study period, children of both genders, aged less than 16 years, with renal biopsies proven FSGS were included. Patient’s demographic along with clinical and laboratory data, urine dipstick for proteinuria, renal functions, 24 hours urinary protein and ultrasonography findings of kidneys, ureters and bladder (KUB) were noted from case records. Response rates of various treatment options and their outcome like remission, partial remission, no remission with stable kidney disease & no remission with progression of kidney disease were noted.Results:During the study duration, out of 307 renal biopsies performed in glomerulonephritis cases, 124 (40.4%) had primary FSGS. In 124 primary FSGS cases, mean age was 8.83±3.05 years while most of the children, 70 (56.5%) were above 10 years of age. Majority of the cases, 64 (51.6%) were male. Mean follow up duration was noted to be 28.35+18.47 months. Most of the cases, 68 (54.8%) were found to have complete remission, 22 (17.7%) partial remission while 11 (8.9%) progressed to ESKD.Conclusions:Among children, frequency of primary FSGS was high at our setting. Most of the cases achieved sustained remission rates with the help of immunosuppressive drugs. Cyclosporine and tacrolimus were found to be the most effective drugs.

Gas-Containing Renal Stones: A Case Report and Literature Review

We report the 11th case of gas containing renal stone. A 92-year-old Chinese female presented with fever and lower urinary tract symptoms. Urine culture grew Escherichia coli (E. coli). CT abdomen pelvis showed a large gas containing partial staghorn stone. She was managed conservatively with two weeks of antibiotics. Follow up plain kidney, ureter and bladder (KUB) radiograph at 3 months showed that the stone was stable in size. She remained asymptomatic at follow up.

Abdominal Distension in an Eleven-Month-Old Male.

An eleven-month-old male was brought in for a 1-day history of abdominal distension and anorexia associated with increased fussiness and multiple bouts of non-bloody diarrhea without any vomiting. A kidney, ureter and bladder (KUB) radiograph and abdominal ultrasound were obtained (Figure 1). (Figure 1). After placing a nasogastric (NG) tube (Figure 2), a repeated KUB showed gastric decompression with the NG tube extending into the stomach. An abdominal ultrasound showed transient small bowel to small bowel intussusception in the left lower quadrant, which spontaneously decreased during the course of the examination (Figure 3).

Percutaneous nephrolithotomy in the pediatric age group: a study from North Karnataka

Background: Nephrolithiasis is major problem in India. It is more prevalent in northern states of India and Karnataka is not an exception to this. Percutaneous nephrolithotomy (PCNL) has been accepted globally as a safe procedure with great success rate with less complication, and it is safe, effective, and suitable for pediatric cases. The aims and objectives of the study were to evaluate the indication of PCNL in children, to identify the complication, prevention and treatment of complication and to evaluate the efficacy and safely, management of kidney stones in children.Methods: Study period Aug 2015 July 2018, total 56 cases of renal stones in pediatric age group admitted in our Hospital, a tertiary care centre. All the patients evaluated for complete urine analysis, urine culture and sensitivity, complete hemogram, renal parameter, X ray KUB (kidney, ureter, and bladder), ultrasound KUB etc.Results: Small-stone (&lt;2 cm) seen in 21.4% and large stone 64.2%. Following complications were noted- Pelvic perforations (3.5%), fever (7.1%) and hematuria (7.1%).Conclusions: PCNL is safe and effective procedure for the managements of renal stones in children with acceptable morbidity.

Ultrasound-guided percutaneous nephrolithotomy for upper urinary tract calculi in patients with spinal deformity: a decade's experience.

To evaluate the efficacy and safety of ultrasound (US)-guided percutaneous nephrolithotomy (PCNL) in managing upper urinary tract calculi in patients with spinal deformity based on our experience over the last decade. A retrospective study was conducted on patients with spinal deformity who were admitted to Beijing Tsinghua Changgung Hospital and collaborative hospitals from August 2004 to August 2017. Patients diagnosed with urolithiasis and who underwent US-guided PCNL, performed by the same surgeon, were included. Patients' data were collected and the following variables were analysed: age; sex; plain abdominal radiograph of the kidneys, ureters and bladder (KUB); computed tomography (CT); stone burden; evaluation of spinal anatomy; respiratory function; operative time; and postoperative findings. The severity of surgical complications was determined according to the modified Clavien classification system (MCCS). A total of 72 patients (41 males and 31 females) were included, with a mean (range) age of 35(21-69)years. The mean (range) stone diameter was 38(19-68)mm. Seven patients had bilateral PCNL, completed in staged surgery with a 1-week interval. Five kidneys received staged PCNL because of either large residual stones or the potential risk of a long operation time. In all, 19 patients underwent the surgery in a prone position, 29 lateral, nine oblique supine, and the other 27 in unconventional positions (lateral prone, lateral supine, and lateral jackknife position). All procedures were successfully completed with no major complications during the operation. The mean (SD) tract building time was 8.5(1.7)min. The mean (SD) stone disintegration time was 39.3(14.6)min. The mean (range) temperature and postoperative haemoglobin (Hb) drop on the first postoperative day were 37.6(36.7-39.2)°C and 1.5(0.2-4.3)g/dL, respectively. Four patients needed blood transfusions and none of the patients had septic shock or severe renal bleeding requiring angiographic renal embolisation or nephrectomy. A stone-free status was achieved in 71 kidneys (89.87%). Eight patients with residual fragments ≥4mm were either observed without treatment during follow-up or re-treated with shockwave lithotripsy (SWL) according to clinical significance. PCNL in patients with spinal deformities is challenging but safe and effective. US-guided puncture and access establishment has its unique advantages when such patients are placed in unconventional positions.

The Association of Encrustation and Ureteral Stent Indwelling Time in Urolithiasis and KUB Grading System.

To evaluate the management of prolonged indwelling ureteral stents and the newly developed KUB (kidney, ureter, and bladder) grading system for the classification of encrusted stents in urolithiasis. This study involved 69 patients that had indwelling and forgotten ureteral stents for more than 6 months after urolithiasis treatment. They were categorized into 4 groups based on indwelling time and were reviewed retrospectively. Patients whose ureteral stent could not be removed with simple cystoscopy were graded according to stone surface area and the KUB system. The mean stent indwelling time was 23.1 months. Stone burden in KUB and, in proportion to that, total KUB (T) score showed increased association that was directly proportional to indwelling time (p < 0.001, p = 0.008). Surgical intervention was required in 73.9% of patients. Among patients requiring surgery, 78.4% were treated in a single session and multi-modal interventions were performed in 70.5%. K score ? 3 was found to be associated with multiple surgery requirements (odds ratio [OR];11.25, %95 confidence interval [CI]:2.132-59.375),multi-modal procedure requirements (OR;16.50, %95 CI:3.434-79.826 ), and lower stone-free rates (p = 0.04). Bscore ? 3 was associated with multi-modal procedure requirements (OR;8.90, %95 CI:1.052-75.462). U score ? 3and T score ? 9 were associated with an operating time >180 minutes (p < 0.001, p = 0.008). Prolonged indwelling time of the ureteral stent in urolithiasis is associated with increased encrustation and stone burden. Since the KUB system specifies stone burden and its particular localization, it can be used as a simple, convenient method for the planning treatment of encrusted ureteral stents.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone.

The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain. A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention. A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8). This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Acute kidney injury in pregnancy with special reference to pregnancy-specific disorders: a hospital based study (2014-2016).

There are numerous reports in the literature describing acute kidney injury in pregnancy (P-AKI) due to various obstetric complications. However, there is a dearth of studies on AKI related to pregnancy-specific disorders from India. We aimed to analyze clinical features and outcome of P-AKI related to pregnancy-specific disorders compared to total pregnancy, in India. All pregnant women attending the department of Obstetrics and Gynecology from November 2014 to July 2016 were screened for AKI based on: (1) sudden elevation of serum creatinine ≥ 1mg/dl; (2) oligoanuria for > 12h; and (3) need for dialysis. The detailed clinical profile of AKI in patients with preeclampsia/eclampsia (PE/E), hemolysis/elevated liver enzymes/low platelet count (HELLP) syndrome, acute fatty liver of pregnancy (AFLP), and pregnancy-associated thrombotic microangiopathy (P-TMA) was analyzed. Laboratory investigations included: complete blood count, renal function tests, urinalysis, coagulation profile (platelet count, INR, prothrombin time and activated partial thromboplastin time), and immunological assay (C3, C4, ANA, anti-dsDNA antibody, antiphospholipid antibody). Contrast-enhanced CT scan of kidney ureter and bladder (KUB) and renal biopsy were performed in selected cases. Maternal and fetal outcome were analyzed individually. The patients were followed for 3 months or longer to determine the recovery of renal function or progression to chronic kidney disease (CKD). Overall, 4741 pregnant women (mean age 26.8 ± 4.8years) were evaluated for AKI. P-AKI was found in 132/4741 (2.78%) patients. In the majority (91.6%), AKI developed in the late 3rd trimester and post-partum period. P-AKI was related to obstetric complications (in 61.4%), pregnancy-specific disorders (in 57.5%) and miscellaneous factors (7.5%). Puerperal sepsis, ante-partum and post-partum hemorrhage were contributing factors for P-AKI in 34 (25.8%), 11 (8.3%) and 28 (21.2%) patients, respectively. P-AKI due to pregnancy-specific disorders developed in 76/4741 patients, i.e. in 1:62 pregnancies. PE/E was the cause of P-AKI in 62 patients (46.9%) followed by HELLP syndrome in 9 (6.8%) and AFLP in 05 (3.8%). P-TMA causing AKI was not observed. Complete recovery of renal function occurred in 89.4% of patients while 6 (4.6%) progressed to CKD (ESRD: 3 and CKD stage IV: 3). Maternal mortality was 6%. Puerperal sepsis was the sole cause of patchy cortical necrosis in 5 (3.7%) cases. Premature delivery occurred in 40.9% patients and full-term delivery in 35.6%. Perinatal mortality was 23.5%, mainly due to intrauterine death (17.5%) and prematurity (6%). PE/E was the commonest cause of P-AKI in our study, similar to the situation in developed countries. Post-partum hemorrhage was the second-most common (21.5%) cause. Puerperal sepsis contributed to AKI in one-fourth of pregnant women. P-TMA was not recorded in this study and AFLP was an uncommon cause of P-AKI in our country. Renal function returned to normal in all patients with P-AKI due to pregnancy-specific disorders. However, perinatal mortality was high despite the good prognosis of P-AKI.

Small intestine obstruction secondary to obturator hernia

An 84-year-old lady presented with a 3-day history of abdominal distention and intermittent colic. She was underweight (body mass index of 12 kg/m2) and received adhesiolysis for ileus several years ago. Physical examination revealed diminished distal bowel sound and intermittent throbbing pain of right groin area. The kidney, ureter and bladder (KUB) radiography demonstrated small intestine obstruction (Fig. 1 A). Symptoms persisted despite of prokinetic agents and enema. Abdominal computed tomography (CT) disclosed bowel segment between right pectineus muscle and obturator externus muscle (Fig. 1B). Mechanical small intestine obstruction secondary to right obturator hernia was diagnosed, and symptoms relieved after segmental resection of incarcerated ileum via laparoscopy. (A) KUB radiography revealed small intestinal obstruction of coiled spring sign. (B) Herniated ileum (arrow head) was noted between right pectineus muscle and obturator externus muscle (arrows). Intestinal obstruction, the interruption of normal intraluminal flow, can be functional or mechanical. Etiologies of mechanical obstruction include postoperative adhesions, hernias, tumors, gallstones, foreign bodies, intussusceptions, etc. Obturator hernia, a rare type of herniation, is abdominal contents protruding through the obturator foramen. It is more common in the elderly and debilitated woman, also named the “little old lady's hernia” [1]. Formerly the diagnosis was established only on surgical explorations due to lack of specific diagnostic clues [2], and now it can be detected early and correctly before operation with the assistance of CT [3], which typically shows herniated bowel between pectineus muscle and obturator muscle. Surgical intervention is the most proper treatment option [1]. In typical patients with intestinal obstruction of unknown origin, image studies such as abdominal or pelvis CT should be considered for obturator hernia. All authors declare no conflicts of interest.