Left Bladder Research Articles

A retrospective study of 96 cases of adrenal metastases

Objective: To analyze the clinical characteristics, etiological composition, imaging features, and prognosis of adrenal metastases. Methods: This study is a retrospective case series that included 96 patients with pathologically confirmed adrenal metastases who were treated at West China Hospital, Sichuan University, from 2007 to 2017. Clinical features such as sex, age, tumor size, biochemical tests, imaging characteristics, postoperative pathology, treatment methods, and prognosis were collected and analyzed. The prognosis of patients and its influencing factors were analyzed by Kaplan-Meier survival curve and single-factor Cox risk proportional model. Results: Among the 96 included patients, 64 were male and 32 were female, with a median age of 60 years. There were 89 cases of unilateral adrenal metastases, five cases of bilateral metastases, and two cases with unspecified laterality. The median diameter of the metastases was 3.5 cm×2.9 cm, with an average CT value of 31 HU. Thirty-four cases of adrenal hormones were evaluated, and no abnormality was found.The primary tumor sites were as follows: lung (n=36), kidney (n=19), liver (n=12), pancreas (n=7), rectum (n=3), stomach (n=2), and one case each of tumor in the esophagus, skin, thyroid, left maxillary muscle, breast, bladder, cervix, chest wall, and gastrointestinal tract. There were three cases with unknown primary tumors. The most common pathological type was lung adenocarcinoma (20.8%, 20/96), followed by hepatocellular carcinoma (9.4%, 9/96) and high-grade invasive urothelial carcinoma of the kidney (8.3%, 8/96). Thirty-nine cases were diagnosed concurrently with the primary tumor, while 37 cases were diagnosed after the primary tumor, with a median interval of 15 months (range: 2-144 months). There was no significant correlation between the death risk of adrenal metastatic tumor patients and gender, age, and the size of the metastatic tumor (all P>0.05). There were 4 patients with radiotherapy and chemotherapy alone, 19 patients with surgery alone, and 6 patients with combined radiotherapy and chemotherapy. The median overall survival was 1, 3, and 7 years, respectively. Conclusions: Adrenal metastases were mostly diagnosed at the same time as the primary tumor or within 15 months after the diagnosis of the primary tumor. Unilateral metastasis is common. The lungs are the most common primary lesion, followed by the kidney and liver. CT is the preferred method for the diagnosis of adrenal metastases, and the plain CT value is more than 30 HU. The overall prognosis of adrenal metastases is poor. The prognosis was better for patients who underwent surgery combined with radiotherapy and chemotherapy than those who received only surgery or radiotherapy and chemotherapy alone.

Rare recurrence pattern after complete response to chemotherapy in a patient with rectal cancer: a case report

BackgroundColorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease.Case presentationA 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis.ConclusionsThis case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.

A Unique Occurrence of Vesical Endometriosis 16 Years After Cesarean Section: A Case Report

<strong>Background:</strong> The rare disorder urinary bladder endometriosis develops when endometrial tissue, which lines the uterus, grows in the bladder wall. This aberrant endometrial tissue causes hematuria, dysuria, and pelvic discomfort. Though, these symptoms are not exclusive to this illness, they make diagnosis difficult. Ultrasound, Magnetic Resonance Imaging, and cystoscopy play a crucial role in confirming the diagnosis. Treatment options range from medical management with hormonal therapies to surgical interventions like transurethral resection or partial cystectomy depending upon personal needs and endometriosis severity. <strong>Case Presentation:</strong> We are presenting a case report highlighting this uncommon yet clinically significant presentation of urinary bladder endometriosis in a 38-year-old female, who had been experiencing cyclical dysuria for about one year. Her medical history included two previous Caesarean deliveries with last being 16 years ago. MRI revealed variable intensity lesion with internal cystic areas along left posterolateral urinary bladder wall which was inseparable from lower segment caesarean section scar, indicative of urinary bladder endometriosis. Patient received medical treatment leading to resolution of her symptoms. <strong>Conclusion:</strong> Urinary bladder endometriosis following caesarean section is an uncommon but clinically significant condition that demands timely recognition and appropriate management. A thorough diagnostic workup, including imaging studies and cystoscopy, is crucial for accurate diagnosis. Tailored treatment plans, ranging from hormonal therapies to surgical interventions, should be considered based on disease extent, fertility desires, and overall patient health.

Successful surgical correction of caudal duplication syndrome in a dog.

To describe a case of caudal duplication successfully operated with long-term follow-up. A 12-week-old female Chihuahua mix. The dog of this report presented for evaluation of duplicate external organs, including 2 anuses, 2 vulvas, and 2 tails. The dog was clinically normal except for signs of cystitis. Contrast CT identified complete urogenital and anorectal duplication, characterized by duplication of the cecum, descending colon/rectum, urinary bladder, urethra, uterus, and ovaries, with left-sided rectovestibular fistula. Exploratory laparotomy was performed to remove the left cecum and colon, the left ureter was transected and implanted into the right urinary bladder, the left bladder and urethra were removed, and bilateral ovariohysterectomy removed 4 ovaries and 2 uteruses. Following abdominal closure, the left anus and vulva with remaining portions of distal rectum and urethra, respectively, were removed en bloc with both tails. Long-term follow-up at 5 years showed the dog to be clinically normal. Caudal duplication is extremely rare in veterinary medicine, and this report details successful surgical correction with good long-term follow-up.

Acceptability, reliability, and validity of a vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia: a cross-sectional study.

Approximately half of people with endometriosis experience deep dyspareunia; however, there is no means of objective self-testing of endometriosis-associated deep dyspareunia. The aim of this study was to assess the acceptability, test-retest reliability, and validity of a vaginal insert for a self-assessment of endometriosis-associated deep dyspareunia. Participants were recruited from a tertiary endometriosis center. Inclusion criteria were: 19 to 49years of age, self-reported deep dyspareunia of ≥4 of 10, and surgically confirmed endometriosis. Participants completed 2 self-assessments using the vaginal insert to self-assess tenderness at the right and left pelvic floor, bladder, cervix-uterus, and posterior cul-de-sac (vaginal fornix). The participants recorded tenderness at each pelvic site and completed a questionnaire regarding the acceptability of the vaginal insert to assess deep dyspareunia. Test-retest reliability was assessed by correlating the tenderness scores between the 2 assessment dates. Over a 4-week period, the participants also recorded deep dyspareunia severity at each penetrative vaginal sex encounter. Validity was assessed by correlating vaginal insert tenderness to deep dyspareunia severity, and also to tenderness reported on a prior gynecologic pelvic examination. The main outcome measures were the acceptability index score, tenderness (0-10) at each pelvic site, and prospective deep dyspareunia scores (0-10) over 4 weeks. There were 19 participants (mean age 34±7years) who completed the study. The majority identified as female (94.7%), heterosexual (89.5%), and white (89.5%). The median acceptability index score was 0.72 (interquartile range, 0.66-0.81). For test-retest reliability, the intraclass correlation coefficients were 0.79 (P = .001) for the left pelvic floor, 0.82 (P < .001) for the right pelvic floor, 0.54 (P = .07) for the bladder, 0.89 (P < .001) for the cervix-uterus, and 0.77 (P = .003) for the cul-de-sac. The correlation between the highest self-assessed mean tenderness in each participant and self-reported deep dyspareunia over 4 weeks was r = 0.32, but correlations for each pelvic site varied significantly. Tenderness at each site on prior gynecologist pelvic exam was associated with higher self-assessed mean tenderness with the vaginal insert in each participant (effect sizes = 0.42-0.88). The vaginal insert is acceptable and reliable for the objective self-assessment of endometriosis-associated deep dyspareunia, with initial evidence of validity. A strength was the inclusion of participants who were avoiding sexual activity and a limitation was the small sample size. Future studies with larger sample sizes are required to further establish the validity of the vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia.

Assessment of Bladder Filling Type on Radiation Dose to Organs at Risk in MR-Guided Intracavity Brachytherapy for Cervical Cancer

In this study, we evaluated whether the classification of bladder shape affects the absorbed dose (Gy) of OARs and its geometrical position to normal organs in MR-guided intracavitary brachytherapy (ICBT). In this study, 269 patients who underwent MR-guided ICBT for cervical cancer from 2016 to 2022 were included. The applicator-inserted bladder filling type (BFT) classification was divided into three types (tilted, curved, and other shapes: group E). The anatomical positional relationship between the uterus and its surroundings was measured on pre-MR images and ICBT simulation MR images. Spearman's rank correlation analysis was used for bladder volume and OAR dose according to BFT. Anatomical differences were analyzed by ANOVA by measuring the distance from the center to both bladder walls. In the correlation analysis considering the shape of the bladder, the tilted, curved, and group E had Spearman's ρ of 0.211; -0.323, 0.412; -0.307 and -0.035; -0.209 for maximum absorbed dose (D2cc) of bladder and small bowel, respectively. It was statistically significant in the tilted type and curved type. The average left and right bladder lengths differences of the tilted type were the highest at 8.47 cm and 7.11 cm, respectively. It was a statistically significant between bladder shape and the difference in left and right bladder lengths differences (p< 0.01). In this study, it was confirmed that bladder distension increased the maximum bladder dose (D2cc) and decreased the maximum bowel dose (D2cc) to the tilted type and curved type. In addition, if the left and right bladder lengths are measured in pre-MR, the degree of bladder distension can be evaluated in advance by checking the shape of the bladder in the case of the tilting type before ICBT. Based on these findings, a prospective study is needed to evaluate the effect of ICBT on cervical cancer treatment outcomes through bladder type classification.

Human factors in the clinical implementation of deep learning-based automated contouring of pelvic organs at risk for MRI-guided radiotherapy.

Deep neural nets have revolutionized the science of auto-segmentation and present great promise for treatment planning automation. However, little data exists regarding clinical implementation and human factors. We evaluated the performance and clinical implementation of a novel deep learning-based auto-contouring workflow for 0.35T magnetic resonance imaging (MRI)-guided pelvic radiotherapy, focusing on automation bias and objective measures of workflow savings. An auto-contouring model was developed using a UNet-derived architecture for the femoral heads, bladder, and rectum in 0.35T MR images. Training data was taken from 75 patients treated with MRI-guided radiotherapy at our institution. The model was tested against 20 retrospective cases outside the training set, and subsequently was clinically implemented. Usability was evaluated on the first 30 clinical cases by computing Dice coefficient (DSC), Hausdorff distance (HD), and the fraction of slices that were used un-modified by planners. Final contours were retrospectively reviewed by an experienced planner and clinical significance of deviations was graded as negligible, low, moderate, and high probability of leading to actionable dosimetric variations. In order to assess whether the use of auto-contouring led to final contours more or less in agreement with an objective standard, 10 pre-treatment and 10 post-treatment blinded cases were re-contoured from scratch by three expert planners to get expert consensus contours (EC). EC was compared to clinically used (CU) contours using DSC. Student's t-test and Levene's statistic were used to test statistical significance of differences in mean and standard deviation, respectively. Finally, the dosimetric significance of the contour differences were assessed by comparing the difference in bladder and rectum maximum point doses between EC and CU before and after the introduction of automation. Median (interquartile range) DSC for the retrospective test data were 0.92(0.02), 0.92(0.06), 0.93(0.06), 0.87(0.04) for the post-processed contours for the right and left femoral heads, bladder, and rectum, respectively. Post-implementation median DSC were 1.0(0.0), 1.0(0.0), 0.98(0.04), and 0.98(0.06), respectively. For each organ, 96.2, 95.4, 59.5, and 68.21 percent of slices were used unmodified by the planner. DSC between EC and pre-implementation CU contours were 0.91(0.05*), 0.91*(0.05*), 0.95(0.04), and 0.88(0.04) for right and left femoral heads, bladder, and rectum, respectively. The corresponding DSC for post-implementation CU contours were 0.93(0.02*), 0.93*(0.01*), 0.96(0.01), and 0.85(0.02) (asterisks indicate statistically significant difference). In a retrospective review of contours used for planning, a total of four deviating slices in two patients were graded as low potential clinical significance. No deviations were graded as moderate or high. Mean differences between EC and CU rectum max-doses were 0.1±2.6Gy and -0.9±2.5Gy for pre- and post-implementation, respectively. Mean differences between EC and CU bladder/bladder wall max-doses were -0.9±4.1Gy and 0.0±0.6Gy for pre- and post-implementation, respectively. These differences were not statistically significant according to Student's t-test. We have presented an analysis of the clinical implementation of a novel auto-contouring workflow. Substantial workflow savings were obtained. The introduction of auto-contouring into the clinical workflow changed the contouring behavior of planners. Automation bias was observed, but it had little deleterious effect on treatment planning.

Unsuspected paraganglioma of the urinary bladder with intraoperative hypertensive peak: A case report

Background. Bladder paraganglioma (BPG) is a very rare tumor. Case report: We report the case of a 48-year-old woman with a history of isolated hematuria. Cystoscopy showed a solid mass on the bottom of the bladder. During the intervention the patient experienced a severe hypertensive episode. BPG was then suspected. Pathology findings confirmed the diagnosis.123I-metaiodobenzylguanidine scan showed a pathological tracer accumulation in the left bladder wall consistent with BPG. The patient underwent a transurethral resection of the bladder after drug preparation. The postoperative course was uneventful and our patient was normotensive. Conclusion. Diagnosis of BPG is often made on histological examination of the tumor.

(123) Evaluation of a Vaginal Insert for Self-assessment of Endometriosis-associated Deep Dyspareunia

Abstract Introduction Among individuals with endometriosis, approximately 50% experience deep dyspareunia. There is a validated test to evaluate superficial dyspareunia (tampon test); however, no such test exists for deep dyspareunia. Thus, we conducted a pilot study to evaluate the use of a vaginal insert for self-assessment of deep dyspareunia. Objective To report test-retest reliability and validity of using a vaginal insert for self-assessment of deep dyspareunia in individuals with endometriosis. Methods This was a prospective cohort study embedded within a pilot RCT. Individuals with a surgical diagnosis of endometriosis aged 19-49, who had a clinic visit between January 2018 and December 2020 were recruited from a prospective data registry at a tertiary endometriosis and pelvic pain centre. Inclusion criteria were assigned female at birth, sexually active or not sexually active due to pain, monogamous partner who consents to participate, and deep dyspareunia score ≥ 4/10. Exclusion criteria were superficial dyspareunia ≥ 4/10, prior use of the intervention under investigation in the RCT, intense fear or anxiety around sexual activity, and severe levels of anxiety or depression on validated screening measures. Participants used the vaginal insert to self-assess tenderness at two time points, one week apart, using a numeric rating scale (0-10) at the right and left pelvic floor, bladder, cervix-uterus, and posterior cul-de-sac. Participants also used a daily diary to record deep dyspareunia severity (0-10) during intercourse over a four-week period. Test-retest reliability was evaluated by correlating tenderness scores between the two time points. Validity was assessed by correlating the vaginal insert tenderness scores with deep dyspareunia scores. Results Nineteen participants completed the study. The average age was 34 ± 7 years, and the majority of participants identified as female (n=18; 94.7%), heterosexual (n=17; 89.5%) and white (n=17;89.5%). Intraclass correlation coefficients for each site showed good test-retest reliability: left pelvic floor 0.79 (p = 0.001), right pelvic floor 0.82 (p &amp;lt; 0.001), bladder 0.54 (p = 0.07), cervix-uterus was 0.89 (p &amp;lt; 0.001), and the cul-de-sac 0.77 (p = 0.003). The strongest correlation between tenderness using the vaginal insert and deep dyspareunia scores was at the cervix-uterus (r=0.35); however, no statistically significant correlations were identified at any of the pelvic sites. Conclusions We found a strong correlation of tenderness scores between assessment dates (test-retest reliability), indicating that the vaginal insert may be a reliable method of assessing deep dyspareunia. A future study with larger sample size will be needed to study the correlations between tenderness assessed with the vaginal insert and prospective deep dyspareunia scores for evaluation of validity. Self-assessment of deep dyspareunia using a vaginal insert shows promise, and may support trauma-informed practice and the collection of ecologically valid data. Disclosure Yes, this is sponsored by industry/sponsor: OhNut Wearable - provided a discount on the silicon buffer used in the trial; ISSWSH Grant. Clarification: No industry support in study design or execution.

Advanced cervical stump cancer after laparoscopic subtotal hysterectomy: a case report of imaging, laparoscopic staging and treatment approach

BackgroundAdvanced cancer of the cervical stump, occurring years after a laparoscopic supracervical hysterectomy (LASH), is a rare but serious clinical condition. Many patients who undergo a LASH are unaware of this possible complication. Upon diagnosis of advanced cervical stump cancer, a holistic approach including imaging, laparoscopic surgery and multimodal oncological therapy is required.Case presentationA 58-year-old patient presented to our department with the suspicion of advanced cervical stump cancer eight years after LASH. She reported pelvic pain, irregular vaginal bleedings and irregular discharge. Gynaecological examination revealed a locally advanced tumor of the uterine cervix with suspicion of infiltration of the left parametria and bladder. After thorough diagnostic imaging and laparoscopic staging, the tumor stage was determined as FIGO IIIB and the patient was treated with combined radiochemotherapy. The patient presented with tumor recurrence 5 months after the completion of therapy and she is currently being treated with multichemotherapy and immunotherapy regimens as palliative treatment.ConclusionPatients should be made aware about the risk of cervical stump carcinoma after LASH and the necessity for regular screening. Cervical cancer after LASH is often diagnosed at advanced stages and the treatment requires an interdisciplinary approach.

Plasmacytoid bladder cancer: a rare case report.

The authors report a case of a patient with locally advanced plasmacytoid urothelial carcinoma (PUC) of the bladder. A 71-year-old man with a history of chronic obstructive pulmonary disease presented with gross hematuria. The rectal examination revealed a fixed bladder base. A computed tomography scan showed a pedunculated lesion arising from the anterior and left lateral bladder wall and extended to the perivesical fat. The patient underwent transurethral resection of the tumor. The histologic examination revealed the presence of muscle-invasive PUC of the bladder. The decision of the multidisciplinary consultation meeting was to do palliative chemotherapy. Thus, the patient could not receive systemic chemotherapy and died 6 weeks after transurethral resection of the bladder tumor. A plasmacytoid variant of urothelial carcinoma is a rare subtype of urothelial carcinoma that has a poor prognosis with a high mortality rate. The disease is usually diagnosed at an advanced stage. Given the rarity of plasmacytoid bladder cancer, treatment guidelines are not clear; therefore, more aggressive treatment may be required. PUC of the bladder is characterized by high aggressiveness, an advanced stage at the time of diagnosis, and a poor prognosis.

Urinary Bladder Hernia: A Rare Cause of Voiding Disorders in Adults - A Case Report

Urinary bladder hernia is a rare event corresponding to the externalization of a bladder segment through the inguinal orifice, resulting from the association of wall weakness with increased intra-abdominal pressure. We report the case of a 38-year-old patient with no particular pathological history who presented to the urological surgery department complaining of dysuria associated with pollakiuria, intermittent left inguinoscrotal bulge, with the need to compress the scrotum to finish urination. The physical examination revealed a large, painless left inguinoscrotal hernia, the pressure of which caused an urge to urinate. Retrograde cystography noted filling of a left inguinoscrotal bladder portion during voiding with upstream bladder emptying. The examination was completed by a CT scan which revealed an inguinal parietal defect with a passage of the anterosuperior part of the bladder which fills up with contrast product at the delayed acquisition. Urinary bladder hernia is most often asymptomatic and its discovery is intraoperative in most cases. The diagnosis is suspected due to the association of inguinoscrotal hernia and urinary signs, especially two-step urination with the need to compress the scrotum during urination. Retrograde cystography is the best technique to image, showing a dogear-shaped bladder in the scrotum.

V03-04 FIRST HUMAN NOTES FOR BLADDER LEIOMYOMA ENUCLEATION AND CYSTORRAPHY

You have accessJournal of UrologyCME1 Apr 2023V03-04 FIRST HUMAN NOTES FOR BLADDER LEIOMYOMA ENUCLEATION AND CYSTORRAPHY Andreia Cardoso, Sara Anacleto, Catarina Laranjo Tinoco, Ricardo Matos Rodrigues, Ana Sofia Araújo, Mariana Capinha, Vera Marques, João Pimentel Torres, Carlos Oliveira, Miguel Mendes, and Emanuel Carvalho-Dias Andreia CardosoAndreia Cardoso More articles by this author , Sara AnacletoSara Anacleto More articles by this author , Catarina Laranjo TinocoCatarina Laranjo Tinoco More articles by this author , Ricardo Matos RodriguesRicardo Matos Rodrigues More articles by this author , Ana Sofia AraújoAna Sofia Araújo More articles by this author , Mariana CapinhaMariana Capinha More articles by this author , Vera MarquesVera Marques More articles by this author , João Pimentel TorresJoão Pimentel Torres More articles by this author , Carlos OliveiraCarlos Oliveira More articles by this author , Miguel MendesMiguel Mendes More articles by this author , and Emanuel Carvalho-DiasEmanuel Carvalho-Dias More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bladder leiomyomas (BL) are rare benign tumors, with roughly 250 cases reported worldwide. Surgical excision is the recommended treatment, classically through open partial cystectomy. As alternatives, minimally invasive approaches, such as laparoscopic (lap), robot-assisted and transurethral (TU) resection (TUR), are arising. In parallel, TU cystorraphy has been reported for vesicovaginal fistulas or traumatic perforations. Thus, to the best of our knowledge, we report the 1st Human Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a purely TU approach for BL enucleation and cystorraphy, without transvesical access, gas insufflation, neither extracorporeal knot tying. METHODS: A 68-year-old woman presented an incidental 22mm lesion on the left posterolateral bladder wall on MRI, highly suspicious for BL. After cystocopic confirmation of a submucosal lesion, TUR was proposed. We performed a pioneer NOTES with total TU BL enucleation and cystorraphy using: 30° lens, white light only, saline irrigation, 26Ch resectoscope, operative cystoscope, Collin’s knife and standard resection loop, bipolar energy, 5mm lap needle holder and 3-0 V-Loc 23cm length suture. RESULTS: BL complete enucleation was done with bipolar energy on Collin’s knife and standard resection loop. Then, V-Loc suture was completely placed inside the bladder through the operative cystoscope, and with the lap needle holder inserted through it, a total intravesical cystorraphy with single hand continuous suture was performed. Operative time was 40min. Patient was discharged on the next day, with bladder catheter for 5 days. There were no complications. CONCLUSIONS: TUR has been used for BL, but without cystorraphy, which is a limitation for bigger or more profound infiltrative lesions. Cystorraphy techniques combining TU, transperitoneal and/or transmural bladder access were reported. A purely TU cystorraphy recently reported required extracorporeal sliding knot techniques, so, it was only possible in women. Thus, our approach may be the most minimally invasive possible for the safest treatment of BL. We combined several techniques aiming to reach an ideal one. Using only regular material, a single urethral route, and no gas insufflation, we achieved a quick and safe procedure, with no need for continuous bladder irrigation and short catheterization. Yet, it requires advanced skills such as single hand lap suturing. Our technique seems also feasible in small bladder perforations, fistulas, or other lesions (e.g.: endometriosis). Additionally, with total intravesical suture, it may also be viable in men. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e247 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andreia Cardoso More articles by this author Sara Anacleto More articles by this author Catarina Laranjo Tinoco More articles by this author Ricardo Matos Rodrigues More articles by this author Ana Sofia Araújo More articles by this author Mariana Capinha More articles by this author Vera Marques More articles by this author João Pimentel Torres More articles by this author Carlos Oliveira More articles by this author Miguel Mendes More articles by this author Emanuel Carvalho-Dias More articles by this author Expand All Advertisement PDF downloadLoading ...

PMON88 A Rare Case of Composite Paraganglioma in the Bladder

Abstract Background Paragangliomas are neuroendocrine tumors that arise from embryonic neural crest cells; they are essentially extra-adrenal pheochromocytomas most frequently found in the head and neck. Composite tumors are rare and consist of the presence of two histologically distinct tissues within a single tumor. Additionally rare is the presence of a composite paraganglioma in the retroperitoneum and urinary bladder, of which there are few reported cases. Case Report We present a case of a 57 year old female who was found to have an incidental pelvic mass noted to progressively increase in size over the years on subsequent imaging. The patient had a cystoscopy and retrograde pyelogram that were both unremarkable. MRI Pelvis showed a 1.8×1.8×1.9 cm rounded, well-circumscribed lesion at the left posterior lateral bladder extending exophytically from the serosa at the ureterovesicular junction. As she had associated hypertension, palpitations, and anxiety, the patient was evaluated for pheochromocytoma.Laboratory workup showed elevated plasma levels of free Metanephrines at 130 (&amp;lt;57 pg/mL), free Normetanephrines at 247 (&amp;lt;148 pg/mL), and a free Total level at 377 (&amp;lt;205 pg/mL). 24-hour urine collection was consistent with mild elevation of Metanephrines at 330 (90-315 mcg/24 h), normal levels of Normetanephrines at 469 (122-676 mcg/24 h), and normal levels of Total urine Metanephrines of 799 (224-832 mcg/24 h). 24-hour urine free Catecholamines showed: Epinephrine of 6 (2-24 mcg/24 h), Norepinephrine of 77 (15-100 mcg/24 h), and a Total (Epi+NE) of 83 (26-121 mcg/24 h), with Dopamine of 220 (52-480 mcg/24 h).Due to mildly elevated metanephrine levels, the patient was started on the alpha-blocker doxazosin. She ultimately underwent a laparoscopic removal of the bladder mass, with pathology reports confirming presence of a composite paraganglioma with atypical features. Additionally, further immunohistochemistry was negative for the SDHB gene mutation in the tissue samples obtained. Conclusion Composite paragangliomas of the urinary bladder are very rare. Certain genetic pathologic variants carry an increased risk for malignancy and possible metastasis; therefore, these neuroendocrine tumors usually require targeted mutation testing. At this time, the pathogenesis of composite paragangliomas is still largely unknown, with little information available about treatment options and clinical outcomes. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

EOSINOPHILIC CYSTITIS IN A PEDIATRIC PATIENT WITH X-LINKED CHRONIC GRANULOMATOUS DISEASE

<h3>Introduction</h3> Pediatric Eosinophilic Cystitis is an uncommon inflammatory disease associated with X-linked Chronic Granulomatous Disease (X-CGD)¹. We present a rare case of a teenage patient with refractory eosinophilic cystitis. <h3>Case Description</h3> Patient is a 14-year-old male with X-CGD, colitis, and complications from chronic steroid use, including bilateral cataracts, osteoporosis, and adrenal insufficiency. His colitis was well-controlled with vedolizumab when he presented for evaluation of new onset dysuria and intermittent scrotal pain that improved with voiding. Infectious workup was unrevealing. CT of abdomen and pelvis demonstrated asymmetric, irregular thickening, nodularity and enhancement of the left bladder wall and bladder base. Pathology from cystoscopy was significant for scattered eosinophils, suspicious for eosinophilic cystitis. He demonstrated mild peripheral eosinophilia (0.63 K/µL). He was started on intravesical dexamethasone 10mg, to minimize complications from systemic steroid use, and oral loratadine 5mg on intravesical treatment days. However, his symptoms did not resolve and intravesical dexamethasone was increased to 25mg then to 50mg. Loratadine was increased to 10mg daily. His bladder ultrasound normalized after 12 doses of intravesical dexamethasone and daily 10mg loratadine. Three weeks after loratadine was weaned to every other day, his urinary symptoms returned. Loratadine was increased to 10mg daily and he remained asymptomatic off steroids. <h3>Discussion</h3> Reported cases of pediatric eosinophilic cystitis are mostly in young children, only requiring a short course of intravesical steroids and oral antihistamine, unlike our patient^2,3. More research is needed to elucidate the history, optimal diagnosis and guide appropriate management of eosinophilic cystitis in pediatric X-CGD patients.

Evaluation of auto-segmentation for EBRT planning structures using deep learning-based workflow on cervical cancer

Deep learning (DL) based approach aims to construct a full workflow solution for cervical cancer with external beam radiation therapy (EBRT) and brachytherapy (BT). The purpose of this study was to evaluate the accuracy of EBRT planning structures derived from DL based auto-segmentation compared with standard manual delineation. Auto-segmentation model based on convolutional neural networks (CNN) was developed to delineate clinical target volumes (CTVs) and organs at risk (OARs) in cervical cancer radiotherapy. A total of 300 retrospective patients from multiple cancer centers were used to train and validate the model, and 75 independent cases were selected as testing data. The accuracy of auto-segmented contours were evaluated using geometric and dosimetric metrics including dice similarity coefficient (DSC), 95% hausdorff distance (95%HD), jaccard coefficient (JC) and dose-volume index (DVI). The correlation between geometric metrics and dosimetric difference was performed by Spearman’s correlation analysis. The right and left kidney, bladder, right and left femoral head showed superior geometric accuracy (DSC: 0.88–0.93; 95%HD: 1.03 mm–2.96 mm; JC: 0.78–0.88), and the Bland–Altman test obtained dose agreement for these contours (P > 0.05) between manual and DL based methods. Wilcoxon’s signed-rank test indicated significant dosimetric differences in CTV, spinal cord and pelvic bone (P < 0.001). A strong correlation between the mean dose of pelvic bone and its 95%HD (R = 0.843, P < 0.001) was found in Spearman’s correlation analysis, and the remaining structures showed weak link between dosimetric difference and all of geometric metrics. Our auto-segmentation achieved a satisfied agreement for most EBRT planning structures, although the clinical acceptance of CTV was a concern. DL based auto-segmentation was an essential component in cervical cancer workflow which would generate the accurate contouring.

Abordaje laparoscópico exitoso de lesión vesical intraperitoneal ocasionada durante una cirugía ginecológica. Reporte de caso

Introduction: Urinary tract injuries are common in the context of pelvic surgery; however, there is little information in the medical literature on the management of these injuries using a laparoscopic approach. The following is the clinical case of a patient with intraperitoneal bladder injury secondary to gynecological pelvic surgery that was successfully treated using a laparoscopic approach. Moreover, a management algorithm is proposed based on the scientific data available. Case report. A 39-year-old female patient was admitted to the hospital with generalized abdominal pain and anuria three days after undergoing a left laparoscopic salpingectomy and resection of a migrated intrauterine device. Laboratory tests showed microhematuria, serum creatinine of 4.35mg/dL, and urea nitrogen of 35.2mg/dL. Computed tomography cystography showed a solution of continuity on the left posterolateral intraperitoneal bladder. The patient underwent successful laparoscopic treatment for the bladder injury, and two weeks later, retrograde cystography confirmed its adequate resolution. Conclusions. Based on the benefits of the laparoscopic approach and after extrapolating the outcomes of the laparoscopic management of bladder trauma, it can be concluded that the laparoscopic approach to surgical injuries of the bladder is a feasible therapeutic option.

Intrarenal pseudoaneurysm after percutaneous nephrolithotomy: a case report

ABSTRACT Background: Percutaneous nephrolithotomy (PNL) is the gold standard to treat large or complex renal stones. Intrarenal pseudoaneurysm is a rare, yet clinically significant, complication of PNL. Case summary: A 58-year-old man with a 3 cm calculus in the lower calyx of the left kidney was operated on by PNL 3 days before presentation to the emergency department. The patient presented with massive hematuria and dizziness. Upon presentation, the patient appeared uncomfortable and in distress. He was in hemorrhagic shock. The patient was resuscitated with intravenous fluids and blood transfusion. An urgent computed tomography scan showed multiple clots in the left renal pelvis and bladder with a retroperitoneal hematoma. The patient underwent angiography which revealed an inferior pole branch pseudoaneurysm. The pseudoaneurysm was treated by endovascular embolization with N-butyl-2-cyanoacrylate. No postoperative complications were seen. Conclusion: Selective renal artery embolization is an effective treatment for pseudoaneurysm post PNL with excellent outcomes.

Presentation of Varicella-Zoster Virus Infection with Bladder Mass and Gross Hematuria

Varicella-zoster virus reactivation can cause painful and vesicular rashes involving some dermatomes, which is defined as herpes zoster. We reported a 68 years old man who had come to the clinic with a complaint of hematuria. In the examination, varicella-zoster lesions were visible on the left buttock. After beginning valacyclovir for the patient, cystoscopy was done due to the existing polypoid mass in sonography. Red patches, fragile and bleeding places were seen in the cystoscopy on the left bladder wall without any evidence of any mass. This patient was managed conservatively. One week after the first ultrasonography, new sonography by the same radiologist showed no evidence of bladder mass.

Robotic Approach to Ectopic Endometriosis in a Patient with Duplicated Ureters

<h3>Study Objective</h3> To demonstrate a minimally invasive approach to excision of ectopic urinary tract endometriosis in a patient with an anomalous duplicated left renal collecting system. <h3>Design</h3> Case report surgical video. <h3>Setting</h3> Single center academic institution. <h3>Patients or Participants</h3> A 45-year-old female with a history of endometriosis with prior robotic hysterectomy and left salpingo-oophorectomy presented with worsening urge incontinence, flank and pelvic pain. Patient was referred after evaluation revealed a mass adjacent to the left ureterovaginal junction and bladder trigone. <h3>Interventions</h3> Initial cystoscopy revealed a left non-intrusive bladder mass near the left ureteral orifices. A 2 cm firm, fixed nodule in the left fornix of the vagina was excised. Endometriosis was confirmed on frozen section. Upon laparoscopic entry, anatomy was noted to be distorted due to extensive scarring in the left pelvic sidewall including the vaginal cuff and bladder. The posterior cul-de-sac, pararectal, and paravesical spaces were then dissected open, allowing for visualization of the intersigmoid recess and the double ureters encased in scar tissue. After creating two small windows to open the peritoneum, continued dissection proceeded laterally along the pelvic sidewall. En bloc endometriosis was noted on the left infundibulopelvic ligament, vaginal cuff, bladder, and ureters. The scarred peritoneum was excised by encircling the affected areas. Concomitant ureteral dissection ensued with simultaneous removal of endometriotic nodules at the vaginal cuff and ureterovaginal junction. The patient then had an uncomplicated right salpingo-oophorectomy. <h3>Measurements and Main Results</h3> The patient was discharged home on postoperative day one and had an overall uncomplicated postoperative course. Final pathology was consistent with endometriosis. At her post-operative appointment, the patient experienced complete resolution of her symptoms. <h3>Conclusion</h3> In a patient with a known history of endometriosis and a newfound bladder mass, ectopic endometriosis should be considered. Robotic surgical excision is an appropriate minimally invasive approach after adequate preparation.