Urinary Tract Obstruction Research Articles

Value of Urine Neutrophil Gelatinase Associated Lipocalin for Prediction of Ureteropelvic Junction Obstruction in Children

Background: Congenital obstructive nephropathy is a significant cause of chronic kidney damage in childhood. Therefore, early diagnosis and management of urinary tract obstruction are necessary to prevent or reduce further renal damage. Various biomarkers have been investigated for the early identification of urinary tract obstruction. Objectives: The aim of this study was to evaluate the excretion of urine neutrophil gelatinase-associated lipocalin (Urine neutrophil gelatinase-associated lipocalin (uNGAL) & uNGAL/Cr) as a useful, sensitive, and non-invasive diagnostic biomarker in children with ureteropelvic junction obstruction (UPJO). Methods: The study cohort consisted of 47 children with obstructive UPJO and 47 healthy children with normal renal ultrasounds. Ultrasonography and 99mTc DTPA radionuclide scans were used for diagnosing UPJO. All affected children had normal renal function based on GFR measurements. Urine neutrophil gelatinase-associated lipocalin was measured using Immunoenzymatic ELISA commercial kits. Results: Urine neutrophil gelatinase-associated lipocalin & uNGAL/Cr levels were significantly higher in children with obstructive UPJO compared to the healthy control group. Additionally, both biomarkers demonstrated acceptable sensitivity and specificity for predicting for predicting UPJO. Conclusions: Based on these results, measuring uNGAL & uNGAL/Cr is suggested for evaluating children with obstructive UPJO.

Eosinophilic cystitis-an obscure case of obstructive uropathy in infancy.

We report on an infant with features of intermittent obstructive uropathy, acute kidney injury, hypertension and type 4 renal tubular acidosis (RTA) despite urethral catheterisation and fluid resuscitation. Radiological findings showed upper tract dilatation, likely bilateral vesicoureteric junction obstruction and bladder base thickening which was concerning for possible malignancy. Renal biopsy demonstrated eosinophilic infiltrate, suggestive of kidney involvement. Bladder biopsy was diagnostic for eosinophilic cystitis (EC) showing mature degranulating eosinophils. EC is a rare, easily treatable and important differential of bladder mass in children which may present with an atypical obstructive uropathy. This report adds to the limited literature of this condition within the paediatric population. EC should be considered early in children presenting with eosinophilia, urinary tract obstruction and kidney dysfunction, with uncertain aetiology. This case also highlights the need for detailed imaging, including visualisation of the bladder base, in cases of likely obstructive uropathy.

Etiological Profile and Short-Term Outcomes of Acute Kidney Injury in Term Neonates at a Tertiary Care Centre in Western Maharashtra, India.

Background Acute kidney injury (AKI) is characterized by a sudden decline in kidney function, leading to a reduced glomerular filtration rate (GFR). This decline results in the accumulation of nitrogenous waste products in the blood, disturbs electrolyte balance, and disruptsfluid regulation. Objective To determine the etiological profile of AKI in term neonates. Methods Aprospective observational study was conducted at the Neonatal Intensive Care Unit (NICU) of our tertiary care hospital and referral and teaching center. The study spanned a period of two years, from August 2022 to July 2024, and comprised a total of 78 term babies diagnosed with AKI, all of whom were enrolled after obtaining consent using a predefined proforma. The neonatal period was defined as the time from birth up to 44 weeks of postmenstrual age (PMA), encompassing a critical developmental phase in newborns. Results In our study of 78 term neonates with AKI, we found a predominant occurrence in males (53, 67.9%) and a significant proportion with low birth weights (41, 52.6%). The most common cause of AKI was sepsis or multiple organ dysfunction syndrome (MODS) (32, 41%), followed by perinatal hypoxia (14, 17.9%) and urinary tract obstructions (12, 15.3%). Urinary tract infections (UTIs) accounted for nine cases (11.5%), hypernatremic dehydration for six cases (7.6%), acute tubular necrosis for three cases (3.8%), and congenital polycystic kidney disease for two cases (2.9%). Mortality was notably high, with 20 neonates (25.7%) dying from AKI, particularly those with sepsis/MODS and perinatal hypoxia. However, conditions such as urinary tract obstructions and UTIs generally had better outcomes. The statistical analysis revealed a significant association between the underlying etiology and outcomes (p<0.001), underscoring the importance of prompt and targeted interventions for different AKI causes in neonates. Conclusion Our findings highlight the diverse etiological spectrum of AKI in term neonates and its significant impact on mortality. Early recognition, appropriate management, and targeted interventions tailored to the underlying cause are crucial in improving outcomes for neonates with AKI.

Lipidomic study of kidney in a mouse model with urine flow obstruction

Obstructed urine flow is known to cause structural and functional kidney damage leading to renal fibrosis. However, limited information is available on the change in kidney lipids during urinary tract obstruction. In this study, we investigated the change in lipidome in a mouse model with unilateral ureteral obstruction (UUO). The establishment of the UUO model was confirmed by histopathological examination using transmission electron microscopy. Untargeted liquid chromatography/mass spectrometry was carried out over a time course of 4 and 7 days. Compared to the sham control, the UUO kidney at 7 days showed dilatation of the renal tubule with loss of brush borders and thickening of the capillary endothelium. In the kidney lipidomes obtained from the UUO 7 days group compared to the control, a significant decrease of ceramide, sphingomyelin, phosphatidylcholine, lysophospholipids, and phosphatidylethanolamine was observed, whereas cholesteryl esters, free fatty acids, phosphatidylglycerol, and cardiolipins were significantly increased. The present study revealed the disturbed lipid metabolism in the UUO model, which may provide a clue to potential lipid pathways and therapeutic targets for the early stage of renal fibrosis.

Isolated posterior urethral valves (PUV) and anterior urethral valves (AUV) with and without concomitant PUV: Matched cohort study at a high-risk pediatric center

ObjectivesTo compare postnatal outcomes of AUV and PUV patients to evaluate for potential differences between these conditions, given that anterior urethral valves (AUV) with or without concomitant posterior urethral valves (PUV) is a rare congenital anomaly leading to lower urinary tract obstruction (LUTO). MethodsWe reviewed our LUTO database and included patients with AUV or concomitant AUV+PUV, managed at our institution between 2003 and 2023 matching them to comparable PUV cases. Assessed variables included prenatal diagnosis, gestational age (GA) at birth, initial management, kidney function, presence and degree of hydronephrosis (HN), and need for renal replacement therapy (RRT). ResultsThe AUV ± PUV group (AUV: n=11, concomitant PUV: n=2) and PUV group (n=26) had similar presenting ages and follow-up times (p>0.05). Only 15.4% of AUV cases presented prenatally compared to 72.0% of PUV cases (p=0.0016), leading to delayed postnatal management in AUV patients (p=0.0260). Findings at presentation included UTI, weak stream or a palpable penile mass. PUV patients demonstrated significantly higher creatinine levels at the initial visit and at last follow-up (p=0.0120 and p=0.0302) than the AUV ± PUV group, with only one patient requiring RRT (p>0.05). At the last follow-up, no patient in the AUV ± PUV group required clean intermittent catheterization compared to 37.5% in the PUV group (p=0.0331) which also demonstrated more patients with persistent HN (p=0.0039). ConclusionAUV with or without concomitant PUV is a rare finding that should be considered in patients presenting with weak stream, UTI, and penile swelling. Our data suggests potential differences in presentation and less severe postnatal outcomes in AUV compared to PUV patients.

Fetal Lower Urinary Tract Obstruction: Current Diagnostic and Therapeutic Strategies and Future Directions.

Fetal lower urinary tract obstruction (LUTO) is a rare congenital anomaly in which the bladder cannot empty properly. The clinical presentation is variable. On the severe end of the spectrum, the amniotic fluid index can be sufficiently low, resulting in fetal lung development that is incompatible with life outside the womb. The pressure in the urinary tract system can also result in severe damage to the kidney, resulting in renal failure in utero or in the first couple years of life. Therefore, much work has been done to determine which fetuses need intervention in utero to allow for survival outside of the womb and avoidance of end-stage renal disease. Multiple therapies have been developed to relieve the obstruction in utero with the mainstay being vesicoamniotic shunting and posterior urethral valve ablation. While much has been investigated to determine which fetuses would benefit from fetal intervention, the current indications are not without their flaws. This review describes the current indications and their shortcomings, as well as new experimental methods of determining need for intervention. Additionally, this review describes the milestone animal studies that established the challenges of current fetal interventions and the utility of an experimental valved shunt in sheep over the last 20 years. Our understanding of LUTO and which fetuses benefit from in utero intervention has grown over the last 20 years. However, traditional markers have proven to be less predictive than previously thought, opening the door to exciting new advances. Vesicoamniotic shunting, while lifesaving, does not preserve bladder function and frequently dislodges. Animal studies over the last 20 years have established the utility of a valved shunt to maintain bladder function. Current advances are working to create such a shunt that can be percutaneously deployed and have greater adherence to the bladder wall to avoid dislodgement.

Canadian Association of Radiologists Genitourinary Imaging Referral Guideline.

The Canadian Association of Radiologists (CAR) Genitourinary Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, family medicine, nephrology, and urology, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 22 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 65 recommendation statements across the 22 scenarios (2 scenarios point to the CAR Obstetrics and Gynecology Diagnostic Imaging Referral Guideline). This guideline presents the methods of development and the referral recommendations for haematuria, hypertension, renal disease (or failure), renal colic, renal calculi in the absence of acute colic, renal lesion, urinary tract obstruction, urinary tract infection, scrotal mass, or pain, including testicular torsion, adrenal mass, incontinence, urgency, and frequency, chronic pelvic pain, elevated PSA, infertility, and pelvic floor.

Risk stratification framework to improve the utility of renal ultrasound in acute kidney injury.

Acute kidney injury (AKI) is common among hospitalised patients and can lead to significant morbidity or mortality if not properly managed. Renal ultrasound (RUS) is often requested in the initial workup of AKI to rule out obstructive uropathy despite pre-renal aetiologies being implicated in most cases, especially in patients without risk factors for obstruction. Determine the utility of RUS in detecting bilateral hydronephrosis in the context of AKI, and identify risk factors that can be used to stratify patients to better guide patient management. Adults who underwent RUS for AKI between January 2019 and December 2021 were reviewed. Renal ultrasound studies that identified bilateral hydronephrosis and the patient characteristics associated with these studies were recorded. Seven hundred and fifty-eight RUS reports were included. Bilateral hydronephrosis was diagnosed in 43 patients (5.7%). Of these 43 patients, 39 (90.7%) had at least one risk factor for urinary tract obstruction. Bilateral hydronephrosis was only diagnosed in 4 (9.3%) patients without any risk factor for obstruction. The risk factors with the highest odds for being diagnosed with bilateral hydronephrosis included a history of previous ureteric stenting or nephrostomy tube insertion (OR 10.37), previous bilateral hydronephrosis (OR 14.56), or multiple risk factors (OR 23.06). Renal ultrasound has limited utility in the evaluation of AKI in low-risk patients. These risk factors can be used to assign patients to high- or low-risk categories to better guide management and reduce the number of unnecessary studies performed while still identifying clinically significant disease.

Initial Experience With Inpatient Hospital Care at Home for Urologic Disease.

In 2020, Mayo Clinic launched Advanced Care at Home (ACH), a hospital-at-home program that cares for high-acuity inpatients via remote monitoring and in-person care. Herein, we describe our initial experience utilizing ACH for patients with urologic problems. We identified ACH patients treated at Mayo Clinic Florida from July 2020 to August 2022. Records were reviewed to identify those with urologic problems, defined as genitourinary infections, urinary tract obstruction, bleeding, or complications following urologic surgery within 90 days of admission. Demographics, Charlson Comorbidity Index, ACH interventions, length of stay, and hospital readmission were assessed. We identified 563 ACH admissions involving 537 patients, of whom 51 (9%) had illnesses with urologic etiology and 3 (0.6%) were admitted for nonurologic postoperative complications following urologic surgery. Admitting diagnoses included pyelonephritis (n = 51, 91%) and epididymoorchitis (n = 2, 4%). Postoperative diagnoses included cellulitis (n = 1, 2%), congestive heart failure (n = 1, 2%), and diverticulitis (n = 1, 2%). Median Charlson Comorbidity Index of admitted patients was 4 (interquartile range: 3-6.8). Twenty-five patients (46%) underwent 38 urologic procedures within 90 days of admission. Interventions included IV antibiotics (n = 51, 91%), IV fluids (n = 12, 21%), IV antifungals (n = 2, 4%), and oral diuretic therapy (n = 1, 2%). Median length of stay was 3 days (interquartile range: 2-4), and 9 patients (16%) were readmitted within 30 days. A total of 216 inpatient hospital days were saved by utilizing ACH. ACH appeared to be a feasible alternative to brick-and-mortar inpatient care for patients with genitourinary infections requiring IV antimicrobials.

Obstructive or non-obstructive megacystis: a prenatal dilemma.

Diagnosis of prenatal megacystis has a significant impact on the pregnancy, as it can have severe adverse effects on fetal and neonatal survival and renal and pulmonary function. The study aims to investigate the natural history of fetal megacystis, to try to differentiate in utero congenital lower urinary tract obstruction (LUTO) from non-obstructive megacystis, and, possibly, to predict postnatal outcome. A retrospective single-center observational study was conducted from July 2015 to November 2023. The inclusion criteria were a longitudinal bladder diameter (LBD) >7 mm in the first trimester or an overdistended/thickened-walled bladder failing to empty in the second and third trimesters. Close ultrasound follow-up, multidisciplinary prenatal counseling, and invasive and non-invasive genetic tests were offered. Informed consent for fetal autopsy was obtained in cases of termination of pregnancy or intrauterine fetal demise (IUFD). Following birth, neonates were followed up at the same center. Patients were stratified based on diagnosis: LUTO (G1), urogenital anomalies other than LUTO ("non-LUTO") (G2), and normal urinary tract (G3). This study included 27 fetuses, of whom 26 were males. Megacystis was diagnosed during the second and third trimesters in 92% of the fetuses. Of the 27 fetuses, 3 (11.1%) underwent an abortion, and 1 had IUFD. Twenty-three newborns were live births (85%) at a mean gestational age (GA) of 34 ± 2 weeks. Two patients (neonates) died postnatally due to severe associated malformations. Several prenatal parameters were evaluated to differentiate patients with LUTO from those with non-LUTO, including the severity of upper tract dilatation, keyhole sign, oligohydramnios, LBD, and GA at diagnosis. However, none proved predictive of the postnatal diagnosis. Similarly, none of the prenatal parameters evaluated were predictive of postnatal renal function. The diagnosis of megacystis in the second and third trimesters was associated with live births in up to 85% of cases, with LUTO identified as the main cause of fetal megacystis. This potentially more favorable outcome, compared to the majority reported in literature, should be taken into account in prenatal counseling. Megacystis is an often misinterpreted antennal sign that may hide a wide range of diagnoses with different prognoses, beyond an increased risk of adverse renal and respiratory outcomes.

Congenital Risk Factors for Chronic Kidney Disease in Patients With Persistent Cloaca: Results From a Nationwide Survey in Japan

BackgroundWe conducted a nationwide survey of persistent cloaca (PC) to investigate the renal function outcomes and factors affecting chronic kidney disease (CKD) in patients with PC. MethodInformation from 466 patients with PC was obtained via a questionnaire in this study. The 290 patients (62.2%) with renal function data were classified into 2 groups based on their estimated glomerular filtration rate: advanced CKD group (<30 mL/min/1.73 m2 [or post-renal replacement therapy]) and non-advanced CKD group (≥30 mL/min/1.73 m2). Univariate and multivariate analyses were performed to identify risk factors for CKD that may affect the renal function, including renal and urinary tract malformations, associated anomalies, and urinary tract treatment. The advanced CKD group was divided into two groups based on age to evaluate age-related differences (younger- and older-age CKD groups). ResultsA regression analysis revealed that congenital renal malformations (odds ratio [OR]: 14.06, 95% confidence interval [CI]:3.07–131.65, p < 0.0001), urinary tract obstruction (OR:4.28, 95%CI:1.12–24.23, p < 0.05), and sacral agenesis (OR:4.54, 95% CI:0.84–30.67, p < 0.05) were significantly associated with advanced CKD. In the univariate analysis of factors affecting the renal prognosis, clean intermittent catheterization (CIC) (OR:4.18, 95%CI:1.21–16.45, p = 0.015), vesicostomy (OR:3.65, 95%CI:1.11–12.98, p = 0.019), and surgery for vesicoureteral reflux (OR:5.43, 95%CI:1.41–22.73, p = 0.006) were significantly associated with advanced CKD. Based on the univariate analysis, hydrometrocolpos was significantly more prevalent in the older-age CKD group compared to the younger-age CKD group (p < 0.05). ConclusionCKD development in patients with PC is influenced by a complex interplay of factors, including renal malformations and neurogenic bladder dysfunction due to spinal anomalies. Level of EvidenceIII (Study of Diagnostic Test, Study of nonconsecutive patients, and/or without a universally applied “gold” standard).

Radiologic feature of complications after artificial urinary sphincter implantation following total prostatectomy.

Incontinence following total prostatectomy for prostate cancer significantly impairs patient's quality of life. In severe cases, implantation of an artificial urinary sphincter (AUS) has shown favorable outcomes, enhancing continence by constricting the bulbous urethra. The AUS system consists of a pressure-maintaining balloon, control pump serving as the operational switch, cuff that constricts the urethra, and tubes and connectors that link these components, maintaining a continuous circuit through an internal pressure medium. Most instances of AUS dysfunction are attributed to circuit leaks leading to a reduction in internal pressure, which is identifiable on imaging by fluid accumulation around the circuit, balloon collapse, control pump deformation, and air within the circuit. When the AUS circuit is uncompromised, dysfunction may arise from issues such as the inability to compress the pump due to pain or displacement outside the scrotum or urinary tract obstruction caused by bladder hemorrhage/hematoma. Imaging plays a pivotal role in the evaluation of urinary tract injuries, hematomas/seromas, and infections associated with AUS placement or replacement. Understanding the function of AUS and its appearance on CT imaging is essential for accurately assessing AUS dysfunction and post-implantation complications, guiding clinical decision-making and improving patient care outcomes.

Impact and Safety of Diagnostic Stewardship to Improve Urine Culture Testing Among Patients with Indwelling Urinary Catheters

Background: Indiscriminate urine culturing of patients with indwelling urinary catheters may lead to overdiagnosis of urinary tract infections, resulting in unnecessary antibiotic treatment and inaccurate reporting of catheter-associated urinary tract infections (CAUTIs) as a hospital quality metric. We evaluated the impact of a computerized diagnostic stewardship intervention to improve urine culture testing among patients with indwelling urinary catheters. Methods: We performed a single-center retrospective observational study at Rush University Medical Center from April 2018 – July 2023. In February 2021, we implemented a computerized clinical decision support tool to promote adherence to our internal urine culture guidelines for patients with indwelling urinary catheters. Providers were required to select one guideline criteria: 1) neutropenia, 2) kidney transplant, 3) recent urologic procedure, 4) urinary tract obstruction; or if none of the criteria were met, then an infectious diseases consultation was required for approval. We compared facility-wide CAUTI rate per 10,000 catheter days and standardized infection ratio (SIR) during baseline and intervention periods using ecologic models, controlling for time and for monthly Covid-19 hospitalizations. In the intervention period, we evaluated how providers responded to the intervention. Potential harm was defined as collection of a urine culture within 7 days of the intervention that resulted in a change in clinical management. Results: In unadjusted models, CAUTI rate decreased from 12.5 to 7.6 per 10,000 catheter days (p=0.04) and SIR decreased from 0.77 to 0.49 (p=0.09) during baseline vs intervention periods. In adjusted models, the CAUTI rate decreased from 6.9 to 5.5 per 10,000 catheter days (p=0.60) (Figure 1) and SIR decreased from 0.41 to 0.35 (p=0.65) during baseline vs intervention periods. Urine catheter standard utilization ratio (SUR) did not change (p=0.36). There were 598 patient encounters with ≥1 intervention. Selecting the first intervention for each encounter, 284 (47.5%) urine cultures met our guidelines for testing and 314 (52.5%) were averted (Figure 2). Of these, only 3 ( &lt; 1 %) had a urine culture collected in the subsequent 7 days that resulted in change in clinical management. Conclusion: We observed a trend of decreased CAUTIs over time, but effect of our diagnostic stewardship intervention was difficult to assess due to healthcare disruption caused by Covid-19. Adverse outcomes were rare among patients who had a urine culture averted. A computerized clinical decision support tool may be safe and effective as part of a multimodal program to reduce unnecessary urine cultures in patients with indwelling urinary catheters.

Detection of non-cardiac fetal abnormalities on ultrasound at 11-14 weeks: systematic review and meta-analysis.

To assess the diagnostic accuracy of two-dimensional ultrasound at 11-14 weeks' gestation as a screening test for individual fetal anomalies and to identify factors impacting on screening performance. This was a systematic review and meta-analysis that was developed and registered with PROSPERO (CRD42018111781). MEDLINE, EMBASE, Web of Science Core Collection and the Cochrane Library were searched for studies evaluating the diagnostic accuracy of screening for 16 predefined, non-cardiac, congenital anomalies considered to be of interest to the early anomaly scan. We included prospective and retrospective studies from any healthcare setting conducted in low-risk, mixed-risk and unselected populations. The reference standard was the detection of an anomaly on postnatal or postmortem examination. Data were extracted to populate 2 × 2 tables and a random-effects model was used to determine the diagnostic accuracy of screening for the predefined anomalies (individually and as a composite). Secondary analyses were performed to determine the impact on detection rates of imaging protocol, type of ultrasound modality, publication year and index of sonographer suspicion at the time of scanning. Post-hoc secondary analysis was conducted to assess performance among studies published during or after 2010. Risk of bias assessment and quality assessment were undertaken for included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. From 5684 citations, 202 papers underwent full-text review, resulting in the inclusion of 52 studies comprising 527 837 fetuses, of which 2399 were affected by one or more of the 16 predefined anomalies. Individual anomalies were not equally amenable to detection on first-trimester ultrasound: a high (> 80%) detection rate was reported for severe conditions, including acrania (98%), gastroschisis (96%), exomphalos (95%) and holoprosencephaly (88%); the detection rate was lower for open spina bifida (69%), lower urinary tract obstruction (66%), lethal skeletal dysplasias (57%) and limb-reduction defects (50%); and the detection rate was below 50% for facial clefts (43%), polydactyly (40%) and congenital diaphragmatic hernia (38%). Conditions with a low (< 30%) detection rate included bilateral renal agenesis (25%), closed spina bifida (21%), isolated cleft lip (14%) and talipes (11%). Specificity was > 99% for all anomalies. Secondary analysis showed that detection improved with advancing publication year, and that the use of imaging protocols had a statistically significant impact on screening performance (P < 0.0001). The accurate detection of congenital anomalies using first-trimester ultrasound is feasible, although detection rates and false-positive rates depend on the type of anomaly. The use of a standardized protocol allows for diagnostic performance to be maximized, particularly for the detection of spina bifida, facial clefts and limb-reduction defects. Highlighting the types of anomalies amenable to diagnosis and determining factors enhancing screening performance can support the development of first-trimester anomaly screening programs. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Implications of Genetic Factors Underlying Mouse Hydronephrosis: Cautionary Considerations on Phenotypic Interpretation in Genetically Engineered Mice.

Hydronephrosis, the dilation of kidneys due to abnormal urine retention, occurs spontaneously in certain inbred mouse strains. In humans, its occurrence is often attributed to acquired urinary tract obstructions in adults, whereas in children, it can be congenital. However, the genetic factors underlying hydronephrosis pathogenesis remain unclear. We investigated the cause of hydronephrosis by analyzing tetraspanin 7 (Tspan7) gene-modified mice, which had shown a high incidence of hydronephrosis-like symptoms. We found that these mice were characterized by low liver weights relative to kidney weights and elevated blood ammonia levels, suggesting liver involvement in hydronephrosis. Gene expression analysis of the liver suggested that dysfunction of ornithine transcarbamylase (OTC), encoded by the X chromosome gene Otc and involved in the urea cycle, may contribute as a congenital factor in hydronephrosis. This OTC dysfunction may be caused by genomic mutations in X chromosome genes contiguous to Otc, such as Tspan7, or via the genomic manipulations used to generate transgenic mice, including the introduction of Cre recombinase DNA cassettes and cleavage of loxP by Cre recombinase. Therefore, caution should be exercised in interpreting the hydronephrosis phenotype observed in transgenic mice as solely a physiological function of the target gene.

Urinary Tract Obstruction Secondary to Fungal Balls: A Systematic Review

Objectives: To understand the clinical characteristics, risk factors, diagnosis, treatment, and outcomes of urinary tract obstruction caused by fungal balls. Materials and Methods: A comprehensive search was conducted across PubMed, Embase, and Medline following the PRISMA guidelines, including case reports and case series. Study quality and risk of bias were assessed using the Oxford Centre for Evidence-Based Medicine (CEBM) document. The systematic review process was aimed at gathering and synthesising all available research evidence on the topic. Results: We included 54 articles reporting on 57 patients, primarily males (61.4%) with a median age of 56 years. The most common presenting symptoms were flank pain (71.9%) and fevers (59.6%). All diagnoses were made on the presence of yeast in urine or intra-operative tissue cultures and the presence of obstruction on imaging. The most common pathogen isolated were those of the Candida species (61.5%) followed by Aspergillus (33.3%). Multimodal management was the mainstay approach with the use of systemic and local antifungal therapy in combination with surgical drainage of the obstruction. The mortality rate was around 12.3%. Conclusions: Management of renal or ureteral obstruction caused by fungal balls requires a multimodal and multidisciplinary approach, comprising systemic antifungal therapy, drainage procedures, and in some instances, surgical intervention. The growing prevalence of antifungal resistance and the high mortality potential of fungal uropathy necessitates ongoing research into the optimal diagnostic and treatment modalities for this condition.

Robotic bladder diverticulectomy with concurrent management of bladder outlet obstruction: A choice to consider.

Acquired bladder diverticula (BD) are associated with bladder outlet obstruction. The aim of our study is to analyse the improvement in lower urinary tract symptoms (LUTS) in patients who underwent robot-assisted bladder diverticulectomy (RABD) combined with transurethral prostatectomy (TURP). A prospectively single-centre, single surgeon cohort of four patients with posterolateral BD due to bladder outlet obstruction (BOO) undergoing RABD combined with TURP between 2018 and 2023 was analysed. Median age and maximum BD diameter were 73.5 years and 16 cm, respectively. All patients had severe LUTS and elevated postvoid residual (PVR). Preliminary uroflowmetry revealed bladder outlet obstruction with a median of maximum urine flow rate of 8.5 ml/s. The median operative time and blood loss were 212 min and 100 ml, respectively. No intraoperative complications were recorded. The median length of stay was 4 days. The International Prostate Symptom Score (IPSS) and PVR were compared between baseline, 1 month and 6 months after surgery. IPSS significantly decreased from 24 (IQR 24-25) preoperatively compared to the postoperative, at 1 month follow up 7 (IQR 6-8) (p < 0.0001). PVR significantly decreased too from 165 (IQR 150-187) to 35 ml (IQR 25-42) (p < 0.0001). In transitioning from the 1-month follow-up to the 6-month follow-up, no substantial statistical improvement was observed. Concomitant performance of TURP with RABD is feasible and safe. Diverticulectomy in addiction at the endoscopic procedure should be discussed with patients who have obstructive lower urinary tract symptoms as viable alternative to single procedure individually performed.

COMPARISON OF SUCCESS OF EXTRACORPOREAL LITHOTRIPSY (ESWL) AND LASER URETERORENOSCOPY IN PROXIMAL URETERIC STONES

Managing ureteral stones to achieve complete stone clearance with minimal patient morbidity involves several therapeutic approaches. The commonly used methods include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), percutaneous nephrolithotripsy, laparoscopic ureterolithotomy, and open ureterolithotomy. However, definitive evidence-based options for managing large proximal ureteral stones are lacking. Objective: To compare extracorporeal shock wave lithotripsy (ESWL) and laser ureterorenoscopy (URS) success rates in treating proximal ureteric stones. Methods: This randomized controlled trial was conducted in the Department of Urology &amp; Renal Transplantation at Bahawal Victoria Hospital, Bahawalpur, from January 1, 2020, to May 31, 2021. One hundred four patients, aged 20 to 60, with single proximal ureteric stones measuring 8-15 mm, were included. Patients with pyonephrosis, sepsis, bleeding disorders, solitary kidney, previous open ureterolithotomy, chronic renal failure, proteinuria, recurrent urinary tract infections, congenital urinary tract obstruction, bladder outflow obstruction, chronic liver disease, or a history of chronic drug usage were excluded. Patients were randomized into two groups: Group A underwent URS lithotripsy with DJ stent placement, while Group B underwent ESWL with DJ stent placement. A single surgeon performed all procedures. Pre-operative antibiotics and analgesics were administered to all patients. Stone clearance was assessed two weeks post-procedure. Statistical analysis was performed using appropriate methods, with a p-value ≤ 0.05 considered significant. Results: The mean age of patients in Group A was 37.52 ± 11.20 years, and in Group B was 36.73 ± 10.57 years. Most patients (75, 72.12%) were between 20 and 40. Out of the 104 patients, 63 (60.58%) were male, and 41 (39.42%) were female, with a male-to-female ratio of 1.7:1. Complete stone clearance was achieved in 44 (84.62%) patients in Group A (URS group) and 30 (57.69%) patients in Group B (ESWL group), with a statistically significant p-value of 0.002. The study concluded that the stone clearance rate after laser ureterorenoscopy (URS) is significantly higher than extracorporeal shock wave lithotripsy (ESWL) for proximal ureteric stones.

#1689 Urosepsis and hypovolemia—the main causes of AKI in nursing home residents

Abstract Background and Aims Nursing home residents are at high risk for acute kidney injury (AKI) due to increased prevalence of comorbidities, prolonged immobilization in bed and altered cognitive function. As our nephrology department is confronted with high addressability of institutionalized adults with kidney impairment, we considered describing the epidemiology of AKI and risk factors for AKI-related mortality in this population. Method All adult patients admitted with AKI (KDIGO creatinine-based diagnostic criteria) in our nephrology department during a 6 months period (1st January-30th June 2023) were included in this study. Patients’ data (age, gender, comorbidities) and AKI-related data (causes, need for dialysis recovery of renal function, death) were compared between institutionalized and non-institutionalized patients. Factors associated with increased risk of death in AKI in nursing home residents were also analyzed. All the data was analyzed using IBM SPSS Statistics 25 (IBM, Corp.); the results were considered significant at P &amp;lt; 0.05. Results During the mentioned period a total of 297 patients with AKI were hospitalized: 57 nursing home residents (19.19%) and 240 patients with community-acquired AKI. The nursing-home residents were significantly older, female gender prevailed and history of stroke was significantly higher than in patients with community-acquired AKI (Table 1); no significant differences were found regarding prevalence of diabetes, chronic heart failure or previous chronic kidney disease. Chronic immobilization in bed was present in all institutionalized patients and in 21 patients with community acquired-AKI (8.75%). Multifactorial AKI, dehydration with hypovolemia and urosepsis were significantly more frequent in nursing-home residents, but there were no differences regarding other causes of AKI (Table 1). Increased prevalence of urosepsis in institutionalized patients was not associated with higher frequency of obstruction of urinary tract. Compared with community-acquired AKI, ICU admission and evolution with multiple organ failure were significantly more frequent in institutionalized patients with AKI, but there were no significant differences regarding the need for hemodialysis/hemodiafiltration, nor regarding the recovery of renal function in survivors. Analyzing factors associated with death in nursing home residents, we found that prolonged hospital stay, ICU admission, sepsis and multiorgan failure were associated with increased risk of in-hospital death (Table 2). Conclusion AKI in chronic institutionalized patients is mainly caused by dehydration and/or non-obstructive urosepsis, is often multifactorial and it is associated with increased risk of multiorgan failure, ICU admission and death. An early recognition and a better awareness of these risk factors in nursing homes can improve the epidemiology and the outcome of this severe disease.

Advancement of 3D printing technology for the development of a training model in US-guided vesicoamniotic shunting for early LUTO therapy.

Prenatal lower urinary tract obstruction (LUTO) is a rare and challenging condition with potential severe morbidity and mortality. Prenatal shunting methods, specifically vesicoamniotic shunting (VAS) and fetal cystoscopy, aim to manage this condition. However, comprehensive education and training are hindered by the rarity of LUTO. To address this gap, we present a low-cost 3D-printed ultrasound training model for VAS in LUTO fetuses. The aim of the study was to evaluate ultrasound and haptic fidelity of the model. Ultrasound images of three LUTO fetuses at 12-14 weeks were utilized to create detailed 3D-printed models. Fusion360TM software generated stereo-lithography files, and the Formlabs Form3® printer, using Flexible 80A resin, produced the models. A simulation box mimicking uterine conditions and fetal anatomy was developed for testing. Ultrasound assessments determined model accuracy, and expert evaluations gauged fidelity for VAS placement. The 3D-printed model accurately replicated LUTO fetal anatomy, demonstrating structural integrity and realistic sonographic and haptic feedback during 20 punctures. Macroscopic visualization confirmed the model's durability and authenticity. This innovative 3D-printed model addresses the scarcity of LUTO cases and the lack of realistic training tools. Simulation models enhance skills, providing a controlled learning environment that bridges theoretical knowledge and clinical application, potentially improving patient outcomes. The 3D-printed training model for VAS in LUTO represents a significant advancement in surgical education, offering realistic anatomical simulation and tactile feedback. Future studies should assess its effectiveness in enhancing surgical skills and impacting patient outcomes in clinical practice.