Minimally invasive procedures for urological disorders in pregnant patients: our experience

Background: Urological disorders like stone disease, pyonephrosis secondary to obstruction and trauma are common during pregnancy with global incidence of 1 in 250 to 1 in 3000. These diseases can complicate any pregnancy and timely diagnosis and management is of utmost importance for safety of the mother and fetus. Managing these cases entails morbidity and minimally invasive procedures avoiding anesthesia have definite advantage.Methods: It was an observational study. Pregnant patients with nephrolithiasis, pyonephrosis, complicated post-traumatic ureteropelvic junction (PUJ) obstruction (PUJO) and trauma were included in the study.Results: Out of total 84 cases, 45 required intervention. Percutaneous nephrostomy (PCN) for pyonephrosis secondary to PUJO and obstructed PUJ calculus was done in 11 and 14 cases respectively. Bilateral PCN for bilateral nephrolithiasis was done in 7 cases. Silicon double-J stenting for ureteric calculus was done in 13 cases. One case of spontaneous fornicial rupture of kidney without stone disease was managed conservatively as were 4 cases of trauma with concomitant renal injury, 18 cases of non-obstructive renal stones and 16 cases of pyelonephritis. Seven patients lost follow-up. One case each of pyonephrosis and polytrauma had fetal death at term unrelated to urological cause. In rest 75 patients, primary pathology was tackled after 6-8 weeks of delivery.Conclusions: Urological diseases during pregnancy are not an uncommon entity and can pose risk to both mother and fetus. With good clinical vigil, use of minimally invasive procedures, close monitoring and follow up, these patients can be safely managed without any adverse events to the fetus and mother.

A retrospective study on maternal and perinatal outcome in pregnancy requiring DJ stent and PCN during pregnancy

Background: Gestational hydronephrosis (GH) is result of dilatation effect of the progesterone and mechanical compression of the gravid uterus. Management during pregnancy is challenging as routine radiological investigations and surgical treatments cannot be applied due to the potential harm to the fetus. Intervention is indicated in women who fail to respond to conservative management. Acute hydronephrosis and renal colic are common etiologies for loin pain, and can lead to severe form of urinary tract infection affecting perinatal outcome. Ureteric stenting and percutaneous nephrostomy (PCN) during pregnancy are safe, requiring no intra-operative imaging, and inserted under local anaesthesia. It provides good symptom relief, low complication rate, efficient and safe modality for women with refractory symptoms.Methods: A retrospective study of pregnant women admitted under obstetric units with acute hydronephrosis requiring DJ stenting and/or PCN. Aim was to evaluate the course and pregnancy outcomes in a tertiary center of Southern India over a period of five years.Results: Descriptive statistical analysis was done in 12 women with acute hydronephrosis in pregnancy. 66.7% were nulliparous and mean gestational age at admission was 31 weeks. Diagnosis was done by USG. One-fourth had pyelonephritis and calculus being the main pathology (n=9;75%).Women requiring DJ stent and PCN were 41.6% and 58.4% respectively. 41.7% had preterm labour. 66.7% delivered vaginally, birth weight was more than 2.5kg in 50%.Conclusions: Maternal and neonatal outcome mainly depends on the early diagnosis. In this study we emphasize on the importance of multidisciplinary team approach in the management of women with acute hydronephrosis. DJ stent and PCN are efficient and safe modalities in women with refractory symptoms.

The evaluation of safety and efficacy of percutaneous nephrostomy in young adult patients with severe hydronephrosis due to uretropelvic junction obstructions

Background: Majority of poorly functioning kidney (PFK) due to primary ureteropelvic junction obstructions (UPJO) in young adult have potential to recover after an attempted percutaneous nephrostomy (PCN). The split renal function measured by nuclear renal scan may not be sufficient enough to predict recovery of such kidney. Therefore, this study was undertaken to determine the functional recovery and potential salvageability of PFK due UPJO. Objective of the study was to evaluate safety and efficacy of PCN in adult patients with severe hydronephrosis due to PUJO.Methods: A total of 25 (10 male and 15 female) young adult patients of severe hydronephrosis due to PUJO and SRF<20% underwent PCN procedures. Only, those who had significant improvement in their SRF ≥10% and developed PCN output ≥400 ml/day underwent Anderson-Hyenas pyeloplasty and rest underwent nephrectomy.Results: Both male and female young patients had significantly improvement after 6 weeks of PCN, their mean pre-PCN SRF changed from 16.30% and 12.27% to became 28.10±08.41% and 18.53±09.89%, respectively. Those with age <30 years improved most with ≥10% increase in the mean SRF and in 72% patients average PCN output increased from 279.80±93.90 ml/day to 445.20±160.341 ml/day at 6 weeks period. Overall, the patients with average PCN output ≥400 ml/day had a mean improvement of 10.33±05.48% in SRF. However, 5(20%) developed haematuria, 8% fever, 16% displaced PCN tip with no major puncture site bleed.Conclusions: The trial of PCN before definite surgery in young adult patients with poorly functioning kidney due to UPJO not only predicts renal renal function recovery but also prevent unwarranted renal loss.

A Imunologia no segundo segmento do Ensino Fundamental Brasileiro / The Immunology in Brazilian Middle School

O presente trabalho apresenta uma pesquisa bibliográfica documental sobre a Imunologia no 2º segmento do Ensino Fundamental (EF) brasileiro. Foram realizados levantamentos em quatro bases de dados e no site de busca Google acadêmico. Ademais, foram realizadas análises interpretativas da Lei de Diretrizes e Bases da Educação e dos Parâmetros Curriculares Nacionais(PCN), visando à identificação da inserção do tema Imunologia nos documentos oficiais que norteiam a educação brasileira. Foram encontrados 21 artigos relacionados ao ensino de Imunologia. Contudo, somente um desses tratava do ensino de Imunologia no EF. Nos PCN, foi verificada a presença da recomendação do ensino do tema com uma abordagem "bélica". Consideramos que, apesar da contemporaneidade e relevância do tema para a formação do cidadão, há pouca investigação sobre a inserção da Imunologia no contexto investigado e sobre o ensino e a aprendizagem do tema

This paper presents a literature search ofdocuments about Immunology in the Brazilian Middle School (MS). Surveys were conducted by using the databases SciELO, PubMed, Science Direct and BVS and the search web site Google scholar, aiming at identifying scientific papersrelated to the teaching of Immunology and the approach given to this fi eld of knowledge in the literature. Further analyses of the Brazilian law and basic guidelines and the Nati onal CurricularParameters (NCP) were conducted, in order to identify the insertion of the topic in the documents that guide the Brazilian education. We found 21 items related to the teaching of immunology. However, only one of these was about the teachingof Immunology in MS. In PCN, we found the recommendation of the teaching of this subject by means of a "war" attitude. Such approach becomes as an epistemological obstacle preventing a broad understanding of immunology in the context ofthe whole organism. We conclude that, despite the contemporary aspect and the importance of the theme for citizenship development, there is scare research on the inserti on of immunology in the investi gated context and in the context of teaching and learning of this subject

Urinothorax - A Rare Cause of Pleural Effusion.

Urinothorax is a rare cause of pleural effusion, which is mostly seen secondary to obstructive uropathy. We report a patient who had nephrolithasis and underwent percutaneous nephrostomy for treatment of hydroureteronephrosis. The patient developed right-sided pleural effusion, five days after percutaneous nephrostomy, which was later diagnosed as urinothorax. Although rare, urinothorax should be considered in the differential diagnosis of causes of pleural effusion, especially in patients with obstructive uropathy, any form of instrumentation of urinary tract or blunt abdominal trauma.The importance of recognizing this entity lies in the fact that the condition is completely reversible following relief of urinary tract obstruction.

Pregnane X Receptor agonist Increases the Expression Levels of the Plasma Membrane Monoamine Transporter

We evaluated the effect of the pregnane X receptor agonist, pregnenolone 16 alpha-carbonitrile (PCN) on the expression levels of plasma monoamine transporter (PMAT) in the intestine. Male C57/BL6 mice were divided into two 2 groups: mice in the PCN group (n=3) were administered PCN once a day for 4 days, while those in the control group (n=3) received the same volume of vehicle once a day for 4 days. After the mice were killed 24 h after administration of the last dose of PCN or vehicle, and the expression levels of PMAT in the intestine tissues were isolated and measured the expression level of PMAT using immunohistochemical and western blotting analyses. The expression level of PMAT expression levels in the small intestine increased after PCN treatment. These results suggest that the induction of PMAT may play a clinically significant role by increasing intestinal absorption of PMAT substrates such as metformin.

Diagnostic Significance of the CEA, AgNORs and PCNA in the Gastric Dysplasia and Adenocarcinoma

This study aimed to differentiate gastric mucosal lesions such as the inflammatory gastric mucosa, gastric dysplasia and adenocarcinoma, using the CEA(carcinoembryonic antigen), AgNORS(Nucleolar organizer regions) and PCNA(proliferating cell nuclear antigen) stains. The tissue samples were taken from 30 cases of inflammatory gastric mucosa (19 gastritis and 11 regenerative hyperplasia), 28 cases of gastric dysplasia (9 mild dysplasia, 10 moderate dysplasia and 9 severe dysplasia) and 21 cases of gastric adenocarcinoma. The CEA was expressed in 16 of 21 adenocarcinomas(76%), but in neither inflammatory nor dysplastic gastric mucosae. The mean number of AgNORs per nucleus was 1.54 in inflammatory gastric mucosa, 1.80 in gastric dysplasia, and 1.88 in adenocarcinoma. The number of AgNORs was increased in dysplasia and adenocarcinoma compared to the inflammatory gastric mucosa without statistical significance. The percentage of the PCN A positive cells was 35.2% in inflammatory gastric mucosa, 44.1 % in gastric dysplasia, and 69.0% in gastric adenocarcinoma. The positivity of the PCNA was significantly increased in adenocarcinoma compared to the inflammatory gastric mucosa and dysplasia. In conclusion, the frequency of the CEA positive staining was increased in the gastric adenocarcinoma, and so CEA stain will be able to provide an additive method for the differential diagnosis between severe dysplasia and adenocarcinoma of the stomach.

Expression of Trans forming Growth Factor-a and Proliferating Cell Nuclear Antigen in Human Gliomas

To evaluate the expression of transforming growth factor-alpha(TGF-alpha) and proliferating cell nuclear antigen(PCNA) and its relation to the differentiation of the tumors, immunohistochemical studies were performed in 49 human gliomas. Tumors were graded by a 3-grade-system; grade I=low grade glioma, grade Il=anaplastic glioma, grade III=glioblastoma multiforme. TGF-A and PCNA were predominantly expressed in malignant gliomas compared with benign gliomas. Malignant gliomas revealed 87% TGF-A reactivity, while benign gliomas revealed 26% TGF-A reactivity. The proliferation index with PCNA was 26%+/-7%(mean+/-standard deviation) in malignant gliomas and 5%?% in benign gliomas. A strong positive correlation between tumor grade and extent of TGF-A and PCNA expression was found(P<0.0001, Chi square and P<0.002, T-test). Synchronous expression of TGF-A and PCNA was observed in 16 cases(33%). The results of this study support the suggestion that the expression of TGF-A might be a useful prognostic indicator in human gliomas.

Percutaneous Nephrostomy in Patients with Ureteral Obstruction Secondary to Pelvic Tumor / 대한비뇨기과학회지

Percutaneous nephrostomy was done in 18 cases for ureteral obstruction secondary to advanced pelvic malignancy from Jan.1990 to Apr.1993. The most common site of the primary malignancy was cervix ( 77% ). The mean survival time after diversion was 4.2 months ; 22.2% (4/18) of the patients lived more than 6 months, and 1 patient is alive at 4 months. In 4 patients the renal function was not improved, whose mean survival time was 1.4 months. We consider that close. periodic follow-up is mandatory to detect the ureteral obstruction in patients With malignant pelvic tumor and early management may improve the survival time. The patients who had previously urinary diversion for unilateral ureteral obstruction should be evaluated periodically for contralateral renal function. However, the exact criteria for the selection of patients for urinary diversion is, not obvious.

Nephropexy Using Percutaneous Nephrostomy (PCN) / 대한비뇨기과학회지

For the past two years, nephropexy using PCN was underwent in 9 cases of nephroptosis (8 patients) with variable degrees of flank pain. All were female and 6 on right, 1 on left and 1 on bilateral. All patients had a very mobile kidney and exact distance of movement measured on the film was greater than 6cm (6 to 15 cm). After this operation, 14-20 Fr. nephrostomy catheter was indwelled for about two weeks. All patients were followed at least 3 months(3 to 32, median 17 months). We followed the patients with symptom relief and IVP after 3 months. Nephropexy was regarded as success if she remained asymptomatic for more than 3 months. Five cases were successful and four cases felt recurrent flank pain within 1 month after the surgery. Among four cases of recurrence, one had repeated PCN and got successful result, another had open nephropexy and the others have been followed so far So overall success rate was 67% (6/9). In conclusion, nephropexy using PCN is less invasive, needs shorter period of admission and leaves ignorable scars postoperatively. Furthermore it can be repeated even in the case of failure or recurrence, which would make this new technique available as the first step for the surgical treatment of nephroptosis. And the success rate could be increased if the nephrostomy tract is dilated upto 30 Fr. and the PCN catheter is placed about 4 weeks.

The Study of Proliferating Cell Nuclear Antigen (PCNA) Reactivity in Fibrohistiocytic Tumors

Fibrohistiocytic tumors are a diverse group of benign and malignant soft tissue lesions, including dermatofibroma, dermatofibrosarcomaprotuberans, and malignant fibrous histiocytoma. On the clinical point of view, the distinction between benign and malignant lesions and malignancy grading is far more important. Therefore, we investigated 23 fibrohistiocytic tumors, using PCNA (PC10) which was a useful marker of proliferating activity, to differentiate the benign lesions from the malignant and correlate with other prognostic factors including tumor necrosis. cellularity, histologic grade, and mitotic counts. The results obtained were as follows 1) Positive tumor cells were clearly identified by the characteristic diffuse or granular nuclear staining. 2) The number of PCNA-positive tumor cells were 2.16+/-2.39% in dermatofibroma, 16.12+/-7.38% in dermatofibrosacoma protuberans, and 28.02+/-17.47% in the malignant fibrous histiocytoma. The numbers of PCNA-positive tumor cells in the malignant lesions higher than in the benign (p5 cm) and recurred or metastatic cases of MFH were more the high PCNA index (more than 20%) than the low index (less than 20%) groups. 4) PCNA index in MFHs had positive correlation with the number of mitotic counts (r=0.7582, p<0.001), cellularity (r=0.5908, p<0.05) and histologic grade (r=0.4164, p<0.05). These results suggested that reactivity on PCNA might assist in the distinction between benign and malignant lesions in fibrohistiocytic tumors, and could be a useful prognostic factor in the patients with malignant fibrous histiocytoma.

Percutaneous Nephrostomy: Experience in 276 Cases / 대한비뇨기과학회지

Today, percutaneous nephrostomy and other related renal procedures are routine in most hospitals. This technique provides safe, rapid and direct access to the upper urinary tract for various diagnostic and therapeutic maneuvers. It has become a vital tool for the urologists who have been able to diagnose and treat ever more diverse pathologies of the urinary tract without open operation. Percutaneous nephrostomy was done on 276 cases with advanced malignancy and benign conditions during the period of March, 1985 to December, 1993. We were successful in using percutaneous nephrostomy as urinary diversion to ureteral obstruction or urinary leakage in 27l cases( 98% ). In four fifths of patients, obstruction was due to neoplasm, with the cervical cancer the leading cause. The post-nephrostomy complications were bleeding in 10 cases, enterocutaneous fistula in 4, perinephric abscess in 3 and sepsis in 1. Percutaneous nephrostomy proved to be ideally suited in condition of obstructive uropathy and urine leakage.

Dissolution of uric acid calculi with alkaline fluid irrlgation through percutaneous nephrostomy tube / 대한비뇨기과학회지

We treated 4 patients with uric acid calculi in the renal pelvis or ureter with alkaline fluid irrigation through percutaneous nephrostomy (PCN) tube. Initial presentations were anuria or severe flank discomfort, we performed PCN to relieve such obstructive symptoms caused by uric acid calculi. We tried to dissolve uric acid calculi with normal saline mixed to sodium bicarbonate through a PCN tube. The success of therapy is believed to be related to the direct and constant urinary alkalinization effect obtained with irrigation compared to be the intermittent alkalization that occurs when oral agent are used.