A Rare Case of Isolated Renal Mucormycosis in an Immunocompetent Individual: Post Covid-19 Infection

Intro: Mucormycosis is known to effect patients with immunocompromised status from a variety of causes such as diabetes mellitus, hematologic malignancy, and HIV infection. Most common form of presentation is rhinocerebral infection. However, isolated presentation of renal mucormycosis is rare. With the ongoing COVID-19 pandemic and use of high-dose steroids and antibiotics, there have been increasing reports of bacterial and fungal coinfections in COVID-19 positive patients. We report a rare case of isolated renal mucormycosis, post COVID-19 infection, in a healthy individual presenting as unilateral right non-functioning pyonephrotic kidney. Method(s): A conscious, well oriented, afebrile 37 years old female patient presented with the complaints of right flank pain for one month. Patient was diagnosed as a case of post COVID-19 renal infarct with perinephric collection, right non-functioning pyonephrotic kidney. She had no previous comorbidities. Routine investigations, chest X-ray and CT scan were done. Finding(s): CT scan findings reveal a large right perinephric hyperdense collection inseparable from right kidney involving the internal oblique, psoas and quadratus lumborum muscles. Right simple nephrectomy was done and specimen was sent for histopathology and fungal culture. Histopathology report showed necrotizing granulomatous inflammation with broad, aseptate, irregularly branched fungal hyphae morphologically resembling Mucor species and fungal culture also confirmed Mucor species.Copyright © 2023

Wunderlich Syndrome: Early Misdiagnosis with Acute Renal Colic During COVID-19 Pandemic.

Wunderlich syndrome, also known as the spontaneous non-traumatic retroperitoneal hemorrhage, is an uncommon condition characterized by acute, spontaneous, non-traumatic renal hemorrhage into the subcapsular or perirenal spaces. The majority of the cases are caused by renal cell carcinoma or renal angiomyolipoma. Other causes are arteriovenous malformation, cystic renal disease, and anticoagulation medications. The classic presentation is "Lenk's triad" of acute flank pain, palpable flank mass, and hypovolemia. The diagnosis is based on clinical suspicion and confirmed by a CT scan, which is the preferred imaging modality. Due to the rarity of these cases and the wide range of clinical manifestations, the treatment is divergent ranging from conservative management to nephrectomy. Herein, we present a case of massive right renal hemorrhage caused by warfarin toxicity that was initially misdiagnosed as acute renal colic due to the patient's refusal to refer to the clinic during Corona Virus Disease- 19 era and was later managed with a right nephrectomy.

Stage Migration in Renal Malignancies in COVID Era: A Single-Center Analysis.

The COVID-19 disease, caused by SARS-CoV-2 virus, attained the status of a pandemic by March 2020. There was apprehension among patients suffering from renal malignancies about balancing cancer treatment and preventing COVID-19 infection transmission. We analyzed 184 patients with renal malignancies retrospectively, who presented to our institute over 2 years: 91 patients of renal malignancies in pre-COVID era (March 2019-Feb 2020) and 93 patients in COVID era (March 2020-Feb 2021). The parameters analyzed were age, tumor size, clinical presentation, clinical stage, pathological stage, nuclear grade, and presence of metastasis. Level of significance was kept at 95%, and p value <0.05 was considered significant. The age of patients was comparable in both groups (p: 0.381). Clinical presentation was also similar in both groups whereas there were more cases diagnosed during routine evaluation in pre-COVID era (p: 0.022). Tumor size was 5.84 ± 3.03cm vs. 7.10±3.83cm (p: 0.017) in pre-COVID vs. COVID era, respectively. Patients in COVID era had significantly higher clinical stage (p = 0.041), pathological stage (p =0.027), nuclear grade (p = 0.007), and presence of metastasis (p = 0.005) as compared to pre-COVID era. Patients, who underwent Nephron-sparing surgery, also had higher pathological stage in COVID era. COVID overshadowed the management of renal malignancies. There was a clear shift and stage migration in patients of renal malignancies in COVID era as compared to pre-COVID era, probably because of less routine health check-ups and patients deferring hospital visits due to fear of contracting COVID infection.

Renal Amyloid-Associated (AA) Amyloidosis in a Sickle Cell Patient: A Case Report and Literature Review.

Renal amyloid-associated (AA) amyloidosis is a rare occurrence in sickle cell disease (SCD). Very little literature is available on renal AA amyloidosis in sickle cell disease. Nephrotic range proteinuria is associated with higher mortality among patients with SCD. We present a case of a young reproductive-age African American woman who presented with massive nephrotic range proteinuria. Other more common causes of AA amyloidosis such as immunologic and infectious etiologies were ruled out by history, physical examination, radiologic investigation, and serology. Renal biopsy showed mesangial expansion with Congo red-positive material. Staining for immunoglobulins was negative. Electron microscopy showed nonbranching fibrils. These findings were consistent with AA amyloidosis. This case report adds to the rare findings of renal AA amyloidosis in sickle cell disease. The patient refused any intervention to decrease her Glomerular Filtration Rate (GFR) in the hopes of potentially reversing the disabling proteinuria. We report sickle cell disease presenting with nephrotic syndrome secondary to AA amyloid.

Last Resort from Nursing Shortage? Comparative Cost Analysis of Open vs. Robot-Assisted Partial Nephrectomies with a Focus on the Costs of Nursing Care.

Despite perioperative advantages, robot-assisted surgery is associated with high costs. However, the lower morbidity of robotic surgery could lead to a lower nursing workload and cost savings. In this comparative cost analysis of open retroperitoneal versus robot-assisted transperitoneal partial nephrectomies (PN), these possible cost savings, including other cost factors, were quantified. Therefore, patient, tumor characteristics, and surgical results of all PN within two years at a tertiary referral center were retrospectively analyzed. The nursing effort was quantified by the local nursing staff regulation and INPULS® intensive care and performance-recording system. Out of 259 procedures, 76.4% were performed robotically. After propensity score matching, the median total nursing time (2407.8 vs. 1126.8 min, p < 0.001) and daily nursing effort (245.7 vs. 222.6 min, p = 0.025) were significantly lower after robotic surgery. This resulted in mean savings of EUR 186.48 in nursing costs per robotic case, in addition to savings of EUR 61.76 due to less frequent administrations of erythrocyte concentrates. These savings did not amortize the higher material costs for the robotic system, causing additional expenses of EUR 1311.98 per case. To conclude, the nursing effort after a robotic partial nephrectomy was significantly lower compared to open surgery; however, this previously unnoticed savings mechanism alone could not amortize the overall increased costs.

Standardization of Surgical Outcome Across the Tumor Complexity Spectrum in Robotic Partial Nephrectomy.

Introduction: Standardization of surgical steps or techniques can decrease error rates, increase efficiency, and ensure reproducible outcomes. In this study, we aimed to analyze the benefit of a standardized approach to robotic partial nephrectomy (RPN) on the reproducibility of outcomes across different tumor complexities. Methods: A single-center study of patients who have undergone a transperitoneal robotic-assisted partial nephrectomy for kidney cancer using the first assistant sparing technique between May 2014 and March 2022 was performed. Overall, 496 patients were included in the analysis. We compared clinical data and perioperative and postoperative outcomes for low, moderate, and high complexity score renal tumors. Tumor complexity was stratified using the Radius, Exophytic/Endophytic, Nearness to the collecting system or sinus, Anterior/Posterior, Location relative to the polar line nephrometry score. Data were compared using Kruskal-Wallis test, Chi-square test of Independence, and Fisher's exact test. Results: Of the patients in the study, 54.64% were low tumor complexities (n = 271), 40.32% were moderate tumor complexities (n = 200), and 5.04% were high tumor complexities (n = 25). High tumor complexity patients had significantly longer operative time (149 minutes versus 137 minutes moderate complexity versus 125 minutes low complexity, P = .001), longer ischemia time (12 minutes versus 11 minutes intermediate versus 10 minutes low complexity, P = .0001), and significant reduction in estimated glomerular filtration rate (-12.58 mL/min/1.73 m2 versus -5.51 mL/min/1.73 m2 intermediate versus -3.08 mL/min/1.73 m2 low complexity, P = .005). There was no significant difference in estimated blood loss (P = .074), blood transfusion rate (P = .454), postoperative complication rate (P = .527), surgical complication rate (P = .210), major complication rate (P = .098), length of hospital stay (P = .583), positive surgical margins (P = .872), and trifecta achievement (P = .740). Conclusion: Irrespective of tumor complexity, approaching RPN using a standardized approach will offer patients favorable perioperative outcomes. This approach has standardized our preoperative counseling, patient expectation, and postoperative surgical pathway across the tumor complexity spectrum.

A Comprehensive Review of 275 Kidney Transplants Performed over 3 1/2 Years;a Single Center Experience

Introduction: Access to kidney transplantation has always been a problem in the African countries with many patients having to travel to other medically advanced countries in Asia, Europe and America. This involves unnecessary excessive expenditure and the travails of journey and stay in an unknown foreign land. To ease this situation and to provide affordable Renal transplant services in their home land, we have made an effort to start the transplant services at our medical facility and have successfully carried out about 275 transplants over a period starting from Nov 2018 till September 2022. Method(s): All the Kidney transplants done between the period Nov 2018- September 2022 (275 cases) were included in the analysis. All the transplants were performed at a single center and the data were collected progressively during their Pre transplant evaluation, perioperative course and post op follow up. All the laboratory and radiological tests were done locally at the center except the HLA cross matches and tissue typing, which were outsourced to Transplant immunology labs outside the country. All the patients with positive DSA titres [about 70%], underwent Plasmapheresis and received IVIg before the transplantation. immunological assessment was done by NGS high resolution, for A B C DP DQ DR loci and X match was done by SAB analysis for class 1 and Class II antigens. All the patients underwent laparoscopic donor nephrectomy. All Patients received vaccinations for Hepatitis B, Pneumonia, Infuenza & Covid. Result(s): A series of 275 kidney transplants were performed over a period of 42 months [ Nov 2018- September 2022] at a private hospital successfully. All the cases were live donor kidney transplants with majority of the donors being 1st or 2nd degree relatives or spousal donors. About 70% of the patients had some degree of sensitization in the form of weakly positive B cell X match, or positive for DSAs at CL I, CLII with MFIs > 1000. All high-risk patients received induction with rabbit Thymoglobulin, and IV methyl prednisolone. Around 50 patients received Basiliximab. Of all patients, 4were HBsAg positive, and 6 were HIV positive,& HCV 1 patient. 8 patients required pretransplant Parathyroidectomy for refractory hyperparathyroidism, 3 patients required simultaneous native kidney nephrectomy at the time of transplant. 25 patients had multiple renal vessels which were double barreled and anastamosed.4 patients had lower urinary tract abnormalities requiring simultaneous/subsequent repair. Overall, 4 patients underwent 2nd transplant. All the donors underwent laparoscopic nephrectomy. Most of the patients had good immediate graft function except in 40 patients, who had delayed graft function;most of them improving over 2 - 6 weeks. 6 Patients had hyperacute rejection and the graft was lost,.4patients had main renal artery thrombosis, Renal allograft biopsy was done in 20 patients. Overall, the Patient survival was 95 %.at 1 year and graft survival 90%. Conclusion(s): Our experience shows that kidney transplantation is a viable and practical option for End stage kidney disease and can be performed even in resource constrained centers in third world countries and the survival rates of patients and the grafts are comparable to other centers across the world. No conflict of interestCopyright © 2023

Surgery for urologic cancers after SARS-CoV-2 infection: Adverse outcomes and optimal delay

Background: Perioperative SARS-CoV-2 infection has been associated with increased adverse outcomes. Research conducted early in the COVID-19 pandemic suggested an 8 week delay after SARSCoV-2 infection prior to undergoing surgery. The aim of this study is to determine if prior COVID-19 infection is an independent risk factor for adverse outcomes following surgery for urologic cancers. A secondary objective was to determine the optimal duration to delay surgery, specifically cystectomy, prostatectomy, or nephrectomy, after COVID-19 infection. Method(s): Data from the National COVID Cohort Collaborative (N3C) data enclave was used to conduct this retrospective cross-sectional study. Patients with cancer diagnoses that underwent surgery for urologic cancers after January 2020 were included in the analyses. Urologic surgeries were queried using standard SNOMED concepts corresponding to cystectomy, nephrectomy, and prostatectomy. Patients were assessed for adverse postoperative events that were defined using standard SNOMED clinical concepts. COVID-19 positive patients were identified via the N3C Knowledge Store using positive lab measurement or a positive SARS-CoV-2 diagnosis. Analyses were conducted in the N3C data enclave. Result(s): The study cohort included 38,974 total patients with 15,216, 14,778, and 8,980, undergoing cystectomy, prostatectomy, and nephrectomy, respectively. 2,807 had a history of COVID-19 infection greater than 20 days prior to surgery. Prior history of COVID-19 was independently associated with adverse outcomes for cystectomy (OR 1.21 [1.03-1.43], p<0.05) and nephrectomy (OR 1.27 [1.06-1.52], p<0.05), but not prostatectomy (OR 1.14 [0.95-1.36]). Multivariable regression assessing time to surgery and risk for any adverse events, did not reveal significant benefit to waiting greater than 20 days after COVID-19 infection to operate. Conclusion(s): Patients with known prior COVID-19 infection who underwent surgical treatment of urologic cancers experienced increased risk of adverse surgical outcomes. Among this group, those who delayed surgery greater than 20 days after infection did not demonstrate decreased risk of these negative outcomes across the procedures studied. Optimal surgical delay in the treatment of urologic cancers after COVID-19 infection does not appear to be greater than 20 days.

List of Abstracts

Aslet, S. Holbrook</td><td>Implementing a dedicated COVID-19 post intensive care unit follow-up clinic to improve the follow-up of patients in a district general hospital</td><td>6</td></tr><tr><td>G. Liddicoat, A. Duffen, H. Howes, E. Hood, H. Wilson</td><td>Obstructive sleep apnoea outcomes after surgery: identifying high-risk patients from a high-risk group</td><td>51</td></tr><tr><td>W. Chawla, L. Kanapeckaite, A. Ireson, G. Kandasamy, S. Philip</td><td>Post-COVID-19 elective surgery and transformation: exploring the role of ambulatory spinals in the high-risk patient population</td><td>14</td></tr><tr><td>M. McClune, K. Bernhardt, A. Shah</td><td>General versus regional anaesthesia in patients undergoing surgery for hip fracture repair: a systematic review and meta-analysis</td><td>100</td></tr><tr><td>R. [Extracted from the article]

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

Feasibility and Safety of Dual-console Telesurgery with the KangDuo Surgical Robot-01 System Using Fifth-generation and Wired Networks: An Animal Experiment and Clinical Study.

The coronavirus disease 2019 pandemic has drawn attention to telesurgery. Important advances in fifth-generation (5G) mobile telecommunication technology have facilitated the rapid evolution of telesurgery. Previously, only a single console was used in telesurgery; thus, there was the possibility of open or laparoscopic conversion. Furthermore, the 5G network has not been available for regional hospitals in China. From October 2021 to April 2022, dual-console telesurgeries with the KangDuo Surgical Robot-01 (KD-SR-01) system were performed using 5G and wired networks in an animal experiment and clinical study. A partial nephrectomy in a porcine model was performed successfully using a wired network. The console time, warm ischemia time, and control swap time were 69 min, 27 min, and 3 s, respectively. The mean latency time was 130 (range, 60-200) ms. A 32-yr-old male patient successfully underwent a remote pyeloplasty using a series connection of 5G wireless and wired networks. The console time and control swap time were 98 min and 3 s, respectively. The mean latency time was 271 (range, 206-307) ms. In the two studies, data pocket loss was <1%. The results demonstrated that dual-console telesurgery with the KD-SR-01 system is feasible and safe using 5G and wired networks. Patient summary: Advances in fifth-generation (5G) mobile telecommunication technology helped in the rapid evolution of telesurgery. Dual-console telesurgery performed with the KD-SR-01 system using 5G and wired networks was shown to be feasible and safe in an animal experiment and clinical study.

List of Abstracts

McClune, K. Bernhardt, A. Shah</td><td>General versus regional anaesthesia in patients undergoing surgery for hip fracture repair: a systematic review and meta-analysis</td><td>100</td></tr><tr><td>R. Liddicoat, A. Duffen, H. Howes, E. Hood, H. Wilson</td><td>Obstructive sleep apnoea outcomes after surgery: identifying high-risk patients from a high-risk group</td><td>51</td></tr><tr><td>W. Aslet, S. Holbrook</td><td>Implementing a dedicated COVID-19 post intensive care unit follow-up clinic to improve the follow-up of patients in a district general hospital</td><td>6</td></tr><tr><td>G. Chawla, L. Kanapeckaite, A. Ireson, G. Kandasamy, S. Philip</td><td>Post-COVID-19 elective surgery and transformation: exploring the role of ambulatory spinals in the high-risk patient population</td><td>14</td></tr><tr><td>M. [Extracted from the article]

Impact of Time-To-Surgery on the Prognosis of Patients with T1 Renal Cell Carcinoma: Implications for the COVID-19 Pandemic.

Background: During the COVID-19 pandemic, elective surgery has to undergo longer wait times, including nephrectomy for T1 renal cell carcinoma (RCC). This study aimed to investigate the time-to-surgery (TTS) of Chinese T1 RCC patients and its influencing factors, and to illustrate the impact of TTS on the prognosis of T1 RCC. Methods: We retrospectively enrolled 762 Chinese patients with pathological T1 RCC that underwent nephrectomy. To discover the impact of TTS on survival outcomes, we explored the possible delay intervals by week using the Kaplan-Meier method and Log-rank test. Cox proportional hazard models with inverse probability-treatment weighting (IPTW) were used to assess the association between TTS and disease-free survival (DFS) and overall survival (OS). Results: The median TTS of T1 RCC patients was 15 days. The Charlson comorbidity index, the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score, and the maximal tumor diameter on presentation were independent influencing factors for TTS. The cut-off point of TTS was selected as 5 weeks according to the Log-rank analysis. For T1a RCC, patients with TTS > 5 weeks had similar DFS (HR = 2.39; 95% CI, 0.82−6.94; p = 0.109) and OS (HR = 1.28; 95% CI, 0.23−7.16; p = 0.779) compared to patients with TTS ≤ 5 weeks. For T1b RCC, patients with TTS > 5 weeks had shorter DFS (HR = 2.90; 95% CI = 1.46−5.75; p = 0.002) and OS (HR = 2.49, 95% CI = 1.09−5.70; p = 0.030) than patients with TTS ≤ 5 weeks. Conclusions: Prolonged TTS had no impact on the prognosis of T1a RCC while surgery delayed for over 5 weeks may lead to worse survival in T1b RCC.

The Impact of Covid-19 Pandemic on Genitourinary Cancers Stage and Grade.

INTRODUCTION: Our study aims to evaluate the impact of the COVID-19 pandemic on the number of uro-oncological surgeries (cystectomy, nephrectomy, prostatectomy, orchiectomy, and transurethral resection of bladder tumor (TURBT)) and pathological staging and grading. MATERIALS AND METHODS: The present study is a retrospective study on patients with genitourinary cancers treated from 2018 to 2021 in a referral tertiary center. The data were obtained from the hospital records with lengths of 22 and 23 months, labeled hereafter as non-COVID and COVID pandemic, respectively (2018/3/21-2020/1/20 and 2020/1/21-2021/12/21). The total number of registered patients, gender, age, stage, and grade were compared in the targeted periods. Moreover, all the pathologic slides were reviewed by an expert uropathologist before enrolling in the study. The continuous and discrete variables are reported as mean (standard deviation (SD)) and number (percent) and the χ2 test for the comparison of the discrete variables' distribution. RESULTS: In this study total number of 2077 patients were enrolled. The number of procedures performed decreased during the Covid pandemic. The tumors' distribution stage and grade and patients' baseline characteristics were not significantly different in non-COVID and COVID pandemic periods for Radical Nephrectomy, Radical Cystectomy, Radical Prostatectomy, and orchiectomy. For TURBT only, the tumor stage was significantly different (P-value<.001) from the higher stages in the COVID pandemic period. CONCLUSION: Among urinary tract cancers, staging of bladder cancer and TURBT are mainly impacted by the COVID-19 pandemic with higher stages compared to the non-COVID period. We evaluate the impact of the COVID-19 pandemic on the number of uro-oncological surgeries based on pathological staging and grading. Total number of 2077 patients were enrolled. Among urinary tract cancers, staging of bladder cancer and TURBT are mainly impacted by the COVID-19 pandemic with higher stages compared to the non-COVID period.

A Fatal Case of Isolated Renal Mucormycosis in an Immunocompetent Male.

Mucormycosis (MM) is an angio-invasive fungal infection that often presents in immunocompromised patients. Isolated renal MM is an uncommon presentation that has been documented as a life-threatening condition in immunocompetent patients due to its poor prognosis. Here, we present a rare case of isolated renal MM in a 27-year-old male who presented with left flank pain, nausea, and vomiting. Upon further investigation, a renal infarct was discovered, and he underwent a subsequent nephrectomy. A renal biopsy revealed MM. The patient's infection spread, and he ultimately succumbed to his illness. Isolated renal involvement of this pathogen is extremely rare in healthy individuals and has poor outcomes. The ubiquitous nature of MM increases the risk of exposure to humans. Comorbidities such as coronavirus disease 2019 and immunosuppressive states are risk factors for the deleterious outcomes of MM. It is unusual for an immunocompetent patient with no underlying conditions to die despite early diagnosis and prompt treatment. This example calls attention to the unpredictable clinical presentation of isolated renal MM. Our case highlights MM as a differential diagnosis in patients with unilateral flank pain and identifies the importance of a prompt clinical diagnosis and treatment due to the rapid progression and poor health outcomes associated with MM infection.

Anti-HLA Antibodies Do Not Increase in Kidney Transplant Recipients During COVID-19 Infection

Purpose: To determine if HLA allo-antibody levels are affected by COVID-19 in renal transplanted patients and to compare the immunoglobulin class and subclass profiles as well as the epitope binding patterns of anti-HLA and anti-SARS-CoV-2 antibodies. Method(s): A cross-sectional study of 46 kidney transplant recipients diagnosed with PCR+ SARS-CoV-2 infection was conducted. Serum samples were collected at the time of infection. For 21 patients, we obtained historical anti-HLA antibody information before COVID-19. Using a single-antigen bead Luminex assay, we determined IgG, IgG1/2/3/4, IgM, and IgA antibodies against Class I and Class II HLA, as well as against five SARS-CoV-2 (Wuhan strain) protein fragments: nucleocapsid, whole spike (S), spike S1, spike S2 and spike receptor binding domain (RBD). Result(s): 26/46 subjects had anti-HLA antibodies of which fourteen had donorspecific anti-HLA antibodies (DSA) compared with 45/46 had anti-SARS-CoV2 antibodies. The majority of DSA were specific to HLA-DQ (10/14), with a dominant IgG/IgG1/IgG3 subclass prevalence. Anti-SARS-CoV-2 antibodies exhibited stronger reactivity towards S and RBD and had increased IgM (38/43, 79%) and IgA (41/42, 85%) prevalence when compared to DSAs (5/14, 35% and 2/14, 14%, p<0.001).Out of 21 patients with pre-COVID-19 data available, calculated panel antibody reactivity (cPRA) levels did not change after COVID-19 in 14 cases (67%);cPRA increased in two cases (10%), both of them with allograft nephrectomy and immunosuppression discontinuation, and decreased in five patients (20%) (from 65.4+/-12.6% before COVID-19, to 29.4+/-33.6% after COVID-19) (Figure 1). Patients with DSA exhibited significantly lower anti-S IgG (9453+/-9945 vs 17975+/-12792;P=0.001), anti-RBD IgM (4464+/-3693 vs 8751+/-6468;P=0.03) and anti-nucleoprotein IgA (998+/-835 vs 5476+/-6895;P=0.001) anti-SARS-CoV2 antibody MFI values than patients without DSA. Conclusion(s): cPRA values did not increase following PCR confirmed COVID-19 diagnosis in renal transplant recipients and those subjects with pre-existing DSA had lower antibody strength directed at SARS-CoV-2 antigens. The lack of increase in alloantibody response is quite remarkable, since over 80% of the patients underwent either significant reduction or withdrawal of mycophenolate mofetil after COVID-19 diagnosis. (Figure Presented).

BELZUTIFAN-INDUCED HYPERSENSITIVITY PNEUMONITIS

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Immunotherapy is now a standard of care in solid-tumor oncology following the approvals of CTLA-4 and PD-1 inhibitors. Belzutifan, a small-molecule HIF-2a inhibitor, has recently gained FDA-approval for the treatment of advanced von Hippel-Lindau (VHL) associated renal cell carcinomas. CASE PRESENTATION: A 63-year-old female presented to our hospital with a one-day history of progressive dyspnea. Medical history is significant for metastatic renal cell carcinoma with pulmonary metastasis. Family and social history were noncontributory. Her cancer diagnosis was established in 2019 and had undergone cytoreductive nephrectomy and treatment with axitinib/pembrolizumab. As she had little improvement with immunotherapy, she was enrolled in a clinical trial at Memorial Sloan Kettering. Due to further disease progression, she was transitioned to lenvatinib/everolimus, though the treatment was discontinued due to anorexia and worsening pulmonary symptoms. Further work up revealed that she had ERG, MPL, VHL gene mutations. Thus, she was started on belzutifan two weeks prior to her presentation. Initial vitals were significant for hypoxia on room air that recovered with high flow nasal cannula (40L/80%). Physical examination was remarkable for severe respiratory distress with coarse breath sounds bilaterally. Laboratory studies revealed an acute leukocytosis with a neutrophilic prominence and a chronic metabolic alkalosis. COVID, flu PCR were negative. Chest x-ray demonstrated diffuse bilateral reticulonodular opacities. CTA revealed innumerable pulmonary nodules with areas of mass-like consolidation and a loculated left-sided pleural effusion. She was covered with azithromycin/ceftriaxone along with high-dose steroids and was admitted to the stepdown unit for further management. While in stepdown, she had a left PleurX catheter placed given her large effusion which was complicated by bloody output that required one unit of blood. Despite high-dose steroids, she had persistent hypoxia. As she remained unstable, goals of care discussions were held, which ultimately led to a change in code status to comfort measures. All aggressive measures were discontinued. She was started on comfort medications and ultimately passed away. DISCUSSION: Currently, neoplasms associated with VHL mutations are managed surgically to minimize the risk of metastatic disease. Nearly 70% of all patients with VHL mutations will develop renal cell carcinomas which means most patients undergo numerous surgical procedures. HIF-2a inhibition therefore offers an effective alternative that could reduce surgical burden and offer a new approach to management of VHL-associated disease. However due to its new approval, several adverse effects have yet to be documented. CONCLUSIONS: We report the only known case of Belzutifan-induced hypersensitivity pneumonitis and hope this case will become a useful contribution to the literature. Reference #1: Jonasch E, Donskov F, Iliopoulos O, Rathmell WK, Narayan VK, Maughan BL, Oudard S, Else T, Maranchie JK, Welsh SJ, Thamake S, Park EK, Perini RF, Linehan WM, Srinivasan R;MK-6482-004 Investigators. Belzutifan for Renal Cell Carcinoma in von Hippel-Lindau Disease. N Engl J Med. 2021 Nov 25;385(22):2036-2046. doi: 10.1056/NEJMoa2103425. PMID: 34818478. DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Raj Parikh

THE GREAT IMITATOR: A CASE OF RENAL SQUAMOUS CELL CARCINOMA DISGUISED AS CHRONIC PYELONEPHRITIS

CASE: A 78-year-old female with a history of recurrent nephrolithiasis and left ureteral reconstruction presented to our institution with hematuria, flank pain, anorexia and weight loss. 3-4 months prior, she had similar symptoms in her home country and was treated with multiple courses of antibiotics. She attempted to present to the US for evaluation earlier, but was unable to due to COVID. She first presented to a nearby US hospital and was diagnosed with an atrophic kidney with a superimposed infection based on imaging and labs. An EGD/ Colonoscopy done for her weight loss was unrevealing. She was discharged on antibiotics and told to follow up for possible nephrectomy. 1 days later, she presented to our institution with continued symptoms. Repeat CT was concerning for emphysematous pyelonephritis. Vital signs were unremarkable. Labs showed no leukocytosis, normal creatinine, hypercalcemia to 13.0 and urinalysis showed hematuria, pyuria and proteinuria. She was initially treated with IV antibiotics and a percutaneous nephrostomy for source control. To continue work up for her weight loss, a CT chest was done that showed multiple lung nodules and a re-review of the CT abdomen noted a T12 lytic lesion. 2 weeks into her admission, she had a left nephrectomy. Pathology revealed an invasive, grade 3, poorly differentiated squamous cell carcinoma arising from the renal pelvis, with lymphovascular invasion. A biopsy of the T12 lesion was consistent with metastasis. Due to her functional status and aggressive nature of her malignancy, palliative therapies were recommended. Patient's course was further complicated by ileus, massive aspiration and spinal cord compression from the T12 lesion. She passed away on hospital day 45. IMPACT/DISCUSSION: Squamous cell carcinoma of the renal pelvis is a rare malignancy. Most present at an advanced stage with a long history of nonspecific symptoms, such as hematuria and/or flank pain, which are typically attributed to recurrent nephrolithiasis;one of the most well-documented risk factors. Additionally, there are no characteristic findings on imaging, making radiological differentiation between renal SCC and other chronic infectious processes difficult. Often there is no suspicion for malignancy until the pathology results. For these reasons, renal SCC should be considered in patients who have underlying risk factors. One may also benefit from a renal biopsy, which can be done before a nephrectomy and has been shown to have a high degree of diagnostic accuracy. Adding to this diagnostic challenge, our patient's care was delayed due to COVID, demonstrating the importance of considering alternative diagnoses when patients have deferred presentations and fractured workups. CONCLUSION: Consider the diagnosis of renal SCC in patients with recurrent nephrolithiasis, UTIs, unexplained hematuria and/or flank pain and refer for a renal biopsy if appropriate. Be mindful of the impact of fragmented and delayed medical care on vulnerable patients.

A RARE PRESENTATION OF RENAL CELL CARCINOMA: PARANEOPLASTIC COUGH

CASE: A 30-year-old woman with a history of hypertension, obesity, and reactive airway disease presents with a two-month history of persistent cough, wheeze, and diaphoresis. At that time, chest x-ray and COVID-19 PCR were negative and pulmonary function tests were within normal limits. Her symptoms were managed with inhaled corticosteroid/long-acting muscarinic antagonist, albuterol, guaifenesin, and second-generation antihistamines. However, she continued to be symptomatic. Two months after these symptoms arose, she presented to the ED with a sixhour history of sudden onset right non-radiating flank pain. Her symptoms were associated with acute onset nausea, vomiting, urinary frequency, urgency, hesitancy, and burning;negative for hematuria. She was hemodynamically stable and physical exam was significant for right flank tenderness. Urinalysis showed proteinuria of 100 mg/dL and gross hematuria. Imaging of the abdomen demonstrated an enlarged right kidney with a large mass involving the cortex with mass effect on the liver. Urology performed a right radical nephrectomy with pathology positive for chromophobe renal cell carcinoma. Following surgery, the patient's original symptoms of cough, wheezing, and diaphoresis resolved. IMPACT/DISCUSSION: The typical symptomatic presentation of renal carcinoma with flank pain, abdominal mass, hematuria, and weight loss occurs in roughly 9% of cases and is indicative of advanced disease. Renal cell carcinoma is most commonly found incidentally on imaging studies, leading to improved outcomes due to early recognition. Young patients, however, are more likely to present symptomatically. Our patients' initial presentation of cough could be due to two different mechanisms. One possibility is chronic irritation of the diaphragm due to mass effect from the growing tumor. This mechanism is possible in our case as there was minor mass effect on the liver which could then disturb the diaphragm. A more likely mechanism is a paraneoplastic process. This has been demonstrated in prior cases with a chronic unremitting cough associated with diaphoresis, not improved with anti-tussives, and resolves upon removal of the mass. The cough has been shown to return with metastases. The proposed mechanism is tumor secretion of prostaglandins which enhance the cough reflex. Our case displays an uncommon symptomatic presentation of renal cell carcinoma in a young woman due to paraneoplastic cough stimulation. This demonstrates the importance of digging deeper when common symptoms such as cough are not successfully resolved with typical treatments. CONCLUSION: Most commonly renal cancer is diagnosed on incidental imaging allowing clinicians to make a diagnosis before symptoms arise. An unremitting cough may be an early warning sign of renal cell carcinoma before urinary symptoms begin, making early diagnosis more likely. Due to this, seemingly minor symptoms such as cough should be followed through to diagnosis as they can have significant consequences.