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Introduction: Pancreatitis is a very common gastrointestinal disease that results in hospital admission. Early detection and treatment leads to better outcomes. This is the first reported case of pancreatitis secondary to elevated tacrolimus in a patient with prior renal transplantation after receiving Paxlovid for a COVID-19 infection. Case Description/Methods: A 57-year-old male with past medical history of 4 renal transplants secondary to posterior urethral valves who presented to the emergency room with acute onset epigastric pain for 24 hours. He was on tacrolimus 5 mg every 48 hours monotherapy for his immunosuppression. 10 days prior to his presentation he had developed chills and anxiety. He tested positive for COVID-19 at that time on a home rapid test. His symptoms had not significantly improved and given his immunosuppressed state he was given Paxlovid (Nirmatrelvir/ritonavir). He took 2 days of Paxlovid, however after his second day of treatment he developed severe epigastric pain requiring him to go to the emergency room. On admission his labs were notable for a lipase of 150 U/L (ULN 63 U/L). He underwent a CT scan was notable for an enlarged pancreatic head and neck with peripancreatic fat stranding (Figure). He also had a right upper quadrant ultrasound without any cholelithiasis and only trace sludge noted. His creatinine was noted to be 1.81 mg/dl which was above his baseline of 1.2 mg/dl. His tacrolimus trough level resulted at a level 45.6 ng/ml and later peaked at 82.2 ng/ml. His liver enzymes were normal. He was treated as acute pancreatitis with hydration and his tacrolimus was held with overall clinical improvement. Discussion(s): Tacrolimus is one of the most common medications used in solid organ transplantation. It is a calcineurin inhibitor that inhibits both T-lymphocyte signal transduction and IL-2 transcription. It is metabolized by the protein CYP3A and levels are monitored closely. Paxlovid is currently prescribed as an antiviral therapy for COVID-19 infection. The ritonavir compound in Paxlovid is potent inhibitor of CYP3A. Currently the guidelines do not recommend Paxlvoid as a therapeutic in patients taking tacrolimus as there is concern about increased drug levels. There have been several case reports of pancreatitis in setting of tacrolimus. This case report helps to demonstrate the need for close monitoring of therapeutics levels, especially in medications with high risk of drug to drug interaction to help prevent serious side effects such as tacrolimus induced pancreatitis.
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INTRODUCTION AND OBJECTIVE: Male stress urinary incontinence (SUI) and climacturia are often comorbid with erectile dysfunction (ED) post prostatectomy. While the inflatable penile prosthesis (IPP) is the gold standard surgical option for ED, there are many surgical options for male SUI as well as climacturia including bulking agents, Virtue male sling, AdVance>= male sling, mini Jupette with IPP, and artificial urinary sphincter (AUS). We present our technique and outcomes for mini male sling (MMS) with IPP insertion for mild SUI and climacturia using a hydrophilic monofilament polyester mesh. METHOD(S): After obtaining IRB approval, a retrospective review of all IPPs performed by a single high volume surgeon was performed. Those men who underwent IPP insertion with concomitant MMS were analyzed. The technique of MMS placement involves measurement of an approximately 5x3cm Parietex>= mesh (Covidien, MN) and overlying this ventrally over the bulbar urethra. The Parietex>= mesh includes a hydrophilic absorbable collagen film to minimize tissue reaction and risk of erosion. The lateral edges of the mesh are sutured to the 3- and 9 o'clock positions on the left and right corporal bodies, respectively, using a nonabsorbable, braided suture in an interrupted fashion. Mesh is sutured just proximal to the corporotomy sites. Tightness of mesh was measured using the proximal end of a Debakey forceps, with ease of passage when IPP deflated and inability to pass forceps when IPP inflated indicative of proper sizing. RESULT(S): A total of 63 men underwent IPP with MMS between January 2018 and October 2022. All patients had ED after radical prostatectomy. Average patient age was 67 years old, and average IPP size was 21cm with 1cm rear tip extender (RTE). A total of 59 men had SUI, with average pad per day (PPD) of 1.5. Twenty-five men with SUI had comorbid climacturia, and 4 men had preoperative climacturia without SUI. Average PPD post IPP with MMS was 0.1. Of the 29 men with preoperative climacturia, only one did not have resolution of his symptoms post MMS. There was only one reported complication of acute urinary retention requiring temporary foley catheter placement. Two patients required subsequent AUS insertion for persistent SUI. There were no reported cases of infection or mesh erosion. CONCLUSION(S): The hydrophilic Parietex>= mesh is a safe, easy to use, nonreactive, and effective material for mini male sling insertion at the time of IPP placement for men with ED and mild/moderate SUI or climacturia.
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INTRODUCTION AND OBJECTIVE: Genitourinary fistulas (GU) in Rwanda have significantly increased in recent years. We previously reported an increase in the proportion of vesicouterine, vesicocervical and uterovaginal fistulas, with the majority occurring after Cesarean section. Our goal is to examine the characteristics of our the most recent cohort. METHOD(S): A cross-sectional study was conducted of women presenting for evaluation to the International Organization for Women and Development (IWOD) in Kigali, Rwanda, from 2018 to 2019, and 2022. No data was collected during years 2020 and 2021, due to the COVID-19 pandemic. Data was collected from medical records and included region of residence, surgical history, presence of fistula, and type. RESULT(S): A total of 434 women were evaluated, of these 194 (44.7%) were diagnosed with GU fistula. In 2018, fistula types were 40 (52%) vesicovaginal, 5 (6%) urethral, 5 (6%) ureterovaginal, 23 (30%) vesicoureterine or vesicocervical, and 7 (9%) juxtacervical. In 2019, the fistula types were 26 (41%) vesicovaginal, 4 (6%) urethral, 6 (10%) ureterovaginal, 17 (27%) vesicoureterine or vesicocervical, and 10 (16%) juxtacervical. In 2022, the fistula types were 33 (61%) vesicovaginal, no urethral fistula reported, 7 (13%) ureterovaginal, 8 (15%) vesicoureterine or vesicocervical, and 6 (11%) juxtacervical. CONCLUSION(S): In comparison to our prior cohort, recent data shows a stable proportion of types of fistulas. The increased number of vesicouterine, vesicocervical, and juxtacervical fistula may be higher due to increased performance of Cesarean sections.
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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
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Introduction and Objective: Telemedicine is an established modality to deliver health care to patients remotely. Its role in pediatric urology followup among middle-class semi-urban families is unknown. We conducted a prospective observational questionnaire-based study to assess the patient and provider(urologist) satisfaction and feasibility of teleconsultation across different socioeconomic strata in follow-up of paediatric urology patients during the COVID 19 pandemic. Method(s): The guardians of children treated earlier and due for follow-up were explained and the appointment for teleconsultation was fixed using a video conferencing app. After consultation, consenting caregivers were explained about study and the provider survey was filled by consulting urologist, while the patient questionnaire was filled by principal investigator telephonically. Result(s): A total of 77 virtual visits were completed over 10 months. Median age was 8 years(IQR= 4 to 12) and 82% were boys. The clinical conditions were posterior urethral valves(22%), hypospadias(18%), PUJ obstruction(18%), vesicoureteric reflux(12%) and others(30%). Clinicians found that virtual visits were effective(78%) in deliverance of the care equivalent to the inpatient visit. Patients were equally satisfied(75%). Technical difficulties due to internet connectivity were faced in 24 visits(31%). Video clarity and inability to examine were additional limitations faced(23%). Majority(90%) belonged to the middle socioeconomic strata as per modified Kuppuswamy scale. Families were estimated to have saved a mean of 26,934 rupees(SD +- 7998.06) and a median of 7 days(Range 1-15) of travel time. Conclusion(s): Telemedicine has potential for successful follow-up with cost and time savings. With improving internet connectivity, its potential is likely to increase in future.
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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.
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Introduction: Stress urinary incontinence (SUI) occurs in part due to a weakened urethral rhabdosphincter. Yoga and Pilates are low-impact workouts that use bodyweight as resistance, and limited evidence shows these exercises improve pelvic muscle strength and decrease incontinence episodes. Objective: The study objective was to evaluate the effect of an 8-week web-based yoga-Pilates exercise program on SUI severity as measured by the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF) and secondarily to evaluate the potential mechanism of action for yoga-Pilates through ultrasound measurement of the urethral rhabdosphincter cross-sectional area (CSA). We hypothesized that yoga-Pilates would decrease SUI severity and cause hypertrophy of the urethral rhabdosphincter. Methods: This was a prospective interventional cohort study from November 2020 through September 2021. The intervention was an 8-week home yogaPilates web-based video that tracked and prompted participation. Participants with SUI underwent in-person visits pre/post-intervention during which they completed quality of life and severity surveys and underwent pelvic exam, including POP-Q, cough stress test, Brink pelvic floor strength score, and resting 3-dimensional transperineal ultrasound [1]. Ultrasound images were masked and measured post-collection. The rhabdosphincter is located in the middle third of the urethra, so 5 CSA measurements were taken: at the midpoint and then at 2.5 mm and 5 mm cranial and caudal from the midpoint [1]. The urethral CSA was determined by subtracting luminal/submucosal area from total urethral area (Figure 1). Pre/post 24-hour voiding diaries and an automated video viewing log were also collected. The study was powered to detect a mean change of 2.0 ± 4.0 ICIQ UI-SF score units and a mean CSA increase of 0.25 ± 0.6 cm2 with 48 compliant participants. All pre/post- intervention changes were analyzed using paired t-tests with a null change of zero. Results: 78 women, ages 46.6 + 10.4 years, enrolled. 60 women completed the study. The cohort was predominantly premenopausal (67%), vaginally parous (65%), and had done yoga (76%) and/or Pilates (44%) in the past. 73% of the completers performed the exercises at least 3x/week. The ICIQ-UI SF score improved from 9.5 (95% CI 8.7-10.4) to 7.1 (95% CI 6.3-7.9) post-intervention (P < 0.001). The number of incontinence episodes decreased post-intervention from 1 (IQR 1-3) to 1 (IQR 0-1) (P < 0.001). The Brink score also improved from 7.1 (95% CI 6.6-7.7) to 7.7 (95% CI 7.2-8.2) (P = 0.013). Participants were very satisfied with the online exercises. The majority (83%) of completers also reported they were “a little better”, “much better”, or “very much better” on patient global impression of improvement. There were no significant changes in urethral measurements from pre- to post-intervention. Conclusions: Although there were no changes in the urethral rhabdosphincter, this web-based yoga-Pilates exercise program improved symptoms of SUI and decreased number of incontinence episodes in women with SUI over 8 weeks. Web-based yoga-Pilates offers women with SUI a nonsurgical treatment that can be performed at home, which is beneficial in the ongoing COVID-19 pandemic.
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Introduction Obtaining samples of Neisseria gonorrhoeae for antibiotic sensitivity testing is important for purposes of antimicrobial stewardship. While urethral and cervical gonorrhoea culture samples are usually taken by a healthcare professional, the Covid-19 pandemic necessitated a reduction in direct patient contact. In our service, patients with confirmed gonorrhoea who did not otherwise require examination were asked to take their own urethral or vaginal culture swabs. Methods GUMCAD coding was used to identify cases of cervical or male urethral Neisseria gonorrhoeae infection diagnosed on nucleic acid amplification testing, where the gonococcal culture result and the identity of the swab-taker (patient/healthcare professional) were recorded in the notes. 50 cases were selected in 2019, and 50 in 2020, after the onset of the Covid-19 pandemic. Proportions of patients taking their own swabs were calculated for the two periods. Culture positivity rates were compared between self-taken and healthcare professional-taken swabs. Results During the pandemic, use of self-taken culture samples increased ten-fold. Although positivity for Neisseria gonorrhoeae was lower for self-taken swabs, 38% of male self-taken urethral samples tested positive for gonorrhoea, and the organism was successfully cultured from a self-taken vaginal swab on one occasion. Discussion Although self-taken gonorrhoea cultures were less likely to grow Neisseria gonorrhoeae than those taken by healthcare professionals, they proved a useful tool in gathering sensitivity data in a time of restricted patient contact. The lower positivity rate of self-taken cultures may be partially attributable to their use in patients with fewer symptoms, and hence a lower bacterial load. (Table Presented).
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A 24-year-old man presented with a 7-day history of oral ulceration and 3-day history of erythema at the urethral meatus with one erythematous papule on the scrotum. The patient had tested positive for COVID-19 on polymerase chain reaction test. The patient had not eaten for 6 days, managing only sips of water. There were no new medications and no recent vaccinations. On examination his lips were ulcerated with haemorrhagic crust. His tongue had significant swelling and ulceration. There was erythema and superficial ulceration surrounding the urethral meatus. Thus, the patient had mucosal involvement only, with no target lesions, blisters or epidermal detachment. Inflammatory markers were raised. The initial impression was that of reactive infectious mucocutaneous eruption (RIME) associated with COVID-19 infection, given the likely viral cause, in a systemically well, young patient. The differential included erythema multiforme major, Stevens-Johnson syndrome and pemphigus vulgaris. Bacterial and viral swabs, septic screen, sexually transmitted infection screen including HIV, circulating skin antibodies were all negative. The patient was treated with topical and systemic steroids, with a catheter to prevent urethral stenosis, intravenous Pabrinex®, oral nutritional supplements, analgesia, Difflam™ mouthwash, betamethasone mouth rinse and lidocaine mouth spray. The patient's symptoms had resolved after 6 weeks. This case demonstrates the multispecialty management of a patient presenting acutely with RIME secondary to COVID-19, who was treated successfully with oral and topical steroids.
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Introduction: Human steroid 5α-reductase 2 (SRD5A2) coded by SRD5A2 gene is an enzyme that catalyzes the reduction of testosterone to dihydrotestosterone. Dutasteride, an SRD5A2 inhibitor, is a widely used antiandrogen for the treatment of benign prostate hyperplasia. Multiple variations have been identified in the SRD5Ar gene. Some of these variations may affect the efficacy and safety of SRD5A2 inhibitors. Dutasteride has also been investigated for intermediate and high-risk nonmuscle- invasive urothelial bladder cancer treatment with the combination of BCG (Bacillus Calmette-Guerin). Objectives: The study aims to evaluate the potential impact of V89L (rs523349) and A49T (rs9282858) variations on the SRD5A2 gene on dutasteride efficacy and safety in bladder cancer patients that have been enrolled in Phase 2 clinical trial entitled 'Efficacy and safety of a 5-alpha reductase inhibitor, dutasteride, added to Bacillus Calmette Guerin (BCG) immunotherapy in the prevention of recurrence and progression of intermediate and high risk non-muscle invasive bladder cancer: A single-arm, Phase 2 clinical trial' Methods: Twenty-one patients on BCG and dutasteride in the Phase 2 clinical trial were included in the study. Genomic DNA was obtained from whole blood samples, and evaluation of V89L (rs523349) (G>C) and A49T (rs9282858) (C>T) variations on the SRD5A2 gene was performed by using TaqMan SNP Genotyping Assay. The severity of the adverse events was graded by the United States National Cancer Institute- Common Terminology Criteria for Adverse Events 5.0. The causality assessment of adverse drug reactions was performed using Liverpool Causality Assessment Tool, Naranjo Algorithm, and World Health Organization-Uppsala Drug Monitoring Centre Causality Assessment System. The response to dutasteride was evaluated as the presence of bladder cancer recurrence. The Chi-Square test was used for testing the relationship between categorical variables. P values of <0.05 were considered significant. Results: All patients were homozygous GG for V89L variation on the SRD5A2 gene. Regarding the A49T variation, only one patient was homozygous CC, 8 patients were homozygous TT and 12 patients were heterozygous TC. One of the 8 patients (%12) was homozygous TT and 3 of 12 patients (%25) were heterozygous TC had bladder cancer recurrence. There was no statistically significant difference between bladder cancer recurrence and A49T variation (p=0.803). None of the adverse events were associated with dutasteride treatment whereas some of the adverse events, mostly urinary tract infections, were associated with the BCG. Other adverse events were upper respiratory tract infections, COVID-19, abdominal pain, vomiting, and loss of appetite. Serious adverse events were coronary artery disease, dyspnea, hypotension, and urethral stricture. None of the serious adverse events were associated with dutasteride or BCG treatment. Conclusion: Neither V89L nor A49T variation on the SRD5A2 gene was found to be associated with the efficacy and safety of dutasteride in medium and high-risk bladder cancer patients. Further studies of these variations with larger sample sizes and/or healthy control groups may lead to a better understanding of the impact of these variations on the efficacy and safety of dutasteride.
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Clinical Information Patient Initials or Identifier Number: BGS 22/0371940 Relevant Clinical History and Physical Exam: We present a case of an 80-year-old man with coronary risk factors diabetes, hypertension, dyslipidemia and familiarity without previous history of cardiac disease and known nephrolithiasis and urethral stenosis. He came to our observation during the second COVID wave pandemic within the emergency department for chest discomfort during hypertensive crisis and evidence of not known complete left bundle branch block and minimal elevation of TnI-HS levels. Relevant Test Results Prior to Catheterization: Echocardiography demonstrated septal dyskinesia with ejection fraction of 53%, no relevant valvular disease. The patient was hospitalized with the diagnosis NSTEMI for early coronary angiography within 24 hours and therapy according to the ESC 2020 NSTEMI Guidelines was initiated: acetylsalicylic acid 100 mg SID (no P2Y12 receptor inhibitors in unknown coronary anatomy), low molecular weight heparin atorvastatin 80 mg, ace-inhibitor, beta-blocker, rapid insulin and adequate hydration. Relevant Catheterization Findings: Angiography shoed critical mid RCA and ostial, LM (Medina 1.1.1) mid LAD and LCx stenosis (Fig.1). The patients definitively refused surgical revascularization choosing percutaneous one. At this point the mid (Fig.2.a.) and ostial RCA (Fig.2.b.) stenosis were fixed with DES with optimal angiographic and IVUS (Fig.2.c-d.) results. The left coronary system was studied with IVUS demonstrating significant LM/LAD/LCx stenosis and presence of circumferential calcification (Fig.3.a-b). [Formula presented] [Formula presented] Interventional Management Procedural Step: As a first step we performed rotational atherectomy on the axis LM-LAD (Fig. 3.c.) and LM-LCx (Fig. 3.d.) with 1,75 mm burr and after rewiring LAD (Renato) and LCx (Sion Blu) we repeated IVUS evaluation. Predilatation with non-compliant balloons of mid LAD and LCx and LM-LAD and LM-LCx (Fig.4.) was performed and then a bifurcation dedicated stent BIOSS was places on the axis LM-LCx (Fig. 5.a-b). The procedure continued with placing of a second DES in the mid LCx (Fig.5.c-d) and third DES in the mid LAD (Fig.6.a-b.). Then we placed a fourth DES (Fig.6.c-d.) in the axis LM-LAD (culottes with the just placed BIOSS on LM-LCx). Procedure was ended with DOT, POT, kissing balloon and final POT. Optimal result with IVUS (Fig.7.a-d) and angiography (Fig.7.e-f.) was achieved. The patient was discharged after 48 hours on DAPT and clinical follow-up was scheduled for 1st and 3rd month and angiography control after 6 months. [Formula presented] [Formula presented] [Formula presented] Conclusions: Adopting the common rules and guidelines in the everyday practice as in our case with NSTEMI patient rule-in/rule-out, early coronary angiography in less than 24 hours from admission, all vessels revascularization during index hospitalization, imaging in the left main treatment, stent like preparation of vessels before stenting and in some cases using of dedicated bifurcation stent can increase the success rate and reduce the complication rate.
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Introduction: The COVID-19 pandemic has changed the lives of many in the past year. As of writing this article, the virus has claimed over half a million American lives and has infected millions more. It has affected many people regardless of age, gender, race, religion, or medical history. We have noticed a unique sequence of events in urology patients with a prior history of inflatable penis prothesis implantation who have gotten critically ill from the SARS-CoV-2 virus. Objective: We report our experience with patients with an inflatable penile prothesis who suffered respiratory failure due to the SARS-CoV-2 virus and findings that would help limit the risk of implant infection and/or erosion if prolonged urethral catherization is needed. Methods: We have encountered 3 patients with a very similar history in the past year. They were all men aged 57-72 years old who had a functioning inflatable penile prothesis (IPP) for many years (3-13) and were intubated for a prolonged period of time (2-4 weeks) after suffering respiratory distress from the SARS-CoV-2 virus. During this time, they all had a prolonged urethral Foley catherization for urinary drainage while in the ICU. They were all subsequently found to have urethral erosion of a penile implant cylinder which was not present prior to hospitalization. Their charts were reviewed. Results: Two patients underwent explantation of their IPP during their hospital stay and one presented to our outpatient office 2 months after discharge with the complaint of urethral cylinder erosion and underwent subsequent explantation. Conclusions: Urethral catheterization is commonly used in the intensive care unit and spinal cord injury patients due to their convenience and efficacy. The friction and inflammation created by prolonged transurethral catheterization can be disastrous for IPPs by increasing the likelihood of infection and/or device erosion. In fact, Steidle and Mulcahy found that five out of their nine patients (55%) with IPPs who had an indwelling or intermittent transurethral catheterization were eventually found to have erosion of their IPP. In addition, indwelling transurethral catheters also confer a higher risk of urinary tract infection. Han et al. found that suprapubic tube placement conferred a statistically significantly lower risk of urinary tract infection when compared to indwelling transurethral catheterization for over five days at an odds ratio of 0.142 (95% CI 0.073-0.0276). Another alternative to bladder drainage in the intubated IPP patient is clean intermittent catherization (CIC), however this poses a unique challenge in the intubated COVID positive patient as it repeatedly exposes healthcare staff the virus-carrying patient. When compared to indwelling transurethral catherization, suprapubic tube placement has been shown to confer a lower risk of urinary tract infection and IPP infection/erosion. This can primarily be explained by its ability to drain the bladder without creating inflammation and friction in the urethra. Therefore, we propose that any team caring for a patient with an IPP and a planned, prolonged indwelling transurethral catheterization consult urology services to have a suprapubic tube temporarily placed. This will ensure that the risk of urinary tract infection and/or IPP erosion is kept as low as possible. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Neotract
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Introduction & Objectives: The HoLERBT (Holmium Laser En-bloc Resection) has emerged as an alternative to classical TURBT (Transurethral Resection of Bladder Tumor) by using the en-bloc tumor resection technique. So far, the tumors in previous studies were mostly <3cm. We performed a previous pilot study with tumors >3cm (3-8cm) submitted to HoLERBT in 2019. All samples had detrusor muscle present and there were no peri-operative complications. These results support the present study to establish the best approach to endoscopic treatment of large bladder tumors. The objectives are to analyze differences between HoLERBT and TURBT in terms of presence of detrusor muscle in the histopathological analysis, intra-operative and peri-operative complications and oncological outcomes in large bladder tumors. Materials & Methods: This is a single-institution, randomized, single-blinded, prospective, controlled trial (RCT). The expected duration is of 24 months. The sample size calculated is 47 patients per group (n = 94). The study was approved by the Institutional Ethical Board and was submitted to the Brazilian Registry of Clinical Trials (ReBEC). Inclusion criteria is bladder tumor >3cm by CT or MRI. The exclusion criteria are diagnosis of invasive tumor on image examination (CT, MRI), urethral stenosis, systemic or intra-vesical chemotherapy or previous radiotherapy. The outcomes analyzed are quality of detrusor muscle, intra-operative and immediate post-operative complications, length of hospital stay (LOS);clinical progression, recurrence-free, overall and cancer-specific survival at 24 months. Results: This is an ongoing trial that began in January 2020, was suspended for 5 months due to Covid-19, restarted recruitment in September 2020 and currently has 9 patients in the group HoLERBT and 11 patients in the group TURBT. The first surgery was in 01/21/20. The current data represents 22% of the estimated sample and the analysis is partial. The median age (years) was 55.8 (29-83) and 65.5 (46-84), the median tumor size (cm) was 3.4 (2.1-5.4) and 3.1 (2.1-5.7), the median time of surgery (min) was 29 (16-49) and 37.6 (13-60), the LOS (days) was 1.25 (1-3) and 2.0 (1-4), complications rates Clavien I was 11% and 36% and Clavien >I was 0% and 9% for HoLERBT and TURBT. The presence of detrusor was 80% in both groups. The interim analysis will be made with 50% of the sample estimated to occur in June 2021 and the final analysis with 2 years of follow up is estimated to occur in January 2023. Conclusions: This is a RCT comparing HoLERBT and TURBT evolving large tumors, with a 2-year follow-up proposal. The initial analysis give support to continue the study in order to assess the real role of laser resection in high volume bladder tumor.