Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume.

PURPOSE: To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. MATERIAL AND METHODS: A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. RESULTS: There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. CONCLUSION: A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

An Unusual Presentation of Pyelonephritis: Is it COVID-19 Related? (preprint)

IntroductionIn severe cases of COVID-19, late complications such as coagulopathy and organ injury are increasingly described. In milder cases of the disease, the exact time frame and causal path of late onset complications has not yet been determined. Although direct and indirect renal injury by SARS-CoV-2 has been confirmed, hemorrhagic renal infection or coagulative problems in the urinary tract have not yet been described.Case PresentationThis case report describes a 35-year-old female without relevant medical history who, five days after having recovered from an infection with SARS-CoV-2, had an unusual course of acute pyelonephritis of the right kidney and persistent fever under targeted antibiotic treatment. A hemorrhagic ureteral obstruction and severe swollen renal parenchyma preceded the onset of fever and was related to the developing pyelonephritis. Sudden thrombotic vascular occlusion in the right eye appeared during admission. Symmetrical paresthesia in de limbs in combination of severe lower back pain and gastro-intestinal manifestation was documented and not been explained despite of intensive investigation.ConclusionWe present the unusual combination of culture confirmed bacterial hemorrhagic pyelonephritis with a blood clot in the proximal right ureter, complicated by a retinal venous thrombosis, in a patient who had recovered from SARS-CoV-2-infection five days before presentation. The case is suspect of a COVID-19 related etiology. 

Live Renal Ultrasonography Facilitates Double-J Ureteral Stent Insertion at the Bedside: A Pilot Study for the COVID-19 Era.

Objectives: To investigate the feasibility and efficacy of live renal ultrasonography to guide Double-J ureteral stent placement at the bedside. Patients and Methods: Between April 12 and June 5, 2020, patients presenting with acute ureteral obstruction requiring decompression were prospectively selected for ultrasound-guided bedside ureteral stent placement. During stent placement, upper tract access confirmed using ultrasound with or without retrograde injection of ultrasound contrast before Double-J stent insertion. A postprocedural abdominal X-ray was obtained for stent position confirmation. Results: Eight patients (four men and four women) were offered bedside ultrasound-guided ureteral stent placement, and all eight consented to proceed. Stents were placed in seven of eight patients. One patient had an impacted ureterovesical junction stone and stricture requiring ureteroscopy and laser lithotripsy in the operating room. All patients tolerated procedures without immediate complications. Conclusion: Live renal ultrasonography can facilitate a high success rate for bedside ureteral stent placement outside the operating room. This approach is an attractive alternative to fluoroscopy-guided stent placement in the operating room and is of particular value in the COVID-19 era when judicious use of these resources is salient.

A rare case of spontaneous parenchymal kidney explosion in a patient with ureteral obstruction caused by a single stone.

INTRODUCTION: Spontaneous rupture of kidney may involve collecting system or parenchyma. Parenchymal rupture usually occurs in patients with renal cell carcinoma, angiomyolipoma, renal cysts, arteriovenous malformation or vascular diseases such as periarteritis nodosa. Collecting system rupture is usually a rare complication of obstructive urolithiasis. We describe the unusual cases of spontaneous kidney rupture in patients with acute urinary obstruction. CASE PRESENTATION: The case report describes the left parenchymal kidney explosion related to ipsilateral ureteral obstruction caused by a single ureteral stone. The patient reached our emergency department with acute left flank pain and massive haematuria. At the moment of admission, the patient was in stage III hypovolemic shock and had a lower haematocrit (haemoglobin = 4.9 g/dL). Despite blood transfusions, emergency surgical exploration, extrafascial nephrectomy and intensive support care, the patient died twelve hours after surgery. CONCLUSIONS: Parenchymal renal rupture can be a life-threatening emergency. Despite its rarity, in the differential diagnosis of acute abdomen, parenchymal renal rupture should always be considered in patients with abdominal pain and an anamnesis or history of urinary stones, pointing out the need of early diagnosis also in benign urological conditions.

Remdesivir inhibits renal fibrosis in obstructed kidneys (preprint)

Aim Kidney impairment is observed in patients with COVID-19. We aimed to demonstrate the effect of anti-COVID-19 agent remdesivir on renal fibrosis. Methods Remdesivir and its active nucleoside metabolite GS-441524 were used to treat TGF-β stimulated renal fibroblasts (NRK-49F) and human renal epithelial cells (HK2). Cell viability was determined by CCK8 assay, and fibrotic markers were measured by Western blotting. Vehicle or remdesivir were given by intraperitoneal injection or renal injection through the left ureter in unilateral ureteral obstruction (UUO) mice. Serum and kidneys were harvested. The concentrations of remdesivir and GS-441524 were measured using LC-MS/MS. Renal and liver function were assessed. Renal fibrosis was evaluated by Masson’s trichrome staining and Western blotting. Results Remdesivir and GS-441524 inhibited cell proliferation and the expression of fibrotic markers (fibronectin, pSmad3, and aSMA) in NRK-49F and HK2 cells. Intraperitoneal injection or renal injection of remdesivir attenuated renal fibrosis of UUO kidneys. Renal and liver function were not changed in remdesivir treated UUO mice. Remdesivir can not be detected, but two remdesivir metabolites were detected after injection. Conclusion Remdesivir inhibits renal fibrosis in obstructed kidneys.