Predictive factors for nephrectomy in renal trauma; assessment of a 6-point score.

PURPOSE: To evaluate predictive and associated risk factors for nephrectomy in renal trauma and assess a 6-point score for surgical decision-making. PATIENTS AND METHODS: This multicenter, retrospective, and observational study assessed 247 subjects with blunt or penetrating kidney trauma. Kidney injuries were classified according to the American Association for the Surgery of Trauma (AAST) Injury Scoring Scale. Renal trauma was classified as "low-grade" (Grades I-III), Grade IV, and Grade V. Subjects were compared according to conservative treatment (CTrt.) or nephrectomy. Predictive factors were evaluated with a multiple regression model. A 6-point score was evaluated with a ROC analysis. RESULTS: Patients requiring nephrectomy had a lower mean arterial pressure MAP compared to CTrt, 64.71 mmHg (SD ± 10.26) and 73.86 (SD ± 12.42), respectively (p = < 0.001). A response to IV solutions was observed in 90.2% of patients undergoing CTrt. (p = < 0.001, OR = 0.211, 95%CI = 0.101-0.442). Blood lactate ≥ 4 mmol/L was associated with nephrectomy (p = < 0.001). A hematoma ≥ 25 mm was observed in 41.5% of patients undergoing nephrectomy compared to 20.1% of CTrt. (p = 0.004, OR = 9.29, 95% CI = 1.37-5.58). A logistic regression analysis (p = < 0.001) showed that blood lactate ≥ 4 mmol/L (p = 0.043), an inadequate response to IV solutions (p = 0.041) and renal trauma grade IV-V (p = < 0.001), predicted nephrectomy. A 6-point score with a cut-off value ≥ 3 points showed 83% sensitivity and 87% specificity for nephrectomy with an AUC of 89.9% (p = < 0.001). CONCLUSIONS: An inadequate response to IV solutions, a lactate level ≥ 4 mmol/L, and grade IV-V renal trauma predict nephrectomy. A score ≥ 3 points showed a good performance in this population.

Perioperative predictors for complications in patients with Xanthogranulomatous Pyelonephritis treated with nephrectomy.

INTRODUCTION: Xanthogranulomatous pyelonephritis is an inflammatory disease characterized by chronic obstruction and infection. This pathology is a life-threatening condition when surgical treatment is carried out. We decided to retrospectively evaluate whether there were perioperative factors that predict complications in patients who undergo nephrectomy. METHODS: We reviewed all nephrectomies done in the period of 2013-2018, in a tertiary referral Hospital with the histopathological diagnosis of Xanthogranulomatous Pyelonephritis. RESULTS: The presence of renal abscess at admission was observed as a risk factor associated with perioperative complications (p = 0.002), presence of abscess was observed in 47.4% of subjects without complications compared to 89.3% of the perioperative complication group. Higher rates of blood transfusion requirement were observed in the perioperative complication group, 89.3% compared to 68.4% (p = 0.029), furthermore, perioperative bleeding was slightly greater in the complication group compared to its counterpart, 700 mL, and 600 mL, respectively (p = 0.01). CONCLUSIONS: Anemia and the presence of abscess were important perioperative factors that predict perioperative complications.

Unusual Presentation of Wünderlich Syndrome.

Background: Wünderlich syndrome is a rare but important condition because it involves a sudden blood collection in the renal fossa that can cause hemodynamic instability. Case Report: A 38-year-old female with a history of type 2 diabetes mellitus and hypertension with poor adherence to treatment presented to the emergency department with abdominal pain of 2 weeks' duration accompanied by irritative lower urinary symptoms. Abdominal computed tomography (CT) scan showed bilateral pyelonephritis and an abscess in the lower pole of the right kidney. A second CT scan, performed because of the patient's abrupt decrease in hemoglobin and hematocrit, showed active bleeding secondary to the infectious process in the right kidney. The patient was hemodynamically unstable, so a nephrectomy was performed. Conclusion: Wünderlich syndrome is a spontaneous renal hemorrhage, in most cases attributed to a tumorous etiology and rarely of infectious origin. The clinical picture is varied but can present with the Lenk triad of acute onset flank pain, flank mass, and hypovolemic shock. It is diagnosed principally via an imaging study such as abdominal CT scan. Treatment is conservative in principle, but urgent surgical intervention is sometimes necessary depending on the clinical situation of the patient.

Emphysematous Pyelonephritis and Emphysematous Cholecystitis: A Result of Uncontrolled Type 2 Diabetes.

Background: Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection that results in the presence of gas in the renal parenchyma, collecting system, and surrounding tissues. Up to 95% of patients with EPN have underlying uncontrolled diabetes mellitus. Emphysematous cholecystitis (EC) is a necrotizing infection defined by the presence of gas in the gallbladder. Concurrent presentation of EPN and EC is limited to anecdotal cases in the literature. Case Report: We present the case of a 44-year-old female who arrived at the emergency department with signs of septic shock and diffuse abdominal pain. Diagnosis of EPN and EC was confirmed. Because the patient did not improve after aggressive medical therapy and percutaneous drainage and cholecystostomy, she was taken to surgery for emergency nephrectomy and cholecystectomy. Conclusion: In unusually extensive and severe cases of EPN, medical and minimally invasive procedures are not enough to control the infection. More aggressive management, including emergency surgery, should be implemented in selected patients who present with refractory septic shock associated with extensive disease.

Gouty Tophus in the Scrotum: An Unusual Extra-Articular Manifestation of Gout.

Background: Gout is a chronic disorder caused by the deposition of monosodium urate crystals in soft tissues. Tophi are granulomatous inflammatory responses to the deposited crystals and manifest as subcutaneous nodules, typically in the first metatarsophalangeal joint but also in the olecranon bursa, Achilles tendon, ears, and finger pulps. Case Report: A 56-year-old male presented to an outpatient clinic with an 8-month history of an expanding scrotal lesion. The patient had no significant family history but had a history of high blood pressure and gout, diagnosed at age 24 years, without current treatment. Excisional biopsy from the ulcerated area of the scrotum was performed for confirmatory diagnosis, and pathology reported gouty tophus. Conclusion: To our knowledge, this case is the first report of a scrotal manifestation of gouty tophus and the second of genital involvement. Awareness of the possibility of genital manifestations of this disease is important because although gouty tophi are rare, they can present in patients with long-term uncontrolled gout.

Emphysematous Pyelonephritis in a Horseshoe kidney.

Emphysematous pyelonephritis is a necrotizing renal infection that results in the presence of gas in renal parenchyma, collecting system, and surrounding tissues. Ninety-five percent of the patients have underlying uncontrolled diabetes mellitus, but non-diabetic patients may be affected due to ureteral obstruction and infection with gas forming pathogens. Several poor prognostic factors have been described, such as thrombocytopenia, acute kidney failure, impaired consciousness, and shock. We present a case of a 41-year-old female who attends to the emergency department with signs of septic shock and diffuse abdominal pain. The diagnosis of emphysematous pyelonephritis in a horseshoe kidney was confirmed.