Emphysematous pyelonephritis in decompensated diabetes: a case report and review of the literature.

Emphysematous pyelonephritis is a rare and severe renal parenchyma necrotizing infection visible just in diabetic patients which results in gas presence--probably produced through the glucose fermentation process--in the collecting system, renal parenchyma and perirenal tissue. We present a case of a not known diabetic female patient with emphysematous pyelonephritis of the left kidney and emphysematous pyelitis of the controlateral kidney.

Ureteral stones: SWL treatment.

UNLABELLED: When stone removal is indicated SWL (Shock Wave Lithotripsy) and ureteroscopy (URS) are the two most commonly offered interventional procedures and they are both acceptable as first-line treatment. The choice of the procedure depends on several factors, including local experience, patient preference, available equipment, and associated costs. The meta-analysis by the EAU/AUA Guideline Panel in 2007 analysed SWL stone-free results for three locations in the ureter (proximal, mid, distal) and reported an overall stone-free rate for proximal ureteral stones of 82%, with no difference in stone-free rate from URS results. However, for stones < 10 mm SWL, at 90%, had a higher stone-free rate than URS and even for mid and distal ureter it reached a stone-free rate of 84% and 86% respectively. It does appear that SWL may be more effective in the paediatric subset than in the overall population, particularly in the mid and lower ureter with a stone free rate of 82% and 80% respectively. In fact, children appear to pass stone fragments after SWL more readily than adults. SWL is a safe method to treat ureteral stones and serious complications occur very rarely when proper indications are followed. A few published studies addressed the role of SWL in acute renal colic. The available data suggest that is a safe procedure, with an overall success of 70-80% and a need for further intervention in 2-20%. In choosing the optimal therapy for an individual patient, several factors that might affect the outcome should be considered to identify the best candidate for SWL. A superior success rate for proximal ureteral stones was reported in the EAU/AUA meta-analysis but stone size over 10 mm appears negatively correlated with the stone-free rate. About composition, calcium oxalate monohydrate, brushite, cystine and matrix are unfavourable compositions for SWL. Finally, impacted stones are often more resistant to fragmentation. Whether hydronephrosis affects the outcome of SWL remains controversial. A body mass index of over 30 has been found to be an independent factor in predicting failure of SWL treatment in ureteral stones. A number of treatment strategies have been proposed to increase SWL efficacy: a promising suggestion to improve SWL outcome is to reduce the shock wave rate. There have also been attempts to improve shock wave efficiency of stone fragmentation with new shock wave lithotriptor devices. But although these innovation are promising, no advantage in stone-free rate or retreatment rate have yet been proven. Acoustic coupling is a key factor affecting the efficacy of shock wave lithotripsy. An accurate pre-treatment assessment of stone burden and composition with unenhanced CT scan provides useful information to discern which treatment strategy should be favoured and may reduce SWL failure. The real cost for SWL and URS varies considerably from one centre to another, as a result of different internal organisations and also due to the principles of reimbursement from the health care system. CONCLUSIONS: SWL is the first treatment choice for stones smaller than 1 cm in the proximal ureter With a lower grade of invasiveness and the possibility to complete the treatment with only analgesics and sedation on an outpatient basis, SWL still appears an excellent alternative for removing ureteral stones and these properties compensate for the higher need for repeated treatments. An accurate pre-treatment assessment of stone and clinical factors to select the best candidates for SWL could improve the stone-free rate and reduce retreatments.

High burden stones: the role of SWL.

Percutaneous nephrolithotomy (PCNL), PCNL and Shock Wave Lithotripsy (SWL), SWL monotherapy and open surgery are nowadays the potential treatment alternatives for patients with staghorn stones. Several groups have proposed classification schemes to better define staghorn calculi dimensions taking into account size, morphology and composition of the stones. More recently the use of a CT imaging with three-dimensional reconstruction or of a coronal reconstruction of axial CT images was reported to obtain an accurate stone volume calculation. The difficulty in accurately assessing stone burden explains the wide range of reported stone-free rates for SWL monotherapy from 22 to 85%. A recent AUA guideline of the management of staghorn calculi stated that stone free rate is 78% for PCNL and 54% for SWL monotherapy and these values are similar to those reported in Segura guideline but the rate for combination treatment (PNL + SWL) is now lower (66% versus 81%) than in the previous guideline. This reduction is probably due to the fact that in the recent meta-analysis SWL was the last procedure and in the previous generally a sandwich therapy was performed with PCNL followed by a SWL and a secondary PCNL. Improved PCNL techniques with use offlexible nephroscopy and multitract PCNL allow to achieve complete stone clearance by PCNL alone. Complete removal of stone is crucial to eradicate infection and prevent further stone regrowth. Residual fragments may perpetuate postreatment infection and stone regrowth has been reported up to 78% in such patients after SWL monotherapy. In our previous experience (prior to 2000) we observed 45 pts with high burden stones: 31/45 pts (68%) underwent combined therapy PCNL and SWL with a successful rate of 65% (stone free and fragments < 4 mm). In our more recent experience ('03-'08) we treated 34 patients with high burden stones: we performed combined therapy PCNL and SWL in 11 pts (32%) with an overall success rate of 63%. PCNL was undertaken initially with the attempt to remove as much stone as possible with the aid offlexible nephroscopy and SWL was used only for residual stones because the passage, even of fragments < 4 mm, does not always occur in dilated renal cavities. SWL monotherapy should not be used for most patients and may be considered only in patients with small volume staghorn stones with normal collecting system.

Primary cell cultures from human renal cortex and renal-cell carcinoma evidence a differential expression of two spliced isoforms of Annexin A3.

Primary cell cultures from renal cell carcinoma (RCC) and normal renal cortex tissue of 60 patients have been established, with high efficiency (more than 70%) and reproducibility, and extensively characterized. These cultures composed of more than 90% of normal or tumor tubular cells have been instrumental for molecular characterization of Annexin A3 (AnxA3), never extensively studied before in RCC cells although AnxA3 has a prognostic relevance in some cancer and it has been suggested to be involved in the hypoxia-inducible factor-1 pathway. Western blot analysis of 20 matched cortex/RCC culture lysates showed two AnxA3 protein bands of 36 and 33 kDa, and two-dimensional Western blot evidenced several specific protein spots. In RCC cultures the 36-kDa isoform was significantly down-regulated and the 33-kDa isoform up-regulated. Furthermore, the inversion of the quantitative expression pattern of two AnxA3 isoforms in tumor cultures correlate with hypoxia-inducible factor-1alpha expression. The total AnxA3 protein is down-regulated in RCC cultures as confirmed also in tissues by tissue microarray. Two AnxA3 transcripts that differ for alternative splicing of exon III have been also detected. Real-time PCR quantification in 19 matched cortex/RCC cultures confirms the down-regulation of longer isoform in RCC cells. The characteristic expression pattern of AnxA3 in normal and tumor renal cells, documented in our primary cultures, may open new insight in RCC management.

A rare case of benign fibroepithelial tumor of the seminal vesicle.

Primary tumors of seminal vesicles are rare. We report on a benign tumor of the seminal vesicle with fibroepithelial and cystic features. We performed a laparoscopic transperitoneal approach. The mass, not fixed to any anatomical structures except to the prostate, was isolated and removed. Histological examination of tumor revealed two distinct components: epithelial and stromal. We consider the term fibroadenoma more appropriate than cystoadenoma, because the stroma is not reactive but a distinct neoplastic component.