Case Report: A Case of Sintilimab-Induced Cystitis/Ureteritis and Review of Sintilimab-Related Adverse Events

Immune checkpoint inhibitors (ICIs) have been proven to be beneficial in multiple advanced malignancies. However, the widespread use of ICIs also occurred with various immune-related adverse events (irAEs). Here, we first report a case of sintilimab-related cystitis/ureteritis. A 53-year-old man with driver gene-negative pulmonary adenocarcinoma (cT1cN3M1c, Stage IVB) was being treated with sintilimab in combination of paclitaxel-albumin and bevacizumab as second-line treatment. He was hospitalized for haematuria, pollakiuria, painful micturition and low back pain after three courses. Urinalysis showed red blood cells (RBCs) and white blood cells (WBCs) were obviously increased, and serum creatinine (sCr) level was also significantly elevated. Urine culture and cytology were both negative, and cystoscopy revealed diffused redness of bladder mucosa. Urinary ultrasonography showed mild hydronephrosis and dilated ureter. The patient was diagnosed as immunotherapy-related cystitis/ureteritis after a multidisciplinary team (MDT) meeting. Once the diagnosis was made, corticosteroid therapy was given, which rapidly resolved the patient’s symptoms and signs. Computer tomography angiography (CTA) and CT urography (CTU) was conducted after sCr level was back to normal and demonstrated ureter dilation and hydroureter. Once symptoms relieved, bladder biopsy was performed and confirmed the bladder inflammation. The patient was subsequently switched to maintenance dose of methylprednisolone and tapered gradually. Since sintilimab has been used in advanced malignancies, we first reported a rare case of sintilimab-induced cystitis/ureteritis and summarized sintilimab-related adverse events to improve the assessment and management of irAEs.

Comparison of static-fluid or excretory magnetic resonance urography with computed tomography urography for visualization of nondilated renal pelvises and ureters in healthy Beagles

OBJECTIVE To assess the usefulness of magnetic resonance urography (MRU) for the visualization of nondilated renal pelvises and ureters in dogs and to compare our findings for MRU versus CT urography (CTU). ANIMALS 9 healthy Beagles. PROCEDURES Dogs underwent CTU, static-fluid MRU, and excretory MRU, with ≥ 7 days between procedures. Contrast medium was administered IV during CTU and excretory MRU, whereas urine in the urinary tract was an intrinsic contrast medium for static-fluid MRU. For each procedure, furosemide (1 mg/kg, IV) was administered, and reconstructed dorsal plane images were acquired 3 minutes (n = 2) and 7 minutes (2) later. Images were scored for visualization of those structures and for image quality, diameters of renal pelvises and ureters were measured, and results were compared across imaging techniques. RESULTS Excretory MRU and CTU allowed good visualization of the renal pelvises and ureters, whereas static-fluid MRU provided lower visualization of the ureters. Distention of the renal pelvises and ureters was good in excretory MRU and CTU. Distention of the ureters in static-fluid MRU was insufficient compared with that in CTU and excretory MRU. Distinct artifacts were not observed in CTU and excretory MRU images. Static-fluid MRU images had several mild motion artifacts. CLINICAL RELEVANCE Our findings indicated that excretory MRU with furosemide administration was useful for visualizing nondilated renal pelvises and ureters of dogs in the present study. When performing MRU for the evaluation of dogs without urinary tract dilation, excretory MRU may be more suitable than static-fluid MRU.

Clinical characteristics and outcome of genitourinary tuberculosis in Sri Lanka: an observational study

Background Although genitourinary Tuberculosis (GUTB) is the second commonest source of extrapulmonary TB in most countries, the reported rate of GUTB in Sri Lanka remains low. The characteristics of GUTB in Sri Lanka have not been studied and documented so far. We aimed to study the clinical and imaging characteristics, treatment modalities and outcome of GUTB in Sri Lanka. Methods Data collected from patients treated by a single urological surgeon in two institutes consecutively over a period of 21 years were analysed. All patients with a microbiological and/or histopathological diagnosis of GUTB were included. Median duration of follow-up was 24 months (range: 6–96). Results There were 82 patients and 45 (54.9%) were men. The median age was 51 (range: 26–75) years. Most patients (39%, n = 32) had vague non-specific symptoms at presentation. Common specific symptoms at presentation were haematuria (15.8%, n = 13) and scrotal manifestations (15.8%, n = 13). Mantoux test was done in 70 patients and was > 10 mm in 62 (88.5%). Erythrocyte sedimentation rate was available in 69 patients and was > 30 mm in 54 (78.3%) patients. Chest x-ray and x-ray kidney-ureter-bladder (KUB) abnormalities were detected in 9 (11%) and 6 (7.3%) respectively. CT-urography was performed in 72 patients and abnormalities were detected in 57 (79%) patients. Forty-two patients underwent cystoscopy and 73.8% (n = 31) had abnormal findings. Microbiological diagnosis was feasible in 43 (52.4%) and rest were diagnosed histopathologically. Commonest organs involved were kidney (64.6%, n = 53), ureter (51.2%, n = 42), bladder (43.9%, n = 36) and testis/epididymis (15.8%, n = 13). One patient had TB of the prostate. All were treated primarily with anti-TB drugs however, 50 (61%) required ancillary therapeutic interventions. The majority of interventions were reconstructive surgeries (n = 20, 24.4%) followed by excisional surgeries (n = 19, 23.2%) and drainage procedures (n = 11, 13.4%). Seven patients developed serious adverse reactions to anti-TB drugs. Five patients developed a thimble bladder with disabling storage symptoms. Eight patients had deranged renal functions at diagnosis and three patients developed progressive deterioration of renal function and two patients died of end stage renal disease. Conclusions The combination of urine for acid-fast bacilli, Mantoux test, CT-Urography, cystoscopy and histopathology is necessary to diagnose GUTB in resource-poor settings. Most ureteric strictures, non-functioning kidneys and epididymal masses need surgical treatment. Long-term follow up is essential to detect progressive deterioration of renal function.

OVARIAN VEIN SYNDROME: A CASE REPORT

The ovarian Vein Syndrome was first reported in 1964, yet its existence as a true pathophysiological entity remains controversial. It may present as an acute ora chronic disease, typically affecting young, multiparous women. We present in this article a 32-year-old patient with chronic renal colic, ultrasound and CT urography showing an extrinsic compression of the right lumbar ureter by the ovarian vein, a ligation, anda resection of the ovarian vein were performed by transperitoneal laparoscopy.

Retrograde Pyelography in the Presence of Urothelial Bladder Cancer Does Not Affect the Risk of Upper Tract Urothelial Cancer: A Retrospective Analysis of a Single-Centre Cohort

<b><i>Objective:</i></b> Patients with bladder cancer (BC) are at risk of developing upper tract urothelial carcinoma (UTUC). Therefore, CT urography is recommended for follow-up. To avoid intravenous contrast agents, retrograde pyelography (RPG) is an alternative. However, it is still unclear whether RPG increases the incidence of UTUC. The aim of this study was to investigate the impact of RPG in the presence of BC on the risk of developing UTUC. <b><i>Patients and Methods:</i></b> Retrospectively analysing a total of 3,680 RPGs between 2009 and 2016, all patients with simultaneous BC (group 1) and those without synchronous BC (group 2) during RPG were compared. All patients were risk stratified according to the EORTC bladder calculator. In patients without BC during RPG, risk stratification was based on the worst prior tumour characteristics. <b><i>Results:</i></b> A total of 145 patients with a history of BC were analysed. Of these, 112 patients underwent RPG with simultaneous BC. UTUC developed in 6 of 112 patients (5.4%) and 58.9% (66/112) had high-risk BC according to the EORTC bladder calculator. In the control group, one out of 33 (3%) patients with metachronous high-risk BC developed UTUC. <b><i>Conclusions:</i></b> Using RPG in the presence of BC did not increase the risk of UTUC. Due to the predominant number of high-risk/high-grade tumours, individual tumour biology appears to be the primary driver for the development of UTUC.

Characteristics of genitourinary tuberculosis in Sri Lanka: A retrospective cohort study

BackgroundAlthough genitourinary Tuberculosis (GUTB) is the second commonest source of extrapulmonary TB in most countries, the reported rate of GUTB in Sri Lanka remains very low. Furthermore, the characteristics of GUTB in Sri Lanka have not been published due to paucity of data. Therefore, we aimed to study the clinical and imaging characteristics, treatment modalities and outcomes of GUTB in Sri Lanka. MethodsA retrospective analysis was performed based on patients treated by a single urological surgeon in two consecutive centres over a period of 21 years. All patients (n=82, males = 45 (54.9%), median age: 51 years; range: 26 - 75) with a microbiological and/or histological diagnosis of GUTB were included. Median duration of follow-up was 24 months (range: 6- 96). Data were obtained from direct patient interview, hospital notes and clinic files. ResultsCommonest prominent symptoms at presentation included haematuria (n=13, 15.8%) and scrotal manifestations (n=12, 14.6%). Mantoux was either positive (>10mm) (n=62/70) or equivocal (>5mm) (n=8/70). Erythrocyte sedimentation rate (ESR) was available in 69 patients and was >30 in 54 (78.3%) patients. Chest x-ray and x-ray kidney-ureter-bladder (KUB) abnormalities were detected in 9 (11%) and 6 (7.3%) respectively. CT-urography was performed in 72 patients and abnormalities were detected in 57 (79%) patients. Forty-two patients underwent a cystoscopy and 73.8% (n=31) had abnormal findings. Microbiological diagnosis was feasible in 42 (51.2%) and rest were diagnosed histologically. Commonest organs involved were kidney (64.6%, n=53), ureters (51.2%, n=42), bladder (43.9%, n=36) and testis/epididymis (14.6%, n=12). One patient had prostate TB. All were treated primarily with anti-TB drugs however, 50 (61%) had indications for some form of therapeutic intervention. The majority of interventions were reconstruction surgeries (n=20, 24.4%) followed by excision surgeries (n=19, 23.2%) and drainage procedures (n=11, 13.4%).Seven patients developed serious adverse reactions to anti-TB drugs. Five patients developed a thimble bladder and 3 patients developed end-stage renal failure. Two patients had relapse of infection. ConclusionCT-Urography, cystoscopy and histopathology are essential adjuncts to diagnose GUTB. Most ureteric strictures, non-functioning kidneys and epididymal masses needed surgical treatment. Long-term follow up is essential to detect progressive renal dysfunction.

Contrast-enhanced ultrasonography promotes differential diagnosis of ureteral neoplasms

Objective: To compare the diagnostic value of contrast-enhanced ultrasonography (CEUS) with baseline ultrasound (B-US) in ureteral neoplasms. Methods: Retrospective analysis, comprising clinical presentation, image appearances, and diagnostic results on B-ultrasound and CEUS, considering pathological result as a gold-standard, was conducted on the clinical information of 39 patients with ureteral neoplasms. CT urography was used to detect and confirm the presence of ureteral neoplasms. Both B-ultrasound and CEUS investigations of those 39 patients under study were performed by a senior radiologist. Results: Pathological outcomes established 27 ureteral malignancies and 12 ureteral benignancies. Ureteral malignancies were observed to occur in older patients than benignancies (p = 0.002). Only the morphological indicator of the ureteric wall on B-ultrasound was different in ureteral malignancies and benignancies (p = 0.030). Tumors with hyperenhancement, larger width, and hyperenhanced ureteric wall were easily diagnosed as malignant on CEUS, whereas iso-/hypoenhanced, narrower, and iso-/hypoenhanced ureteric wall indicated benign tumors. Moreover, the lesion widths, enhanced morphologies of the ureteric wall, and the ureteral wall’s linear boundaries on CEUS were different between high- and low-stage ureteral urothelial carcinomas (p = 0.012, 0.002, 0.001, respectively). Conclusion: The display of microvessels in ureteral neoplasms was significantly enhanced by CEUS, thus contributing to the differential diagnosis of ureteral neoplasms while assisting the staging of ureteral urothelial carcinoma. Advances in knowledge: The imaging features of different ureteral neoplasms on CEUS were analyzed in this study. The diagnostic performances of CEUS and B-ultrasound in ureteral urothelial carcinomas were also explored.

1191 The Use of CT Urography to Diagnose Upper Tract Urothelial Carcinomas (UTUC); Managing Surgical Resources During The COVID-19 Pandemic

Introduction Upper tract urothelial carcinomas (UTUC) account for 5-10% of urothelial malignancies. Rapid diagnosis is essential as 60% are invasive at diagnosis and confer poor prognoses. European Association of Urology (EAU) guidelines recommend CT urography (CTU) for initial diagnosis and staging of UTUCs. Diagnostic ureteroscopy (URS) is used second line where diagnosis is unclear. The COVID-19 pandemic has limited theatre access and may delay diagnosis of suspected UTUC. Our aim was to evaluate specific CTU findings in predicting UTUC to aid prompt diagnosis and risk stratification in a tertiary centre. Method A retrospective analysis was performed on 122 patients who underwent CTU with diagnostic URS over two years from 2018-2019 for possible UTUC. Data including demographics, imaging and histology were collected from our electronic database. Results 57 patients had confirmed UTUC, all had CT changes. CTU had an overall positive predictive value (PPV) of 45%. CT findings were divided into: hydronephrosis; filling defect/lesion; urothelial thickening; normal; or other. The PPV was highest for filling defects/lesions at 60%, hydronephrosis was 38%, urothelial thickening was 30%, and other was 33%. Of those with high-grade histology, 61% had evidence of filling defects/lesions and 24% had hydronephrosis. Conclusions A specific CTU finding of filling defect/lesion in combination with cytology can aid diagnosis and risk stratification of UTUC. This may enable us to reduce use of diagnostic URS, as well as associated risks of intravesical seeding, necessary in the COVID-19 pandemic. With other CTU findings of hydronephrosis or urothelial thickening, a diagnostic URS may be required.

Upper tract imaging modality to investigate haematuria: cancer detection rates and changing guidelines

Background To assess the imaging modalities used to investigate both visible haematuria and non-visible haematuria along with their detection rate of malignancy at two hospitals and the corresponding radiological workload produced. Methods A retrospective study was conducted across two hospitals. All CT urograms and ultrasound scans investigating haematuria in the outpatient setting over a 12-month period were evaluated. Results The detection rate for upper tract urothelial cancer with visible haematuria was 0.97% and for renal cell carcinoma was 0.64%. Of all the CT urograms performed for non-visible haematuria 4.9% had suspicious findings but none of these represents an underlying malignancy. Of all the ultrasound scans performed for either visible or non-visible haematuria, none were shown to have an underlying malignancy. The detection rate was thus zero for an upper tract urinary cancer or renal cell carcinoma in the non-visible haematuria group. A CT urogram was performed in 27% and 67% of cases in each respective hospital to further investigate non-visible haematuria. CT urography makes up 2.3% and 5.2% of each hospitals overall respective workload in the CT department. CT urography to investigate non-visible haematuria could be replaced by ultrasound in low-risk patients. Conclusions Radiological investigations are a limited resource and better rationalisation of upper tract imaging is needed in the setting of haematuria. Risk stratification of patients would be of benefit to help prevent a significant delay in timely diagnostics for higher risk individuals presenting with haematuria.

Outcome of simultaneous angioembolization and nephron sparing surgery in large renal angiomyolipomas

Aim: To study the outcome of simultaneous angioembolization and nephron sparing surgery in large renal angiomyolipomas. Materials and methods: A prospective study of carried out from 2016 to 2019. A total of 15 patients were included in the study with a lesion (angiomyolipoma) more than 10 cm in size, suitable for nephron sparing surgery. The workup of the patients included history, baseline blood investigations, ultrasonography, and CT urography including angiographic films. All the patients were taken up for selective of angioembolization of the feeding vessels of the AML carried out by the interventional radiologist followed by nephron sparing surgery in the same sitting. The short term outcomes studied were warm ischemia time, average blood loss, and length of post-operative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen and functional outcome by assessing the function of the preserved renal parenchyma. Results: Twelve out of fifteen cases were female. The mean age was 42.25 years. All the patients had lesion more than 10 cm with seven tumors located at the lower pole, four at mid-pole, and four at upper pole. Eight patients had low complexity score on RENAL score (i.e. 4–6), five patients medium complexity score (i.e. 7–9), and two had high complexity score (i.e. ⩾10). Average blood loss was 200 ml, warm ischemia time was 18.46 min and postoperative stay was 3.55 days. All the 15 specimens sent for histopathology were confirmed as AML (angiomyolipomas) with margins free of tumor. Follow up CECT done at 4 months postoperatively revealed functioning residual renal parenchyma with prompt excretion of contrast. Conclusion: Large AML’s are also amenable to nephron sparing surgery. However patient should always be warned about the possibility of total nephrectomy. Selective angioembolization helps in reducing the blood supply and risk of torrential bleeding thus facilitates in the removal of the tumor and increasing the chances of nephron sparing surgery.