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Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
Enteric infectious diseases claim more than 1 million lives annually and are among the top ten causes of death in children younger than 5 years. Remarkable global investment has been dedicated to enteric infectious disease prevention and control; however, the shifting global health landscape is testing the continuance of progress. To evaluate the current status and guide future interventions, we present the latest epidemiological estimates of enteric infectious diseases from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 and assess progress towards the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) mortality target of fewer than 20 deaths per 100 000 children younger than 5 years by 2025. We quantified the incidence, mortality, and disability-adjusted life-years (DALYs) of enteric infectious diseases by age, sex, and year across 204 countries and territories from 1990 to 2023. In GBD 2023, the following were considered under the category of enteric infectious diseases: diarrhoeal diseases, enteric fever (typhoid and paratyphoid), invasive non-typhoidal Salmonella spp (iNTS) infections, and other intestinal infectious diseases. We also examined 15 aetiologies contributing to diarrhoeal diseases. Incidence and prevalence were estimated with DisMod-MR (version 2.1), a Bayesian meta-regression tool, drawing on data from systematic reviews, population-based surveys, claims data, and hospital sources. Cause-specific mortality was modelled with Cause of Death Ensemble Modelling based on data from sources including vital registration, mortality surveillance, verbal autopsy, and minimally invasive tissue sampling. Years of life lost and years lived with disability were computed and combined to derive DALYs. For aetiology-specific estimation, population-attributable fractions (PAFs) for 15 pathogens were derived with a counterfactual framework. Point estimates and 95% uncertainty intervals (UIs) were generated from 250 draws from the posterior distribution. In 2023, enteric infectious diseases resulted in an estimated 1·27 million (95% UI 0·963-1·68) deaths globally, declining from 3·69 million (3·04-4·56) in 1990. The global age-standardised mortality rate (ASMR) decreased from 74·1 (62·0-92·9) per 100 000 population to 16·4 (12·6-21·3) per 100 000 population during the same period. Diarrhoeal diseases accounted for most deaths in 2023 (1·11 million [0·811-1·54]), followed by enteric fever and iNTS. South Asia and sub-Saharan Africa remained the most affected regions in 2023, with 599 000 (441 000-882 000) and 501 000 (373 000-648 000) deaths due to enteric infectious diseases, respectively, predominantly from diarrhoeal disease. Rotavirus was the leading cause of all-age diarrhoeal disease deaths (PAF 16·3% [12·0-21·5]), followed by norovirus (10·2% [2·4-17·0]) and Shigella spp (9·3% [5·4-15·2]). Among children younger than 5 years, PAFs of deaths due to diarrhoeal diseases were 40·2% (32·5-48·5) for rotavirus, 24·0% (15·1-36·7) for Shigella spp, and 23·4% (13·7-34·3) for adenovirus. Across 204 countries and territories, 141 met the GAPPD mortality target in 2023. The driving aetiologies among countries that did not meet the target in 2023 varied slightly by GBD super-region, but the highest or second-highest number of deaths in children younger than 5 years were consistently attributed to rotavirus. Astrovirus and sapovirus, newly included in GBD 2023, were responsible for 24 600 (6290-49 000) and 18 800 (4650-44 400) deaths, respectively, in 2023, mainly in children younger than 5 years. Our findings show that mortality and ASMRs of enteric infectious diseases declined substantially between 1990 and 2023. This decline is consistent with the expansion of public health measures and broader socioeconomic development. However, the burden in 2023 remains considerably high, with the highest mortality concentrated in sub-Saharan Africa and south Asia. Considering that more than a quarter of all countries had yet to meet the GAPPD mortality target in 2023, sustained efforts are needed to address the persistent burden in affected countries and to adapt to the changing global health landscape. Gates Foundation.
Penile melanoma is an extremely rare malignancy, representing less than 0.1% of all melanomas. It most commonly arises from the glans, foreskin, or urethral meatus. Deep cavernosal involvement without clinically evident cutaneous, mucosal, or urethral disease is an unusual presentation and poses significant diagnostic and therapeutic challenges. A 23-year-old male presented with progressive penile induration and pain. MRI revealed a lesion predominantly involving the corpus cavernosum, with no clinically evident cutaneous, mucosal, or urethral involvement. An excisional biopsy established the diagnosis of malignant melanoma; however, the initial specimen showed tumor involvement of the resection margin and did not include epidermal sampling. Systemic staging with whole-body CT and PET-CT showed no evidence of metastatic disease. The patient subsequently underwent partial penectomy with bilateral sentinel lymph node dissection, showing negative sentinel lymph nodes and free final surgical margins. One year later, 18F-FDG PET-CT demonstrated nodal and osseous metastatic disease, with hypermetabolic lymphadenopathies in the distal retroperitoneal, left iliac, and left inguinal regions, osseous lesions in the sternal manubrium, and a new right upper-lobe pulmonary micronodule. The patient received immunotherapy with a limited clinical response. This case describes an unusual presentation of melanoma predominantly involving the corpus cavernosum without clinically evident cutaneous, mucosal, or urethral involvement. The absence of epidermal sampling prevents definitive histological exclusion of a regressed or deeply invasive mucosal/cutaneous primary lesion. This report highlights the aggressive behavior of deeply located penile melanoma and the need for careful clinicopathological correlation and individualized multidisciplinary management.
Idiopathic scrotal calcinosis (ISC) is a rare, benign condition characterized by painless, calcified nodules within the scrotal dermis. Although typically asymptomatic, progressive growth and cosmetic concerns often lead patients to seek surgical intervention. We report a 35-year-old male with multiple asymptomatic scrotal nodules progressively enlarging over 3 years. Physical examination revealed firm, subcutaneous nodules ranging from 2 to 20 mm. Laboratory investigations, including serum calcium, phosphate, and parathyroid hormone, were unremarkable. Histopathological examination confirmed the diagnosis of ISC, revealing basophilic calcified deposits within a fibrous stroma without cystic epithelial lining, consistent with dystrophic calcification. A "pinch-and-punch" excision technique was performed under regional anesthesia supplemented by tumescent local infiltration. Individual nodules were elevated by pinching the overlying scrotal skin, followed by targeted removal using 2-4 mm disposable biopsy punches. No sutures were required. The procedure was completed with minimal bleeding and no intraoperative or postoperative complications. Complete epithelialization occurred within 1 week via secondary intention. At 3-month follow-up, no recurrence was observed and the patient reported high satisfaction with the aesthetic outcome. The pinch-and-punch excision technique-distinguished by its combination of the tissue-elevation pinching maneuver, tumescent infiltration for hydrodissection, and sutureless wound management-is a safe and cosmetically favorable approach to ISC, particularly for patients with multiple nodules. Histopathological confirmation remains essential. Further prospective studies with longer follow-up are warranted.
Mitomycin gel for the pyelocaliceal system (UGN-101) is an approved kidney-sparing therapy for upper tract urothelial carcinoma (UTUC). Little to no data exist on its safety and efficacy in patients with a history of urinary diversion. We report our experience with overcoming the anatomical challenges of UGN-101 instillation in patients with UTUC and prior history of radical cystectomy with urinary diversion. Retrospective review was performed on all patients with pre-existing urinary diversion who underwent UGN-101 instillation for management of UTUC at a single academic institution. Surgical techniques for instillation are described, and the clinical course, including complications and disease status, are reported. Two patients met inclusion criteria. One patient had carcinoma in situ in the renal pelvis and was treated with antegrade instillation via nephrostomy tube at an infusion clinic. The second patient had multifocal disease in the renal pelvis and the distal ureter and was treated with targeted antegrade instillation using an end-hole catheter. Both patients experienced infectious complications, and one had a ureteral stricture that resolved without intervention. No diversion-related complications were observed. Both patients are disease-free at last follow-up (10 months) on endoscopy and biopsy, although one patient required systemic immunotherapy. Our series highlights the potential role of UGN-101 in patients with UTUC and pre-existing urinary diversion. Antegrade instillation of UGN-101 can be tailored to specific disease locations and should be considered for patients with a history of urinary diversion who are not candidates for extirpative surgery.
The patient is an 80-year-old woman who initially underwent transurethral resection of a bladder tumor (TURBT) 7 years ago for bladder cancer at another hospital and was diagnosed with urothelial carcinoma (UC), high grade, pT1, followed by 8 cycles of intravesical BCG instillation therapy. Subsequently, her voiding urine cytology began to show suspicion of malignancy. When voiding urine cytology started to show positive findings, two transurethral biopsies of bladder mucosae and one selective upper tract urine cytology were performed with no evidence of malignancy, so she was followed up as an outpatient. She began experiencing spontaneous pain near the urethra and pain on urination 5 years after the initial TURBT. At this time, cystoscopy revealed redness on the posterior bladder wall. Additionally, redness of the vagina and induration of the labia were observed, raising suspicion of Paget's disease or Bowen's disease. She underwent a biopsy of the vulvar, which revealed UC. Ultimately, biopsies of the bladder, urethra, and vulvovaginal regions were performed at our hospital to determine a treatment plan. Immunohistochemical staining of the vulva was positive for cytokeratins 7 and 20 and negative for GCDFP15, confirming a diagnosis of extramammary Paget disease secondary to bladder CIS. As a result, the patient underwent radical surgery, including removal of the vagina, uterus, bladder, and labia. Pathological findings showed extensive CIS in the vagina and labia majora. Herein, we report a very rare case of secondary extramammary Paget disease extending from bladder CIS to the vagina and labia.
Testicular metastases from prostate carcinoma are exceedingly uncommon, particularly from the ductal histological subtype, which is associated with aggressive clinical behavior and a propensity for atypical metastatic dissemination. We report the case of a 73-year-old male with a history of prostate ductal adenocarcinoma (PDA) treated in 2018 with robot-assisted radical prostatectomy (RARP) and extended pelvic lymphadenectomy. Pathological staging was pT2c R0 N0 (0/53 nodes), and postoperative PSA was undetectable. The patient remained free of recurrence for 5 years. In March 2023, a biochemical recurrence prompted repeated thoracoabdominal computed tomography (CT) and pelvic magnetic resonance imaging (MRI) scans; neither study included dedicated scrotal imaging, and both were negative for recurrence. By March 2024, serum PSA had increased to 5.6 ng/mL, coinciding with the onset of progressive, painless enlargement of the left testicle. Scrotal ultrasonography revealed a solid mass replacing the left testicular parenchyma. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) and choline PET/CT showed a hypermetabolic lesion confined to the left testis, with no evidence of extratesticular disease. The patient underwent left inguinal orchiectomy. Histopathological examination revealed metastatic adenocarcinoma with papillary architecture, morphologically consistent with ductal prostate origin. PSA levels declined rapidly postoperatively, reaching 0.07 ng/mL within 40 days. At 13-month follow-up, the patient remained clinically and biochemically free of disease without further treatment. This case represents one of the few documented instances of solitary testicular metastasis from PDA. It underscores the importance of continued PSA monitoring and highlights that isolated testicular involvement, whereas rare, may confer a more favorable prognosis than typically expected in metastatic PDA. In selected cases, orchiectomy may serve both diagnostic and therapeutic roles, supporting a conservative postoperative approach.
Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is a rare and distressing condition characterized by unwanted genital arousal without associated sexual desire. While cases of PGAD/GPD in association with interstitial cystitis, urethritis, urinary tract infection, and urethral diverticulum have been described, bladder cancer has not yet been reported. To our knowledge, the present report describes the first known case of PGAD/GPD as the initial presentation of low-grade papillary urothelial carcinoma of the bladder in a young female. A 26 year-old healthy female presented with a 3-month history of constant, distressing clitoral engorgement, throbbing, and pain in her vulvar vestibule that began during masturbation. She also noted dysuria, urinary frequency, urgency, intermittent hematuria, and nocturia two to three times per night, pelvic floor hypertonicity, and restless legs. She denied any smoking history but did report a history of occasional resin exposure while making jewelry as a hobby. She underwent a bladder ultrasound that revealed a 7 × 5 × 6-mm nonmobile lesion in the left posterior bladder wall, lateral to the ureteral orifice. Cystoscopy and pathology revealed low-grade papillary (Ta) urothelial carcinoma of the bladder, and transurethral resection of bladder tumor was performed. Symptoms had completely resolved 3 months after the procedure, with continued use of topical lidocaine gel applied to the clitoris and pelvic floor physical therapy. Our postulate to account for the constellation of symptoms tumor-induced chronic irritation of the pelvic nerve resulting in reflexive bladder hypermotility, clitoral engorgement, and bowel dysfunction. In addition, central cross-sensitization at the level of the sacral spinal cord could activate the postsynaptic neurons that normally respond to pudendal nerve afferent activity, resulting in clitoral and vestibular dysesthesia, reflexive pelvic floor hypertonicity via postsynaptic pudendal nerve efferents, and reflexive restless legs via postsynaptic sciatic nerve efferents. Further investigation is warranted to better understand the relationship between bladder tumors, PGAD/GPD, and related viscero-visceral and viscero-somatic reflex activity.
Testicular compartment syndrome (TCS) is a rare phenomenon with around 14 cases reported in the literature. It occurs when extraluminal compression or increased venous resistance leads to raised intratesticular pressure. The fibrous tunica albuginea covering the testes does not distend, meaning the pressure is not relieved and compartment syndrome can develop. The ensuing reduction in perfusion and subsequent reperfusion injury can compromise testicular viability, making prompt identification and early surgical intervention essential in optimising outcomes. A 41-year-old male presented to the emergency department with acute severe bilateral testicular pain 1 day after bilateral microdissection testicular sperm extraction (mTESE) for primary infertility and azoospermia. He reported a gradual onset of bilateral testicular pain throughout the day accompanied by oozing and bleeding from the surgical wound. The pain escalated with time, and both testicles were exquisitely tender on palpation. Ultrasonography (US) demonstrated diffuse scrotal sac thickening, heterogenous testicles with hyperaemia on Doppler flow and bilateral hyperaemic enlargement of both epididymi. Thus, an emergency scrotal exploration was performed with evacuation of a left intratesticular haematoma and a right peritesticular haematoma. This restored perfusion to both testes and the patient had an uneventful postoperative course. A follow-up US after 6 weeks revealed both testicles had a reduction in volume and reduced blood flow. TCS is a previously undocumented complication of mTESE that should be considered in any patient presenting with pain out of proportion to clinical findings. Although the diagnosis is primarily clinical, US features, such as initial hyperaemia progressing to reduced blood flow, can support the diagnosis. Early surgical intervention to decompress the testis by incising the tunica layers is critical to reduce intratesticular pressure, restore perfusion and preserve testicular viability.
Penile venous abnormalities are an uncommon cause of erectile dysfunction and are rarely implicated in isolated glans tumescence impairment. We report what may be the first successful surgical treatment of glandular tumescence dysfunction caused by an anomalous venous communication between the deep dorsal vein of the penis and the left great saphenous vein. A 42-year-old man presented with lifelong inadequate glans tumescence and mild erectile maintenance difficulty (International Index of Erectile Function-5 score, 18). Physical examination and hormonal evaluation were unremarkable. Dynamic penile color Doppler ultrasonography after intracavernosal prostaglandin E1 demonstrated normal cavernosal arterial inflow and preserved cavernous veno-occlusive function but showed markedly increased flow in the deep dorsal vein despite rigid shaft erection and persistent poor glans engorgement. Dynamic cavernosography identified an isolated anomalous collateral vessel connecting the deep dorsal vein to the left great saphenous vein, with no additional venous leakage sites. Surgical correction consisted of ligation and excision of the anomalous collateral vein, excision of the deep dorsal vein through an anterograde penile skin degloving approach, and selective ligation of cavernous veins. The patient reported complete restoration of glans tumescence at 1 month, sustained at 1 year, with improvement of the International Index of Erectile Function-5 score from 18 to 23. This case highlights the diagnostic value of cavernosography in selected patients with discordant findings between shaft rigidity and glans engorgement and suggests that targeted surgical correction may be effective when a highly localized venous shunt is identified.
Ureteral strictures are a well-documented pathology in urology, commonly resulting from congenital anomalies, iatrogenic injury, or other acquired conditions such as infection, trauma, or radiation. While ischemic and nonischemic strictures are recognized, bilateral idiopathic ureteral strictures remain rare, particularly when associated with systemic thrombotic microangiopathy. This case report describes a 25-year-old female with a history of IgA deficiency and atypical hemolytic uremic syndrome (aHUS), who developed bilateral ureteral strictures following envenomation by a brown recluse spider. The purpose of this report is to highlight an unusual cause of ureteral stricture formation, discuss its underlying pathophysiology, and evaluate long-term surgical outcomes, including the failure of a Yang-Monti neoureter and the subsequent necessity for left renal autotransplantation. The patient initially developed bilateral ureteral ischemia and subsequent stricture formation, requiring percutaneous nephrostomy tubes for urinary drainage. The left ureter exhibited an 8-9 cm occlusion, leading to the decision to perform a Yang-Monti neoureter using a jejunal interposition graft. Despite initial surgical success, the patient later presented with left-sided hydronephrosis and recurrent urinary tract infections, revealing complete stricture of the neoureter. After thorough evaluation, she underwent left renal autotransplantation with ureteral reimplantation. Postoperative outcomes were favorable, with stable renal function, although complicated by transient ileus. This case underscores the challenges of managing extensive ureteral stricture disease, particularly when secondary to systemic microangiopathic processes triggered by envenomation. To our knowledge, this is the first documented case of long-segment ureteral stricture as a sequela of brown recluse spider envenomation. The venom's prothrombotic and endothelial-damaging effects likely contributed to progressive ischemic injury and fibrosis, leading to bilateral stricture formation. While the Yang-Monti technique provided temporary urinary diversion, its long-term viability was limited, necessitating a definitive solution via renal autotransplantation. This case highlights the need for increased awareness of envenomation-related ischemic complications, particularly in patients presenting with delayed-onset ureteral obstruction. Future research should further explore envenomation-induced microangiopathy and optimal surgical management strategies for complex ureteral stricture disease.
Small cell carcinoma of the bladder (SCCB) is a rare aggressive cancer, representing less than 1% of bladder cancers. Similar to small cell lung cancer (SCLC), it progresses rapidly, metastasizes early, and has a poor prognosis, complicating treatment. Unlike more common bladder cancers, SCCB often resists localized treatments and responds better to chemotherapy. However, its management generally relies on protocols for SCLC due to limited specific research. A 47-year-old male from Bangladesh presented with intermittent painless hematuria, weak urinary stream, and incomplete voiding for 2 months. His medical history includes diabetes mellitus, chronic kidney disease, hypothyroidism, adrenal adenoma, and coronary artery disease. His physical examination was unremarkable. His blood work up showed hypochromic microcytic anemia and elevated creatinine. Urine cytology revealed atypical degenerated urothelial cells, polymorphonuclear leukocytes, and red blood cells. He underwent flexible cystoscopy, which showed a nodular tumor with a wide base at the left lateral bladder wall measuring less than 3 cm. He had a CT scan, which revealed irregular thickening in the left posterolateral bladder wall, suggesting muscle-invasive carcinoma extending into the perivesical fat. He had an MRI scan which confirmed a 4 x 4.5 - cm mass with extravesical involvement. Histopathology examination from his transurethral resection of bladder tumor specimens showed mixed carcinoma, comprising both classic invasive urothelial carcinoma (UC) and SCCB. The small cell component exhibited scant cytoplasm, high nuclear-to-cytoplasmic ratio, hyperchromatic nuclei, and numerous mitotic figures, with synaptophysin and weak chromogranin positivity; UC cells were GATA-3 positive. Surgical resection removed most of the tumor. The patient tolerated the procedure well, with no complications. After four chemotherapy cycles, he had a follow-up PET CT, which showed significant tumor regression. This case highlights the unusual early coexistence of SCCB with classic UC in the bladder, emphasizing the importance of comprehensive histopathological and immunohistochemical evaluation for accurate diagnosis and treatment planning. Further research on SCCB could improve diagnosis, treatment strategies, and identification of molecular targets, potentially enhancing survival rates and patient quality of life.
Priapism is a condition characterized by prolonged erections lasting longer than 4 h, classified as ischemic and nonischemic. This case series is aimed at reporting the therapeutic approaches employed and the outcomes observed in patients with prolonged priapism. We reported seven consecutive cases of prolonged priapism managed by the authors. Collected data included duration of priapism, interventions performed, and posttreatment outcomes. In Cases 1 and 2, drainage procedures and shunts were ineffective, resulting in erectile dysfunction. Cases 3 and 4 involved the implantation of semirigid prostheses after 6 and 40 days. In Case 5, an infectious complication occurred following prosthesis implantation in a patient with previous distal shunts. Case 6 demonstrated a patient with priapism had success with early prosthesis implantation. Case 7 described a patient with cocaine-induced priapism received a prosthesis on the sixth day. The management of ischemic priapism directly depends on the time elapsed since the onset of symptoms. After 48 h, necrosis of the corpora cavernosa becomes inevitable, and surgical shunt procedures show limited efficacy. Early implantation of penile prostheses is an effective strategy to avoid late complications such as penile fibrosis. However, the decision must consider risks such as infection and prosthesis extrusion. Shunt procedures prior to penile implantation should be indicated with caution. The implantation of penile prostheses is a safe and effective therapeutic option for prolonged priapism. Excessive surgical manipulation of the penis with attempts at cavernous shunting in these cases often provides no benefit and may increase the risk of prosthesis infectious complications.
Primary signet ring cell carcinoma (SRCC) of the bladder is an exceptionally rare and aggressive malignancy, accounting for only 0.12%-0.6% of all bladder cancers. This case report describes a 54-year-old female who presented with urinary incontinence and abdominal pain, initially misdiagnosed as a urinary tract infection. Imaging revealed suspicious bladder findings, and subsequent cystoscopy with transurethral resection identified SRCC, later confirmed by immunohistochemistry (PD-L1 positive, CDX-2/ER negative). Despite peritoneal carcinomatosis, the patient responded to cisplatin/gemcitabine chemotherapy and immunotherapy, demonstrating tumor shrinkage on follow-up imaging. This case highlights the diagnostic challenges of SRCC due to its nonspecific symptoms and potential histological overlap with other metastatic gastrointestinal tumors. Early recognition and a multidisciplinary approach are critical for improving patient outcomes.
The diagnosis of primary renal synovial sarcoma (PRSS) is challenging due to nonspecific clinical semiology mimicking renal carcinoma and significant histologic overlap with other kidney tumors like sarcomatoid renal cell carcinoma, clear cell sarcoma of the kidney (CCSK), and BCOR-altered sarcoma, necessitating molecular confirmation via the detection of SS18::SSX gene fusion. This case report highlights a 39-year-old male patient presenting with abdominal pain and hematuria. Imaging revealed a large, heterogeneously enhancing left renal mass. Left-sided nephrectomy revealed a tumor, which on histopathology revealed a monophasic spindle cell neoplasm with areas of necrosis. Immunohistochemistry (IHC) demonstrated diffuse positivity for pan-keratin (clone AE1/AE3), EMA, CD99, BCL2, cyclin D1, SS18, and paradoxically, BCOR-a marker classically associated with BCOR-rearranged sarcoma/CCSK. Fluorescence in situ hybridization assay confirmed SS18 gene rearrangement without the presence of BCOR gene molecular alterations, establishing the diagnosis of monophasic synovial sarcoma. This case report highlights a critical diagnostic pitfall comprising of aberrant BCOR immunoreactivity, usually reported in synovial sarcomas of soft tissues, but hitherto unreported in PRSS. This aberrant immunoexpression of BCOR probably reflects epigenetic dysregulation, occurring in the absence of underlying BCOR genetic rearrangements. Coexpression of BCOR and cyclin D1 can also lead to a misdiagnosis as CCSK. Therefore, owing to overlapping IHC profiles, definitive diagnosis of PRSS warrants SS18::SSX gene molecular testing to avoid misclassification, especially given the therapeutic and prognostic implications. Integration of morphology, IHC, and molecular studies remains paramount for accurate diagnosis of such rare renal spindle cell neoplasms.
Sporotrichosis is an endemic fungal infection in Brazil, caused by a dimorphic fungus of the genus Sporothrix. Transmission occurs through traumatic inoculation from soil, contaminated plants, and zoonotic sources, mainly from cats, as well as through inhalation of conidia. It commonly presents as localized, lymphocutaneous, disseminated, or systemic forms. The testicles are among the organs that can be affected, often manifesting as a testicular mass. This work is aimed at analyzing a clinical case along with a bibliographic review on the testicular involvement of sporotrichosis. A 35-year-old male with positive HIV serology and a history of psychoactive substance use presented with disseminated ulcerated lesions that progressed over 1 month, with a positive blood culture for sporotrichosis. Upon hospitalization, a painless lump in the right testicle was diagnosed upon palpation and peripheral vascularization. An orchiectomy was performed, and anatomopathological analysis revealed the presence of Sporothrix. Few reports on testicular sporotrichosis were found in the literature. Systemic forms are rare and are often associated with immunosuppression, particularly in cases of HIV and chronic alcoholism. This immunosuppression can favor the prevalence and dissemination of the fungus. The fungus also produces melanin, which aids in evading the immune system. The gold standard for diagnosis is culture. Furthermore, the treatment of choice is prolonged therapy with Amphotericin B, followed by itraconazole. Given the suspicion of disseminated sporotrichosis and the presence of a testicular nodule, the possibility of testicular sporotrichosis should be evaluated while maintaining attention to the differential diagnosis for neoplasia.
Wunderlich syndrome (WS) is a rare phenomenon. It was first described by Carl Wunderlich in 1857 as a clinical picture of spontaneous renal bleeding with dissection of blood into either or both the subcapsular and perinephric spaces. Tumours, vascular malformations, coagulopathy and inflammatory states have been shown to be aetiological factors, yet up to 10% of cases remain idiopathic. WS is usually diagnosed on CT imaging due to the variable history and signs on examination which can mimic many other abdominal conditions. Management strategies include conservative treatment, embolisation and surgical nephrectomy. A 37-year-old female presented to the emergency department with acute onset severe right flank pain after performing deadlift exercises in the gym. She collapsed on arrival. Clinical observations and blood results were indicative of haemorrhagic shock. Computed tomography (CT) with angiography demonstrated an acute right renal haemorrhage with active extravasation and the formation of a large perirenal haematoma. Blood products and vasopressors were administered to resuscitate the patient. Definitive management with embolisation was undertaken by the interventional radiology team. WS is a rare diagnosis that should be considered in patients presenting with flank pain and evidence of haemorrhagic shock. Weightlifting can act as a trigger for this condition. Early recognition and intervention can enable successful resuscitation and definitive treatment with minimally invasive embolisation.
Renal transplantation (RTx) is the preferred treatment for end-stage renal disease (ESRD), reducing mortality and improving quality of life. However, long-term immunosuppression increases the risk of malignancy, with renal cell carcinoma (RCC) occurring in approximately 0.6%-0.7% of renal transplant recipients, most commonly arising in the native kidneys. Bilateral RCC is rare and is typically associated with papillary histology and acquired cystic kidney disease (ACKD). A 16-year-old male with ESRD secondary to diffuse mesangial hypercellularity underwent living-related renal transplantation from his mother. Fourteen months posttransplant, routine ultrasonography revealed bilateral renal masses in the native kidneys. Contrast-enhanced computed tomography confirmed multiple lesions in both kidneys. The patient underwent bilateral laparoscopic nephrectomy. Histopathology revealed bilateral clear cell renal cell carcinoma, confined to the kidneys with negative surgical margins. Multiple benign cortical cysts suggested early acquired cystic kidney disease. At 1-year follow-up, the patient showed no evidence of recurrence, with normal serum creatinine and stable graft function. Bilateral RCC after renal transplantation is rare and is usually associated with papillary histology and acquired cystic kidney disease. The early occurrence of bilateral clear cell RCC in a pediatric transplant recipient is unusual and may indicate an underlying predisposition. Early detection through routine imaging allowed timely surgical management with preservation of graft function. This case highlights the rare occurrence of early bilateral clear cell RCC in a pediatric renal transplant recipient. Careful surveillance of native kidneys in transplant recipients may facilitate early diagnosis and favorable outcomes.
Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare congenital disorder characterized by Müllerian duct malformation and ipsilateral renal abnormalities. Variant forms associated with hypoplastic kidneys and ectopic ureteral insertion in the vagina may require nephrectomy because of persistent urinary incontinence. In such cases, urinary drainage through a vaginal opening permits direct ureteral access via vaginoscopy without the size limitations associated with transurethral cystoscopy. Therefore, retrograde catheter placement is technically feasible in patients with OHVIRA syndrome. Consequently, OHVIRA is a particularly suitable indication for ureteral catheterization. Fluorescent ureteral catheters, which were recently introduced in surgery for adults, enable real-time intraoperative visualization of the ureter and may further enhance surgical safety. We report a case involving laparoscopic nephrectomy for OHVIRA syndrome with an ectopic ureter and severely hypoplastic kidney in a pediatric patient. The ectopic ureteral orifice was successfully identified during vaginoscopy when the patient was 5 years of age; therefore, retrograde placement of a fluorescent ureteral catheter was feasible. Intraoperative fluorescence enabled the reliable identification of both the ureter and small renal remnant, thus facilitating safe dissection and resection. This case demonstrates that retrograde placement of a fluorescent ureteral catheter via vaginoscopy is feasible and useful for pediatric patients with OHVIRA syndrome who require nephrectomy. This technique may improve intraoperative ureteral visualization and surgical safety; therefore, it should be considered for selected patients with ectopic ureteral drainage.
Urothelial carcinoma (UC) of the bladder has a high recurrence rate. Non-muscle-invasive bladder cancer (NMIBC) requires careful follow-up after transurethral resection (TUR). Some cases of extravesical recurrence of UC have been reported following radical cystectomy or nephroureterectomy; however, few such cases following robot-assisted radical prostatectomy (RARP) are known. A 77-year-old man presented to our hospital with high serum prostate-specific antigen (PSA) levels and atypical urothelial cells. Prostate biopsy and photodynamic diagnosis (PDD)-TURBT were performed. Pathological diagnoses were adenocarcinoma (Gleason score 3 + 4) of the prostate and UC (high grade, pT1 + Tis) of the bladder. Intravesical Bacillus Calmette-Guerin (BCG) was administered. One year after BCG therapy, examinations showed no evidence of UC recurrence; RARP was performed in another hospital on his will. Four months following RARP, elevated serum carbohydrate antigen 19-9 (CA19-9), palpable port-site subcutaneous indurations, and intraperitoneal nodules were detected by blood test and positron emission tomography/computed tomography (PET/CT). The subcutaneous indurations were pathologically diagnosed as UC. Platinum-based chemotherapy decreased the level of serum CA19-9. Cancer progression with the elevation of serum CA19-9 was observed during subsequent avelumab therapy, and enfortumab vedotin therapy was initiated. The patient died from cancer progression 30 months after extravesical recurrence of UC. RARP for patients with a past history of bladder tumor presents a risk of dissemination of UC due to urine leakage. Thorough examination for UC before RARP is recommended.