Cystitis glandularis: Management and challenges in a renal transplant recipient.

Cystitis cystica or glandularis is a clinical and pathological entity of the bladder mucosa occurring secondary to inflammation or chronic obstruction. Its premalignant nature remains controversial, especially in an immunocompromised transplant recipient. We present a rare case where a chronic kidney disease patient was found to have cystitis glandularis while being worked up for living-related donor renal transplant and describe its subsequent management.

Urodynamic evaluation of urinary disturbances following traumatic brain injury.

OBJECTIVES: To identify the incidence and the type of voiding dysfunction by doing urodynamic studies (UDS) in head injury patients. The purpose of this paper is to present our findings and promote research in this field. PATIENTS AND METHODS: A prospective study was conducted recruiting patients sustaining head injuries with positive CT scan findings. Clinical and radiological evaluation was done. Patients then underwent standardized UDS. The urodynamic findings were correlated with outcome and analyzed. RESULTS: Three out of 11 patients (27.3%) had unstable bladder with multiple involuntary contractions in the filling phase. All of them had significant contusions in the right frontal region and 2 of them had subarachnoid hemorrhage. All of these patients had normal proprioception, voluntary detrusor contractions and nil post-void residue. Two out of the 3 patients had catheter in situ and 1 patient had complaints of frequency and urgency. At 1 year of follow-up, all 3 patients had a normal voiding pattern and the upper tracts were normal on ultrasound in all patients. CONCLUSIONS: Voiding dysfunction is a significant problem in patients with head injury. Bladder hyperreflexia is seen in patients with injuries above the pontine micturition center. The voiding abnormality has good prognosis and resolves spontaneously. Treatment in the acute phase may require anticholinergics for a few months.

Dorsolateral onlay urethroplasty for anterior urethral strictures by a unilateral urethral mobilization approach.

CONTEXT: For management of long segment anterior urethral stricture, dorsal onlay urethroplasty is currently the most favored single-stage procedure. Conventional dorsal onlay urethroplasty requires circumferential mobilization of the urethra, which might cause ischemia of the urethra in addition to chordee. AIMS: To determine the feasibility and short-term outcomes of applying a dorsolateral free graft to treat anterior urethral stricture by unilateral urethral mobilization through a perineal approach. SETTINGS AND DESIGN: A prospective study from September 2005 to March 2008 in a tertiary care teaching hospital. MATERIALS AND METHODS: Seventeen patients with long or multiple strictures of the anterior urethra were treated by a dorsolateral free buccal mucosa graft. The pendulous urethra was accessed by penile eversion through the perineal wound. The urethra was not separated from the corporal bodies on one side and was only mobilized from the midline on the ventral aspect to beyond the midline on the dorsal aspect. The urethra was opened in the dorsal midline over the stricture. The buccal mucosa graft was secured on the ventral tunica of the corporal bodies. STATISTICAL ANALYSIS USED: Mean and median. RESULTS: After a follow-up of 12-30 months, one recurrence developed and 1 patient needed an internal urethrotomy. CONCLUSIONS: A unilateral urethral mobilization approach for dorsolateral free graft urethroplasty is feasible for panurethral strictures of any length with good short-term success.

Laparoscopy-assisted transperitoneal percutaneous nephrolithotomy for recurrent calculus in isthmic calix of horseshoe kidney.

BACKGROUND AND PURPOSE: Management of urolithiasis in a horseshoe kidney (HSK) poses a unique challenge. Although most patients can be managed by a combination of percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (SWL), calculi in the isthmic calix remain difficult to treat, as this area is out of reach during rigid PCNL, and, owing to the poor evacuation of the fragments, the results of SWL are suboptimal. CASE REPORT: A 59-year-old man known to have an HSK presented with right-sided lower-abdominal pain and episodes of urinary infection. In the past, he had undergone pyelolithotomy and lithotripsy for lithiasis in the kidney. Imaging studies identified a large recurrent calculus in the anteriorly directed isthmic calix. This was treated successfully by a laparoscopy-assisted transperitoneal PCNL. The laparoscopic view allowed the bowel to be retracted away from the site of the HSK, and PCNL guided by fluoroscopy and laparoscopy was performed. Complete stone clearance was achieved in a single stage. The patient remains free of symptoms and recurrence 3 months later. CONCLUSION: We believe this to be the first report describing this novel approach to lithiasis in an HSK.

Buccal mucosal graft onlay repair for a ureteric ischemic injury following a pyeloplasty.

A 38-year-old female presented with long stricture in the left upper ureter following a pyeloplasty causing persistent flank pain. A left PCNL with an antegrade endopyelotomy was attempted in view of a concomitant left renal 1.5 cm calculus in the lower calyx but it failed. Subsequently, a buccal mucosal onlay graft was applied on the strictured ureter. Follow-up at 3 months showed good uptake of the graft with patent passage for urine drainage.

Bilateral single-system ectopic ureters opening into vaginalized urogenital sinus.

A 5-year-old female presented with continuous dribbling of urine without any voiding stream since birth. Upon investigations, the bladder neck and both ureters were opening into the vaginalized urogenital sinus and the urethra was absent. Coarctation of the aorta was an associated anomaly. To our knowledge, this is the first report in literature of bilateral single-system ectopic ureters opening into vaginalized urogenital sinus. The report highlights the necessity for consideration of continent diversion in such cases because of the absence of the urethra in addition to an incontinent bladder neck and tiny dysfunctional bladder.

Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture.

OBJECTIVE: To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. METHODS: From October 1995 to March 2008, a total of 58 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (3), endoscopic realignment (7), or open urethroplasty (8). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. RESULTS: Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. CONCLUSIONS: Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise.

Factors predicting success in hypospadias repair using preputial flap with limited pedicle mobilization (Asopa procedure).

OBJECTIVES: To analyze the objective factors determining success in hypospadias repair by the Asopa technique of limited preputial pedicle mobilization. METHODS: This was a prospective study involving a cohort of 48 patients (age range 1-19 years) who underwent hypospadias repair in a tertiary care teaching institution, with a follow-up of 20-58 months. Patient inclusion criteria were absence of past history of any local surgery with urethral plate less than 6 mm and hooded prepuce. RESULTS: At a median follow-up of 33.5 months, the overall complication and fistula rates were 22.9% and 16.7%. Complication and fistula rates were 40% and 30% with tube repairs vs. 18.4% and 13.2% with onlay repairs. CONCLUSIONS: In patients unsuitable for Snodgrass repair, the Asopa technique of transverse preputial flap repair provides reasonably good results. Patients with proximal hypospadias, conical glans configuration, tube repairs, and more advanced age had higher complication rates with transverse preputial flap repair.