Genitourinary Fistula: An Indian Perspective.

BACKGROUND: In developing countries, obstetric trauma is the most common cause of genitourinary fistulae. But over the last two decades, health care facilities have been improved and the scenario has been changed. PURPOSE: The aim of the present study is to share our experience with genitourinary fistula in terms of mode of presentation, diagnostic modality, and management with the emphasis on the surgical approach and a parallel review of the available literature. MATERIALS AND METHOD: During a 6-year period from January 2007 to December 2013, 41 cases of genitourinary fistula, who admitted and treated in the urology department of a tertiary care center, were retrospectively analyzed for etiology, site, size and number of fistulae, clinical presentation, diagnostic modalities, and management. The literature search was done using the Medline database. RESULT: Mean age of the patient was 27 years (range 16-51). Primary and simple fistulae were common. Obstetric trauma was the most common etiology (56.09 %) followed by iatrogenic (39.03 %). Vesicovaginal fistula was the most common type (78.37 %) and trigone was the most common site involved (51.72 %). 51.35 % of patients were approached successfully by the vaginal route. Ancillary procedures were required in patients for various other associated anomalies at the time of fistula repair. The success rate on follow up was 94.5 %. In the mean follow up of 3 years, 35 patients were sexually active. CONCLUSION: Genitourinary fistula is a frustrating entity with potentially devastating psychosocial consequence. Its management poses a tricky challenge to the surgeon. Accurate and timely diagnosis, adhering on basic surgical principle, and repair by an experienced surgeon provide the optimum chance of cure.

Penile Fracture: Our Experience in a Tertiary Care Hospital.

PURPOSE: Penile fracture is rare, but it is a urological emergency that always requires immediate attention. Moreover, penile fracture has been reported more frequently in recent years. It may have devastating physical, functional, and psychological consequences if not properly managed in time. MATERIALS AND METHODS: The objective of this study was to highlight the causes, clinical presentation, and outcomes of cases of penile fracture. This was a prospective observational study extending from November 2012 to November 2014. Each patient underwent a thorough clinical evaluation and received proper treatment. RESULTS: Twenty patients with penile fracture, aged 19 to 56 years (mean, 28 years) were evaluated in this study. Vaginal intercourse was the most common mechanism of injury. Most of the patients (95%) were diagnosed clinically with a proper history and clinical examination. Nineteen patients were treated surgically. The patients underwent six months of follow-up, and were evaluated with local examinations, questionnaires, and colour Doppler ultrasonography as necessary. CONCLUSIONS: Although penile fracture is an under-reported urological emergency, its incidence is increasing. It is usually diagnosed based on a clinical examination, but ultrasonography can be very helpful in diagnosis. Especially in cases where treatment is delayed, surgery is preferable to conservative management, because it is associated with better outcomes and fewer long-term complications.

Penile lichen sclerosus: An urologist's nightmare! - A single center experience.

PURPOSE: Penile lichen sclerosus (LS) is a nagging condition and its progression result in devastating urinary and sexual problems and reduction in the quality-of-life. This study has been carried out to present our experience about this disease with simultaneous review of the available literature. MATERIALS AND METHODS: This retrospective study has been done at a tertiary care center of eastern India. The data of 306 patients affected with LS were analyzed for clinical presentation, physical examination, investigations, and treatment offered. RESULTS: Presenting symptoms were non-specific. The prepuce was most commonly involved location followed by glans and meatus. Urethral involvement was not isolated as the primary site. Circumcision was done in 237 patients, while 63 patients underwent meatotomy. Thirty-six of 39 cases of LS induced stricture were treated with buccal mucosal graft (BMG) either in one stage or in two stages. CONCLUSION: LS varies from being a highly aggressive disease of the penis and anterior urethra to a burnt out condition affecting just the meatus and surrounding glans. Early diagnosis and treatment are required to prevent its complication and associated morbidity. Management depends on the anatomical location of lesion, extent of involvement, rapidity of progression and its severity. Use of BMG in LS induced urethral stricture has shown encouraging results.

Retained fragmented double J ureteric stent: A report of four cases with review of the literature.

Polyurethane double-J ureteral stents are widely used in the field of urology. Postoperatively, patient education about the ureteral stent and making sure it is removed at the prescribed time is an utmost necessity. Forgotten ureteral stent is not only disastrous for the patient but also fraught with serious medico-legal implications for the urologist. Herein, we present four cases of long-term retained part of ureteral stent with its varied presentation and subsequent management.

Polymorphisms in CaSR and CLDN14 Genes Associated with Increased Risk of Kidney Stone Disease in Patients from the Eastern Part of India.

Kidney stone disease (KSD) is a major clinical problem imposing a large burden for both healthcare and economy globally. In India, the prevalence of kidney stone disease is rapidly increasing. This study aimed to evaluate the association between genetic defects in vitamin D receptor (VDR), calcium sensing receptor (CaSR) and claudin 14 (CLDN14) genes and kidney stone disease in patients from eastern India. We enrolled 200 consecutive kidney stone patients (age 18-60 years) (cases) and their corresponding sex and age matched 200 normal individuals (controls). To identify genetic variants responsible for KSD, we performed sequence analysis of VDR, CaSR and CLDN14 genes. Four non-synonymous (rs1801725, rs1042636, rs1801726 and rs2228570), one synonymous (rs219780) and three intronic single nucleotide polymorphisms (SNPs) (rs731236, rs219777 and rs219778) were identified. Genotype and allele frequency analysis of these SNPs revealed that, rs1801725 (Ala986Ser), rs1042636 (Arg990Gly) of CaSR gene and rs219778, rs219780 (Thr229Thr) of CLDN14 gene were significantly associated with KSD. Serum calcium levels were significantly higher in subjects carrying 986Ser allele and calcium excretion was higher in subjects bearing 990Gly allele. In conclusion, rs1801725, rs1042636, rs219778 and rs219780 SNPs were associated with kidney stone risk in patients from the eastern part of India.

Meatotomy using topical anesthesia: A painless option.

AIM: Urethral meatotomy is an office procedure often done under local anesthesia with or without penile block or under short general anesthesia. Whatever may be the method, the patient has to bear the pain of injection. To avoid painful injections, in the present study, topical anesthesia in the form of eutectic mixture of prilocaine and lidocaine anesthetics (EMLA/Prilox) has been used to perform such procedures and its effectiveness determined. MATERIALS AND METHODS: A total of 48 consecutive patients with meatal stenosis who attended urology outdoor were enrolled in this study. After exclusion, in 32 patients, 3-4 g of Prilox cream was applied over the glans and occlusive covering was maintained for 45 min before the procedure. Meatotomy was done in a standard manner with hemostat application at the stenosed segment for 2-3 min followed by ventral incision at meatus. The patient's pain perception was measured using visual analog score. RESULTS: Out of 32, only one patient that had inappropriate application of cream, had a perception of pain during the procedure. Rest all the patient had no discomfort during the procedure. Mean visual analog score was 1.8 which is not a significant percepted pain level. No patient had any major complication. CONCLUSION: Use of topical anesthesia in form of Prilox (EMLA) cream for meatotomy is safe and effective method that avoids painful injections and anxiety related to it and should be considered in most of such patients as an alternative of conventional penile blocks or general anesthesia.

Evaluation of silodosin in comparison to tamsulosin in benign prostatic hyperplasia: a randomized controlled trial.

OBJECTIVES: Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms in elderly men. Selective alfa1-adrenergic antagonists are now first-line drugs in the medical management of BPH. We conducted a single-blind, parallel group, randomized, controlled trial to compare the effectiveness and safety of the new alfa1-blocker silodosin versus the established drug tamsulosin in symptomatic BPH. MATERIALS AND METHODS: Ambulatory male BPH patients, aged above 50 years, were recruited on the basis of International Prostate Symptom Score (IPSS). Subjects were randomized in 1:1 ratio to receive either tamsulosin 0.4 mg controlled release or silodosin 8 mg once daily after dinner for 12 weeks. Primary outcome measure was reduction in IPSS. Proportion of subjects who achieved IPSS <8, change in prostate size as assessed by ultrasonography and changes in peak urine flow rate and allied uroflowmetry parameters, were secondary effectiveness variables. Treatment emergent adverse events were recorded. RESULTS: Data of 53 subjects - 26 on silodosin and 27 on tamsulosin were analyzed. Final IPSS at 12-week was significantly less than baseline for both groups. However, groups remained comparable in terms of IPSS at all visits. There was a significant impact on sexual function (assessed by IPSS sexual function score) in silodosin arm compared with tamsulosin. Prostate size and uroflowmetry parameters did not change. Both treatments were well-tolerated. Retrograde ejaculation was encountered only with silodosin and postural hypotension only with tamsulosin. CONCLUSIONS: Silodosin is comparable to tamsulosin in the treatment of BPH in Indian men. However, retrograde ejaculation may be troublesome for sexually active patients.

A study to correlate histopathology, biochemical marker and immunohistochemical expression of sex-steroid receptors in prostatic growth.

Prostate gland is a fibromusculoglandular structure situated at the neck of urinary bladder. So, enlargement or growth of prostate due to nodular hyperplasia (NHP) or prostatic intraepithelial neoplasia (PIN) or adenocarcinoma may give rise to bladder outlet obstruction. Malignant growth i.e., PIN or adenocarcinoma cases are associated with increased blood level of prostate-specific antigen (PSA) and increased expression of different sex-steroid receptors because the growth is dependent on the interactions of androgen, progesterone and estrogen. The aim of our study is to correlate the histopathology, PSA levels and expression of different sex-steroid receptors by immunohistochemistry in different prostatic growth lesions. Among the total 50 cases received, inclusive of transurethral resection of prostate (TURP), transrectal ultrasound-guided biopsy and radical prostatectomy, 34 cases were diagnosed as NHP, 4 cases as PIN and 12 cases as adenocarcinoma histopathologically. Serum PSA values above 10 ng/ml were seen in 2 cases of PIN and 11 cases of adenocarcinoma and none of NHP. Estrogen receptor (ER) () expressions were negative in all cases. Progesterone receptor (PR) expressions were strongly positive in 35% cases of both NHP and adenocarcinoma, whereas androgen receptor (AR) expressions were strong among all cases of adenocarcinoma and only in four cases of NHP. By observing these findings it can be suggested that antiandrogen and antiprogesterone therapy simultaneously will do better than antiandrogen alone in treating prostatic growth lesions.

Development of VVF following double J stent placement.

Double J stent (DJ stent) is commonly used in various urological conditions. Theoretically stent-induced tissue erosion can be a possibility, but fistula formation is rarely reported. The present case was a case of genitourinary tuberculosis diagnosed 4 years ago and had received complete treatment. Two months ago she presented with recurrent urinary tract infection and diagnosed to have vesicoureteric reflux with secondary obstruction for which DJ stent was placed, after 15 days of which the patient reported leakage of urine per vagina. She was diagnosed to have vesicovaginal fistula (VVF) with in situ stent eroding through the bladder wall. Stent was removed and fistula was corrected surgically. This is the first reported case of stent-induced VVF, a rare complication of ureteral stent placement.

Prostatic utricle cyst: a clinical dilemma.

Prostatic utricle cyst is a rare midline cystic lesion between the urinary bladder and the rectum, commonly associated with hypospadias. Along with its rarity, it presents a challenge in its diagnosis and proper management. We report a case of large prostatic utricle cyst that was managed conservatively.

Extragenitourinary retroperitoneal primary hydatid cyst: a rare cause of bilateral lower ureteric obstruction and unilateral limb edema.

Hydatid cyst is an endemic disease in our country. Most commonly, it occurs in the liver and lungs. Bilateral hydroureteronephrosis is one of the rare presentations of hydatid disease. Herein, we are reporting an unusual case of hydatid disease where the primary mode of presentation was external iliac vein compression with chronic renal failure because of bilateral ureteric involvement. The patient was treated with bilateral double-J stenting to improve the renal function and operated later for removal of hydatid cyst under albendazole drug treatment.

Synchronous primary cancers of urinary bladder and kidney and prostate.

Synchronous occurrence of two or more than two primary cancers of the urinary tract is quite rare, and poses a difficult treatment challenge. Here, we present a case of synchronous renal cell carcinoma, transitional cell carcinoma of urinary bladder and adenocarcinoma of prostate diagnosed within a short period. To the best of our knowledge, this is the first case reported from India and the youngest patient reported in the literature having this combination of urinary cancers.

Squamous cell carcinoma in exstrophic unreconstructed urinary bladder in an adult.

Bladder exstrophy is rare and associated with an increased incidence of bladder cancer. Unreconstructed bladder extrophy presenting in an adult is very rare as most of the patients undergo repair in childhood. Most of the cancers are adenocarcinomas. We report a rare case of squamous cell carcinoma occurring in exstrophic unreconstructed bladder in a 58-year-old male patient.

Study of immunohistochemistry in prostatic lesions with special reference to proliferation and invasiveness.

Prostatic lesions on routine staining sometimes cause diagnostic dilemma especially in premalignant lesions like atypical adenomatous hyperplasia and prostatic intraepithelial neoplasia. Benign small acinar lesions also may be difficult to differentiate from small acinar adenocarcinoma. An important differentiating point is the loss of basal cell layer in adenocarcinoma and its presence in benign lesions. Basal cell markers (e.g. 34ßE12 cytokeratin) & proliferative markers (e.g. AgNOR and PCNA) can help in this regard. Total 60 cases of different prostatic lesions studied. After history taking, clinical examination, radiological & other investigations were done. Routine H&E staining, immunohistochemical staining against 34ßE12 cytokeratin & proliferative markers (AgNOR & PCNA) was performed. Statistically significant differences found in expression of 34ßE12 cytokeratin and proliferative markers between benign, premalignant and malignant prostatic lesions. Basal cell markers and proliferative markers are important parameters to distinguish between different benign, premalignant and malignant prostatic lesions.

Plasmacytoma of the kidney.

Extramedullary plasmacytoma is a rare malignant neoplasm typically arising outside the bone marrow of patients who show no clinical evidence of multiple myeloma. Kidney is a rare site for plasmacytoma. We present here a case of primary renal plasmacytoma confirmed on histopathology of the specimen and immuno-histochemistry studies. Patient was treated with radical nephrectomy followed by radiotherapy. The case is presented due to its rarity.

Virilising adrenocortical carcinoma.

A 16-year-old, Hindu, female presented with rapidly growing abdominal lump for 6 months, primary amenorrhoea and non-development of secondary sex characters. Her BP was 180/120 mmHg. There was an excessive hirsutism involving face, neck, shoulders, abdomen and thighs. A lump was felt at left lumbar region extending on to left hypochondrium and part of umbilical region. Her serum testosterone level was 224 ng/dl and cortisol level was 15 microg/dl. Ultrasonography revealed a solid mass arising from the upper pole of left kidney. Exploratory laparotomy revealed a huge left adrenal tumour which was removed completely. Histopathology of the resected mass showed sheets of large round to polyhedral cells with hyperchromatic nuclei and eosinophilic granular cytoplasm with numerous giant cells. The case was diagnosed as virilising adrenocortical carcinoma.