Ileal neobladder adenocarcinoma occurring twenty-five years post ileocystoplasty: a case report.

De-tubularised ileum is one of the most common segments used for augmentation cystoplasty. It is associated with complications such as metabolic disturbances, recurrent urinary tract infections, and stone formation. However, adenocarcinoma arising in an augmented bladder is a rare occurrence. We report a 37-year-old female, case of ileocystoplasty 25 years ago due to a thimble bladder (genitourinary tuberculosis) who presented with hematuria for one month. Cystoscopy showed bladder mass in the transposed ileal segments. The patient underwent transurethral resection of the bladder lesion, and the histopathology was suggestive of adenocarcinoma of the ileum. Subsequently, she underwent anterior pelvic exenteration and post-operative recovery was uneventful. The 6-month follow-up showed that the patient was asymptomatic without recurrence. In conclusion, even though adenocarcinoma in the ileal neobladder is rare, life-long with close follow-up with routine cytologic, radiologic, and cystoscopic evaluation for early cancer detection and treatment at an early stage is crucial.

Unique case of colovesical fistula in a renal allograft recipient.

Colovesical fistula is commonly suspected in cases of diverticular disease, malignancy, trauma, iatrogenic injury or radiotherapy. In a case of allogenic live related transplant, this is rarely expected, especially after 20 years. The presence of gas in the bladder in the absence of history of instrumentation of urinary tract should prompt us to evaluate for colovesical fistula. Pneumaturia, faecaluria and recurrent urinary tract infection are tell-tale features of colovesical fistula, and when patients who are renal allograft recipient present with them, it should prompt a proper workup and swift surgical management, since the outcome is uniformly favourable. From our knowledge in this realm, we know that these are immunocompromised patients and have a high tendency to develop risk factors like malignancy and/or diverticular disease and eventually form colovesical fistula. An expected time period could be from 2 months to 6 years. But in our case, fistula formation occurred long after peak corticosteroid action, in the absence of conventional aetiologies.

Unusual presentation of seminal vesicle abscess: a report of two cases.

Seminal vesicle abscesses (SVA) are a rare condition, and their diagnosis is challenging with non-specific clinical presentation. Only a few cases of SVA have been published. Here we report two cases of SVA. The first one is a 58-year-old male with HIV and diabetes who presented with painful swelling in the left groin for 15 days. The second patient was a 65-year-old man who presented with painful swelling in the perineum for 15 days. Both patients were radiologically (computed tomography scan) diagnosed to have SVA. The first one was treated via surgical drainage for groin abscess and SVA was treated conservatively with intravenous broad-spectrum antibiotics. The latter was treated with SVA transurethral drainage. The pus culture showed Escherichia coli. Postoperative antibiotic therapies were contented without complications. In conclusion, although SVA may be clinically unsuspected, cross-sectional radiologic imaging findings should not be underestimated in order to promptly initiate treatment.

Isolated renal mucormycosis masquerading as emphysematous pyelonephritis.

Mucormycosis is an acute, life-threatening infection and isolated renal involvement is rare. Due to the angioinvasive nature of the disease, it is rapidly progressive and can be lethal if not managed expeditiously. In patients with underlying conditions of immunosuppression, diabetes mellitus, transplantation, COVID-19, intravenous drug and substance use and pyelonephritis, which is unable to be controlled via regular antibiotics, mucormycosis must be considered on the differential and antifungals must be empirically started. Most cases are often diagnosed on histopathology, which causes delayed treatment and resolution. We present a case of emphysematous pyelonephritis diagnosed on imaging and was later found to have mucormycosis on histopathological examination.

A Rare Case of Urinary Bladder Exstrophy Presenting With Signet Ring Cell Adenocarcinoma in an Adult.

Due to the conspicuous morphology of the deformity and the fact that primary reconstruction is typically performed in infancy, untreated bladder exstrophy in adults is infrequent. An adult presenting with bladder exstrophy is quite uncommon. We present a 32-year-old man with a bladder mass that existed since birth. He complained of an unpleasant discharge from the mass upon presentation, and on examination, a mass was seen on the urinary bladder's exposed surface, coupled with penile epispadias, a deformed scrotum, and undersized bilateral testicles. Ultrasonography of the kidneys, ureters and urinary bladder (USG KUB), contrast-enhanced computed tomography (CECT) of the abdomen and pelvis, and mass biopsy were all used to investigate the patient. The patient was found to have signet ring adenocarcinoma of the urinary bladder. A radical cystectomy with an anterolateral thigh flap was performed. The clinical and radiological characteristics, treatments, and results of this uncommon presentation are discussed in this case report.

Concomitant Vaginal Laceration and Urinary Bladder Injury With Pubic Diastasis: A Case Report on a Rare Complication During Obstructed Labor.

A serious uro-obstetric emergency is the concurrent rupture of the uterine and urine bladder following a protracted difficult delivery. In the absence of circumstances that would make the bladder more likely to cling to the lower uterine segment, the involvement of the urinary bladder in a primigravida is unique and relatively infrequent. We discuss a case of a 21-year-old patient who had an obstructed labor complicated with bladder and vaginal injury. At laparotomy, we found a pubic bone diastasis, a vaginal injury, and a bladder injury at the urethrovesical junction. As a result, bladder neck repair with urethrovesical anastomosis and vaginal repair with an external fixator were carried out for pubic bone diastasis.

Gonadal dysfunction in male patients with Budd Chiari syndrome and its reversibility with treatment.

BACKGROUND AND AIMS: Budd Chiari syndrome (BCS) commonly affects adolescents and adults. With improved survival, important quality-of-life parameters such as sexual life and fertility become more relevant. This study was aimed to assess the gonadal function in male patients with BCS and the effect of treatment on gonadal function. METHODS: Thirty male patients with newly diagnosed BCS were prospectively assessed for the presence of gonadal dysfunction. Erectile function was assessed using standardized International Index of Erectile Function questionnaire (IIEF). Follicular stimulating hormone (FSH), luteinizing hormone (LH), sex hormone-binding globulin (SHBG), estradiol, total testosterone (TT), calculated free testosterone (cFT), calculated bioavailable testosterone (cBT), sperm count, and sperm motility were compared at baseline and at 6 months of treatment for the assessment of gonadal function. RESULTS: Sixteen (53.3%) out of 30 patients were sexually active at the time of study and 5/16 (31%) had erectile dysfunction. Hypogonadotropic hypogonadism (HH) was the most common pattern seen in 50% cases followed by hypergonadotropic hypogonadism (HyH) in 23% cases. 27% patients had eugonadism. At 6 months of treatment, 60% of patients in HH group became eugonadal as compared to only 14% in HyH group. Proportion of patients with erectile dysfunction reduced (5/16 vs 1/16) after 6 months of therapy. The improvement in sperm count and sperm motility was not significant. CONCLUSION: Gonadal dysfunction is common in male patients with BCS. HH remains the most common type of hypogonadism BCS and the type which improves significantly after treatment.

Impact of surgical intervention on progression to end-stage renal disease in patients with posterior urethral valve.

BACKGROUND: Posterior urethral valve patients present with varied presentations at any age of life and have significant associated morbidity and require long-term follow-up and care. METHODS: This was a single-center ambispective cohort study carried out over a period of 2 years. Patient data regarding the symptoms, investigations, interventions, secondary complications were recorded and were followed up regularly during the study till either normalization of their creatinine level which was maintained up to one-year post-fulguration (non-CKD) or progression to end-stage renal disease (ESRD) requiring renal transplant. Various clinical factors were then compared between these groups. RESULTS: The age of presentation varies from 6 months antenatal period to a maximum of 34 years. Most common symptom was of lower urinary tract obstruction, followed by recurrent febrile UTI. The interval between disease presentation detection and PU valve fulguration ranged from 6 days to more than 5 years, median duration being 1 month. 85.7% patients had hydroureteronephrosis on initial USG. In VCUG, there was no significant difference found between the presence of reflux and poor renal outcome. Age of presentation greater than 2 years was seen in 52% of patients with CKD compared to only 10% patients in non-CKD group (significant, p value 0.02). Among patients who developed CKD, 60% of patients had PU valve fulguration after one month of disease presentation, while in contrast, among the non-CKD group, 80% of patients had it done within one month of disease presentation. (significant, p value 0.03). CONCLUSIONS: Late age of presentation, delayed fulguration with high initial creatinine, and failure of serum creatinine to return to normal after one-month post-fulguration are important risk factors in the progression of the disease to ESRD. Symptomatic improvement after interventions does not correlate with progression to ESRD. The number of interventions also does not predict progression to ESRD. Interventions should be chosen wisely on case to restore near-normal physiology and delay progression to ESRD.

A case report of emphysematous cystitis with spontaneous intraperitoneal bladder perforation in an operated case of prolapsed intervertebral disc.

This is a case report of emphysematous cystitis with spontaneous intraperitoneal bladder perforation in postoperative period of pedicle fixation surgery for prolapse intervertebral disc (L3-L4). The patient developed urinary retention with overflow incontinence with abdominal tenderness and fever 3 days after orthopedic procedure which on computed tomography (CT) scan found to have abundant air in urinary bladder with multiple air foci in bladder wall with suspected leak into intraperitoneal pelvic cavity, proven only after CT cystogram.

Impact of COVID-19 pandemic on non-COVID patient's management in urology: a public hospital experience in Mumbai.

BACKGROUND: To evaluate the impact of COVID-19 lockdown on non-COVID urological patient's management in tertiary care urology centres. METHODS: This is an observational study in which data of patients visiting the urology department of all the MCGM run tertiary care hospitals were recorded for the duration of 1 April 2020 to 31 July 2020 and were compared to data of pre-COVID-19 period of similar duration. RESULTS: There was a decrease of 93.86% in indoor admissions of urology patients during the COVID-19 lockdown. Indoor admissions for stone disease, haematuria, malignancy accounted for 53.65%, 15.85%, 9.75%, respectively. Elective surgeries had the highest percentage decrease followed by emergency and semi-emergency procedures. There was a reduction of more than 80% in patients attending outpatient clinics. Stone disease and its consequences were the main reasons for visiting outdoor clinics (39%). A substantial number of patients presented with flank and abdominal pain (14.8%) and benign enlargement of the prostate (10.23%). Malignancy accounted for a very small number of patients visiting outdoor clinics (1.58%). CONCLUSIONS: COVID-19 pandemic has a profound impact on patient care and education in Urology. There was more than ninety percent reduction in indoor admissions, operative procedures, and outpatient clinics attendance. Once the pandemic is controlled, there will be a large number of patients seeking consultation and management for urological conditions and we should be prepared for it. Surgical training of urology residents needs to be compensated in near future. Long-term impact on urological patient outcome remains to be defined.

Role of Testicular Size as a Parameter for Predicting Infertility in Indian Males.

CONTEXT BACKGROUND: While the semen analysis appears to be the cornerstone in the evaluation of male fertility, the testicular size is a cheap, easy, and convenient to measure yet an ignored parameter for predicting the same. There is insufficient literature for identifying the testicular size cutoff among the Indian men. AIMS: The study is aimed to correlate between the testicular volume and length with exocrine testicular function and to set a cutoff size for infertility in Indian men. SETTINGS AND DESIGN: The study examined 354 cases over a period of 2 years. The cases comprised 258 men presenting with infertility as well as 96 fertile men as control. MATERIALS AND METHODS: All the patients had their testes examined using Seager's calipers and Prader's orchidometer, infertile men had their semen analysis. STATISTICAL ANALYSIS: SPSS software and Chi-square test were applied, keeping P < 0.05 statistically significant. RESULTS: The mean testicular volume and length in azoospermic patients were 10.3 ml and 2.4 cm, respectively, whereas in oligoasthenospermic patients they were 13.2 ml and 3.2 cm, respectively. The mean testicular volume, length among cases, and controls were 12.6 ml, 3.2 cm, 18.3 ml and 3.81 cm, respectively. CONCLUSION: Testicular size correlates significantly with severity of exocrine and endocrine functions. The testicular volume and length average for predicting infertility among Indian men should be 18 ml and 3.8 cm, respectively, unlike the international standards of 20 ml and 4.6 cm.

To study the incidence and preintervention factors associated with acute kidney injury in patients diagnosed with ureteric calculi.

AIMS AND OBJECTIVES: The study aims to evaluate the incidence and factors associated with acute kidney injury (AKI) among patients presenting with ureteric calculi. We also intend to study the impact of time delay since first symptom to presentation to our hospital among patients with ureteric calculi and its influence on AKI. MATERIAL AND METHOD: The study is a prospective observational study and included all symptomatic ureteric calculi patients. AKI was defined as per the KDIGO guidelines. All the patients diagnosed with ureteric calculi were grouped into those having an episode of AKI and those without an episode on AKI. RESULTS: The incidence of AKI in our study was 14.63% (18 patients) among 123 patients of ureteric calculi. Average time delay from time of diagnosis to presentation among patients with AKI was 31.7±6.2 days (mean ± S.D) as compared to 19.5±5.7 (mean ± S.D) days among all cases. Factors which were significantly associated with AKI in patients with ureteric calculi include time delay, diabetes mellitus, bilateral ureteric calculi, stone size greater than 10 mm, solitary functioning kidney and urine culture showing gram negative growth. Fifty percent of the AKI group eventual required nephrectomy of one renal unit. CONCLUSION: This study will help us streamline our resources predominantly towards those patients who present with factors associated with increased risk of AKI. As the time delay to presentation in patients with AKI with ureteric calculi is significantly higher, it is imperative to counsel patients with stone disease.

Importance of time in management of fracture penis: A prospective study.

BACKGROUND: The presentation of penile fracture may vary depending on the delay to seek medical attention and on the presence of associated injuries. Delay in presentation has been linked previously to embarrassment associated with this condition. AIMS AND OBJECTIVES: The study aims to share our clinical experience in management of penile fracture and its complications and specifically highlights the impact of time delay on post-operative outcome in patients presenting with penile fracture. MATERIAL AND METHODS: The study is a prospective observational study conducted from July 2014 till January 2017. All the patients presenting to the emergency with a clinical presentation of penile fracture and a tear in the tunica albuginea of the penile cavernosal tissue, confirmed on ultrasound were included in this study and intraoperative and postoperative data was analysed. RESULTS: The most common cause for fracture noted was coitus. The average time delay from the time of insult to presentation to the emergency department was 25.11 ± 12.48 hours. The parameters that have significantly been altered by a time delay of more than 24 hours include post-operative wound infection, erectile dysfunction at 1-year, post-operative hospital stay. Two patients develop chordee at 6 and 9 months respectively and both patients presented beyond 24 hours. All patients with hematoma size on color Doppler of more 10cc and intraoperative tear >10mm had developed post-operative wound infection. Patients with urethral injury or post-operative cavernositis or wound infection had significant association with erectile dysfunction. CONCLUSION: Penile fracture although a rare urologic emergency, it has a significant impact on sexual health of a young man. An early intervention along with identifying and managing early complications factors would help patients of fracture penis lead an almost normal sexual life.

Placenta percreta with bladder invasion: The armamentarium available in its management.

Placenta percreta is a rare life-threatening condition associated with high morbidity and mortality due to severe obstetric hemorrhage. It can be associated with bladder invasion which leads to hematuria. Treatment is decided on a case-to-case basis, and there have been no guidelines proposed so far. Strategies include obstetric hysterectomy, leaving the placenta in situ with postoperative methotrexate therapy and removal of the placenta with bladder reconstruction in a single stage. An unusual case of a patient with placenta percreta and bladder invasion who presented with delayed hematuria after the placenta was left in situ has been reported. The patient was managed conservatively for 10 days postdelivery after which a decision to do an obstetric hysterectomy with focal cystectomy was taken in view of persistent hematuria. An algorithm for managing cases of placenta percreta with bladder invasion has been proposed to manage these difficult situations.

Outcome following renal autotransplantation in renal artery stenosis.

INTRODUCTION: With significant advances in the area of interventional radiology, angioplasty and stenting have become preferred first-line treatment in patients with significant renal artery stenosis. However, not all patients have favorable anatomy to undergo minimally invasive treatments, and reconstruction of the renal artery is an option. In select cases, either improved renal function or maintenance of existing function and sometimes resolution of hypertension can follow surgical treatment. MATERIAL AND METHODS: This was a prospective observational study conducted from August 2010 to June 2016. Patients <45 years of age with uncontrolled hypertension secondary to renovascular hypertension (RVH) and refractory to medical management and renal arterial disease unfavorable for percutaneous intervention were included in the study. All patients were evaluated thoroughly using computed tomography angiography and diethylenetriaminepentaacetic acid renal scan. Patients underwent autotransplantation either into the right or left iliac fossa. Some kidneys required bench reconstruction of the renal artery and/or its branches before being implanted into either iliac fossa. RESULTS: Nine patients were included in the study. The mean age was 27 years. Seven were males and two were females. Five patients had bilateral renal artery stenosis. After autotransplantation, initially five patients became free of antihypertensive medicines, but on the follow-up, two patients showed rising trend of blood pressure. The evaluation revealed narrowing at anastomosis site in both patients with salvageable kidney function in one patient. Angioplasty with stenting was done in this patient while the second patient underwent secondary nephrectomy. At 2 years of follow-up, four patients required no antihypertensive medicines. CONCLUSION: Autotransplantation can be a successful treatment of severe RVH and should be considered in patients with renal arterial disease unfavorable for percutaneous intervention.

Comparing diabetic and nondiabetic emphysematous pyelonephritis and evaluating predictors of mortality.

Mortality among patients with emphysematous pyelonephritis (EPN) has reduced from 78% to 21%, yet it is one of the most serious urologic emergencies. This prospective observational study aims to study and compare clinical profile, management, and outcomes in diabetic and nondiabetic patients with EPN. All patients of EPN admitted to emergency medical services were included in the study. Patients were grouped into diabetic and nondiabetic EPN, and the eventual predictors of mortality were assessed. The mean age of patients was 55.43 years, with 36 (65.7%) female patients. Mortality was found to be 18.86%. On univariate analysis, the factors significantly associated with mortality include dyspnea at presentation, altered consciousness, blood pressure <90 systolic, oliguria, decreased platelet count (<100,000/mm[3]), urine culture positive for Escherichia coli, hyponatremia (Na <132), hyperkalemia (K >5.0), higher computerized tomography (CT) grade, and emergency nephrectomy as an intervention modality (P <0.05). Mortality was comparable among diabetics and nondiabetics. Diabetics had a lower CT score and higher creatinine (>2 mg/dL) as compared to nondiabetics. Most patients having urolithiasis were nondiabetic. Although nondiabetics had a higher CT score as compared to diabetics, the mortality in nondiabetics and diabetics was equivalent. This may suggest that either diabetics have a rapid deterioration of EPN status or intercurrent metabolic factors in diabetics may contribute to mortality among diabetics. Raised serum creatinine and immunocompromised status owing to diabetes may also play a role.

Use of ileum for complex ureteric reconstruction: Assessment of long-term outcome, complications, and impact on renal function.

INTRODUCTION: Defect in ureteral continuity can be due to various etiologies. The surgical options for management of complex long-segment ureteric defects are limited. Use of ileum is indicated in these cases; however, the technique is challenging and outcomes need to be assessed in detail. MATERIAL AND METHODS: It is an observational study conducted over 4 years. After preoperative optimization, ureteric reconstruction was performed using standard techniques of ileal interposition in cases of unilateral and bilateral long-segment ureteric defects. Patients were followed up at regular interval to assess outcomes and see for complications. RESULTS: A total of 14 patients were studied. Two most common indications for performing ileal ureter were iatrogenic injury and radiation-induced strictures (5-5 cases). Most common site of ureteric involvement was lower and midureter seen in 6 cases. The mean length of the ileum used was 11.2 cm. Mean preoperative nadir creatinine level was 1.57 mg/dL in this study. Average postoperative creatinine level at 4-week follow-up was 1.75 mg/dL and 1.45 mg/dL and 1.37 mg/dL, at 3 and 12 months, respectively. The most common short-term complication was paralytic ileus and long-term complication was recurrent urinary tract infection UTI. There was no mortality. CONCLUSION: Ileal ureter is found to be relatively easy and safe surgery even in patients with borderline high creatinine. There was no worsening of renal function attributable to the conduit in this study. In patients with limited surgical options, it is a suitable alternative, rather than keeping patient on permanent percutaneous nephrostomy or regular stent change. Metabolic acidosis and mucous-associated complications such as pain, infection, and stone formation can be minimized by adherence to strict protocol.

An overview of serum prostatic surface antigen cut points for recommendation of prostatic biopsy.

INTRODUCTION: Patients in India frequently present with prostatic surface antigen (PSA) report and request for prostatic biopsy to rule out malignancy. With fear of harboring malignancy set in patient's mind, it becomes difficult to counsel them about absolute indications and need of biopsy. Whether serum PSA has same predictability in symptomatic patients in the Indian context for advising prostatic biopsy at same reference ranges as in western countries, remains to be answered. MATERIALS AND METHODS: Symptomatic patients between 45 and 70 years of age presenting with either raised serum PSA (>4 ng/ml) reports or abnormal digital rectal examination (DRE) were considered as cases. Standard 12 core transrectal ultrasound-guided prostatic biopsy was done. Statistical analysis using optimal cut points, an R package was done to overview different PSA cut points for the recommendation of prostatic biopsy. RESULTS: A total of 534 patients were included. Mean age was 64 years. Malignancy was detected in total 77 patients (14.42%). Malignancy was identified in 3.59% (10/279) and 30% (63/210) patients at serum PSA ranges 4-10 ng/ml and serum PSA >10 ng/ml, respectively. Both, maximum sensitivity and specificity were found at PSA cut point 9.7 ng/ml. We evaluated these patients to identify the PSA cut point above which unnecessary biopsies will be avoided. We kept power of study maximum, i.e., 1 with confidence interval of 0.95. CONCLUSION: PSA value 9.7 ng/ml should be considered as the cut point above which prostatic biopsy should be done to avoid unnecessary biopsies. Unless accompanied by abnormal DRE finding at PSA range 4-10 ng/ml, morbidity of prostatic biopsy procedure can be avoided using this cut-point.

Laparoscopic assisted percutaneous nephrolithotomy in chronic kidney disease patients with ectopic pelvic kidney.

PURPOSE: Patients with deranged renal functions have a number of associated factors which can impair healing of wound and increase postoperative morbidity. This study was conducted to assess the problems while managing ectopic pelvic kidney calculi using laparoscopic approach for percutaneous nephrolithotomy (PCNL) in chronic kidney disease patients. SUBJECTS AND METHODS: Patients with calculi in ectopic kidney with increased serum creatinine level secondary to obstruction were included in the study. Initially, obstruction was relieved. Patients later underwent laparoscopic-assisted PCNL. Patients were monitored postoperatively. RESULTS: Three patients with large renal calculi in ectopic pelvic kidney had presented in 2 years. Laparoscopic-assisted PCNL was done to remove the stone. Patients had persistent urine leak post-operatively. Mean duration for removal of nephrostomy tube and drain removal were 4.67 days and 6.67 days, respectively. These patients also had paralytic ileus for prolonged duration. CONCLUSION: Although laparoscopic assisted PCNL is an option in the management of patients with stone disease in ectopic pelvic kidney, prolonged time for healing of tract may increase postoperative morbidity in these patients with impaired renal function.