Large spontaneous steinstrasse: Our experience and management issues in tertiary care centre.

BACKGROUND: Steinstrasse, is described as array of stone pieces in the ureter following extracorporeal shock wave lithotripsy (SWL). It is well-recognized, transient event. Steinstrasse clears spontaneously, however about 6% require intervention. Spontaneous steinstrasse without prior history of SWL is a rare occurrence and only few case reports are published in literature. Objective of the study was to assess the aetiology and management issues of large spontaneous steinstrasse in our centre. METHOD: From February 2017 to March 2019, 684 patients underwent SWL for renal or ureteric stones. Twenty-eight patients presented with steinstrasse of which nine patients had no prior history of SWL. Detailed clinical profile and management issues have been discussed. RESULT: Among the nine patients of spontaneous steinstrasse, there were six males and three females. Mean age of the patients was 39 years (±13 years SD). Bilateral large spontaneous steinstrasse was seen in one out of nine patients. Seven patients had associated renal stones. Five patients presented with obstructive uropathy and three out of them had urosepsis as initial presentation. Ureterolithotomy and percutaneous nephrolithotomy were commonly performed procedures for stone clearance. Metabolic work was done in all cases in follow up period. Three patients had hypercalciuria and hypocitraturia suggestive of renal tubular acidosis. CONCLUSION: Large spontaneous steinstrasse is uncommon case scenario. It can be subtle in presentation and yet have significant patient consequence in terms of renal function and infection. Prompt management is essential to preclude permanent loss of renal function. Metabolic evaluation is indispensable in such cases.

Comparison of stent related symptoms in patients taking mirabegron, solifenacin, or tamsulosin: A double blinded randomized clinical trial.

BACKGROUND: The present study aims to assess the efficacy of mirabegron, a novel beta-3 agonist for ameliorating stent related symptoms (SRSs) as compared to tamsulosin and solifenacin. METHODS: Total of 150 patients undergoing ureteral stent placement following ureteroscopic lithotripsy, percutaneous nephrolithotomy, or laparoscopic/robotic pyeloplasty were randomized in 1:1:1 fashion to receive mirabegron 50 mg (group A), solifenacin 5 mg (group B), and tamsulosin 0.4 mg (group C) OD respectively. Patients were followed at POD10 (I visit), 4 weeks (II visit) after surgery, and 2 weeks post-stent removal. Validated vernacular version of ureteric stent symptoms questionnaire (USSQ) was administered to the patients at each visit. RESULTS: Out of 150 patients randomized, 123 patients (A; n = 41, B; n = 40, and C; n = 42) completed the study. The groups were comparable in terms of urinary index score of USSQ at I and II visits (p = 0.119 and 0.076, respectively). A lower proportion of patients in group B experiencing bodily pain at II visit (p = 0.039), however, pain scores were comparable. Significantly lower general health index scores were observed in group A at I visit and over 4 weeks (p = 0.007). No significant differences were observed in other domains of USSQ. Age, sex, and surgical procedure undertaken did not significantly impact the scores in various USSQ domains. CONCLUSION: Mirabegron demonstrates comparable benefit in alleviating SRSs with better general health indices and may be an effective alternative for SRSs, especially when tamsulosin or solifenacin are contra-indicated or poorly tolerated.

Conquering new battlegrounds: Successful management of isolated giant retrovesical hydatid cyst with robotic assistance.

Hydatid disease (HD) is an accidental human parasitic infestation by cestodes and is most commonly caused by Echinococcus granulosus. Liver happens to be the most common site of involvement, although involvement of other organ symptoms is not uncommon. Involvement of the retrovesical pouch by hydatidosis is generally secondary in nature with an incidence of 0.1%-0.5% only. Primary retrovesical hydatid cyst (RVHC) is extremely rare with only few cases in existing literature. RVHC can present with a wide gamut of symptoms ranging from asymptomatic to obstructive uropathy. A 38-year-old male presented to us with complaints of lower urinary tract symptoms (LUTS) and was found to have an isolated primary retrovesical hydatid cyst on evaluation. The RVHC had compressed the right ureter leading to a grossly hydronephrotic non-functional right kidney. The patient was started on albendazole therapy and underwent robot assisted right nephroureterectomy and partial pericystectomy for the RVHC. The postoperative period was uneventful with resolution of symptoms. This report highlights the various clinical presentations of RVHC as well as the minimal invasive management of this rare entity.

Absence of SARS-CoV-2 infection in the semen of men recovering from COVID-19 infection: An exploratory study and review of literature.

The effect of COVID-19 on the male reproductive tract has been sparsely studied. This exploratory study was designed to determine the presence of SARS-CoV-2 in the semen of men recovering from COVID-19. A systematic literature review was also performed as per PRISMA guidelines to gather perspective on this topic. The prospective study included men 21 years and older recovering from COVID-19 with nasopharyngeal swab negative for SARS-CoV-2 or at least two weeks from the last COVID RT-PCR positivity. After clinical evaluation, freshly ejaculated semen sample by masturbation was collected in a sterile container. Samples were processed for the detection of SARS-CoV-2 by RT-PCR. Twenty-one patients were contacted for the study, 11 of which consented to provide a semen sample. The mean age of the cohort was 29.72 ± 4.52 years. None of the patients gave a history of epididymo-orchitis or sexual dysfunction at the time of assessment. None of the semen samples demonstrated SARS-CoV-2 on RT-PCR. Median duration of semen sample collection from the COVID positivity was 44 days (Range 19-59 days). Detailed literature review revealed that SARS-CoV-2 is not found in patients recovering from COVID-19 infection. We conclude that SARS-CoV-2 is not found in the semen of patients recovering from COVID-19.

Mucosal coaptation technique for early urinary continence after robot-assisted radical prostatectomy: a comparative exploratory study.

INTRODUCTION: Urinary incontinence is a troublesome complication following radical prostatectomy. Various robot-assisted radical prostatectomy (RARP). We describe our technique (Santosh-PGI) of urethral and urinary bladder mucosa coaptation for early continence following RARP. MATERIAL AND METHODS: We performed a prospective comparative study of patients planned for RARP between July 2018 and December 2019 at our centre. A total of 40 patients were enrolled in the study protocol. Following prostatectomy, patients were alternatively assigned into two groups. In one group, urethral and urinary bladder coaptation sutures were placed in a purse string manner using 3-0 Monocryl sutures and none in the another group. All patients underwent standard end to end vesico-urethral anastomosis as described by Van Velthoven. The urinary catheter was removed on day 10 after surgery. All patients were evaluated on day 1, 30 and 90 after catheter removal. RESULTS: The two groups, each with 20 patients, were comparable in terms of age, clinical staging and D'Amico risk classification. The operative time, blood loss and surgical margin positivity were comparable. Following catheter removal, 75% of patients in Group A (Mucosal coaptation) and 50% in Group B (Standard technique) were continent (p = 0.264). At 30 and 90 days, 90% and 95% in Group A and 60% and 80% in Group B reported continence respectively (p-0.078). Four patients in group B reported bothersome incontinence at 90 days follow-up. CONCLUSIONS: Urethral and urinary bladder mucosal coaptation is a simple innovative technique for early continence following RARP.

Evaluation of YouTube Videos as a Source of Patient Information for Ureteric Stent Placement: A Quality Assessment Study.

OBJECTIVE: To assess the quality of YouTube videos on ureteric stent placement (USP) as a source of patient available. METHODS: YouTube was searched using search terms "DJ stenting," "Double J stenting," and "ureteric stenting." The initial 100 videos displayed with each of the above mentioned search terms were scrutinized. The selected videos reviewed by 3 independent consultant urologists against a pre-agreed scoring system based upon European Association of Urology (EAU) patient information sheet on ureteric stent placement. The videos were scored qualitatively and quantitatively based on the scores achieved in various domains of the scoring Performa. Data was also collected for the number of views, likes, dislikes, and time duration of each video. RESULTS: A total of 22 videos which fulfilled the inclusion criteria were reviewed. All the videos were uploaded by healthcare organizations or healthcare websites. None of the videos were classified as "Good" based on reviewer scores and only one video was classified as "acceptable." Fourteen videos were classified as "very poor" with a score of <5/20. General information about stents was described by majority of the studies whilst preoperative information, procedure description, danger signs, and follow up were scarcely described by most videos. CONCLUSION: Majority of YouTube videos on USP are of poor overall quality and lack pertinent information. This calls for creation of comprehensive and unbiased videos for patient information on USP.

Dismembered extravesical reimplantation of ectopic ureter in duplex kidney with incontinence.

Ectopic ureter is a rare but pertinent cause of incontinence in young women. We report a 12-year-old girl who presented with reports of incontinence since birth. She was evaluated and found to have complete duplication of the left ureter, with the upper moiety ureter opening into the vestibule of the vagina just below the external urethra meatus. She was managed surgically by dismembered extravesical reimplantation of the upper moiety ureter instead of the conventional method of common sheath reimplantation, sparing the patient a wide cystostomy and intravesical dissection. One year postsurgery, the patient is asymptomatic and dry. Dismembered reimplantation of the ectopic ureter is a simple and reproducible technique which avoids manipulation of the normal lower moiety ureter and its associated potential complications. At the same time, it ensures that the patient is dry without any adverse effect on the lower moiety or its ureter.

Robot-assisted Repair of Complex Vesicovaginal Fistulae: Feasibility and Outcomes.

OBJECTIVE: To share our experience and techniques of robot-assisted repair of complex vesicovaginal fistulae. METHODS: Prospectively maintained data of patients undergoing robot-assisted repair of complex vesicovaginal fistula (VVF) from December 2014 to October 2019 were analyzed. Patient characteristics, operative data, postoperative events, and follow-up outcomes were noted. All cases underwent preoperative cysto-vaginoscopy and upper tract imaging. The procedure was completed in a standard fashion. Additional procedures included Boari flap reimplantation, Burch-colposuspension, ureteric reimplantation and Vaginal flap incorporation. On follow-up, successful repair was defined as no urine leak after removal of catheter. RESULTS: Out of 73 patients undergoing robot-assisted VVF repair at our institute, 33 were classified as complex VVF. Mean age was 42.7 ± 7.2 years. The most common cause of VVF was posthysterectomy (81.8%) with 21 (63.1%) recurrent VVFs. Thirty patients (90.0%) had supratrigonal fistulae; multiple fistulae were present in 3 cases. Two patients underwent Boari flap ureteric reimplantation for concomitant ureteric stricture and ureteric neocystostomy was required in another patient. One patient underwent our novel technique of vaginal flap incorporation and a Burch colposuspension was performed simultaneously in one patient with stress incontinence. The median follow-up was 35 months (interquartile range 8.5months). Successful outcome was noted in 31 (93.9%) patients; recurrence requiring further repair in 2 patients. CONCLUSION: The current series presents the largest number of complex VVFs repaired by robotic assistance. Robot-assisted repair can be considered as one stop procedure for such complex and vexing problems.

IgG4-related Retroperitoneal Fibrosis: An Emerging Masquerader With a Sinister Presentation.

OBJECTIVE: Retroperitoneal fibrosis (RPF) is a rare proliferative fibro-inflammatory disease involving the soft tissues of the retroperitoneum. IgG4 related retroperitoneal fibrosis is an emerging entity which needs to be distinguished from idiopathic RPF. We describe a clinical case of IgG4 related RPF highlighting the importance of clinching this diagnosis. METHODS: A 70 year old female was referred to the outpatient department of our institute with complaints of fatigue, bilateral flank pain and loss of appetite for the past 1 month. The CT and PET scan demonstrated a uniformly enhancing bulky retroperitoneal mass causing bilateral hydroureteronephrosis. The biopsy from the mass lesion revealed IgG4 related disease. The patient was started on corticosteroids after percutaneous nephrostomy placement. RESULTS: Three months post induction of therapy, repeat PET-CT shows resolution of the mass with no FDG avid lesion. Serum IgG4 levels were reduced to normal (27 mg/dL) suggestive of response to treatment. The percutaneous nephrostomies were removed and the patient is doing well on maintenance dose of corticosteroids for her disease. CONCLUSION: The availability of serum IgG4 levels for monitoring treatment response and follow-up can curtail the repeated radiological imaging and associated contrast exposure as compared to idiopathic RPF. Secondly, the diagnosis of IgG4-related RPF shall alert the clinician to look out for extra-retroperitoneal diseases on follow up of this multi-organ disease.

Bilateral simultaneous "Santosh Post-graduate Institute tubularized flap pyelovesicostomy" in a case of bilateral pelvi-ureteric junction obstruction with bilateral giant hydronephrosis.

We present a case of bilateral giant hydronephrosis (HDN) secondary to bilateral pelvi-ureteric junction obstruction (PUJO) in a young girl, managed successfully by robot-assisted bilateral tubularized flap pyelo-vesicostomy. This case report highlights the feasibility, reproducibility and technicalities of this procedure.

Robot-assisted boari flap calycovesicostomy for failed uretero-pelvic junction obstruction: a novel approach to a complex problem.

Uretero-pelvic junction obstruction (UPJO) is a common condition, often presenting in adulthood in developing countries. These cases can pose significant problems owing to late presentation and complications such as infection, stones, and impaired renal function. We present the case of a 28-year-old female who presented to us with recurrent symptoms and impaired drainage following a failed open pyeloplasty and robot-assisted ureterocalycostomy for right UPJO. She was managed by robot-assisted boari flap calycovesicostomy, an innovation which helped in salvaging her kidney; ensuring good drainage in the involved kidney. To our knowledge, this is the first such case in the literature in the management of complex UPJO.

Robot assisted intra-corporeal ileocalicostomy ureteral substitution for complex uretero-pelvic junction obstruction: a novel and feasible innovation.

A 33-year-old female presented to the emergency department of our hospital with urosepsis and hematuria with clot retention secondary to a complicated pyelolithotomy for left-sided pelvic calculus. A percutaneous nephrostomy was placed for drainage as a DJ stent could not be traversed into the left renal pelvis with retrograde pyelography demonstrating complete cut-off at L4-L5 level. After stabilization, she was found to have uretero-pelvic junction obstruction (UPJO) in left solitary functioning kidney with long-segment upper ureteric stricture and nadir serum creatinine 1.5 mg/dL. Nephrostogram and CT scan revealed an intra-renal pelvis with no passage of contrast into the ureter. Primary hyperparathyroidism secondary to parathyroid adenoma was also detected and she underwent excision of the same. The long-segment ureteric stricture and need for a wide drainage ruled out pyeloplasty and ureterocalicostomy as treatment options. A wide-bore communication between the lower calyx and bladder was necessary and robot assisted ileocalicostomy was performed in this case. A 20-cm-long segment of ileum was used to replace the ureter with a suprapubic 16 Fr Foley's catheter as splint. Postoperative course was uneventful with all tubes removed by third postoperative week. Nephrostogram demonstrated gravity-dependent drainage into the bladder with no leak or anastomotic narrowing. The patient is doing well at 6 months of follow-up with a stable renal function. Robot assisted ileocalicostomy is a safe and effective technique which provides wide gravity-dependent drainage in complex UPJO with long-segment ureteric stricture and intra-renal pelvis.

Massive Bleed Following Optical Internal Urethrotomy: An Unforeseen Doom Discussing the Unique Management Technique.

Objective: To demonstrate the unique management technique of ultrasound (USG)-guided compression repair for bulbourethral artery pseudoaneurysm following optical internal urethrotomy (OIU) for short segment bulbar urethral stricture. Methods: A 40-year-old man underwent day care OIU for short segment bulbar urethral stricture. The procedure was uneventful and the patient was discharged the same day. After catheter removal on day 7, the patient had massive bleed from urethra. Perineal compression stopped the bleeding; however, the patient bled again and needed blood transfusion. CT angiography revealed right bulbourethral artery pseudoaneurysm. Results: USG colour Doppler was performed to find out the exact site of pseudoaneurysm, and focused compression was given for 25 minutes. Later assessment showed no flow in pseudoaneurysm and tract was obliterated. Conclusion: Minor bleed following OIU is quite common and generally subsides spontaneously or with pressure dressing. Massive bleed is uncommon, although reported in the literature, and requires angioembolization of the feeding vessel. Before going for invasive procedure, this simple technique of USG-guided compression can be tried as it is simple, cost-effective, and highly successful in small pseudoaneurysm.

Penoscrotal lymphangioma circumscriptum following circumcision.

We present a 15 year old boy with multiple vesicular lesions involving the scrotum and penile skin which developed following circumcision. Surgical excision of the penoscrotal skin with local flap cover was done. Histopathology was consistent with lymphangioma circumscriptum. To our knowledge this was the first case of penoscrotal lymphangioma circumscriptum which was seen after circumcision.

A rare inflammatory myofibroblastic bladder tumor masquerading urachal carcinoma.

Inflammatory pseudotumor is a rare benign condition of unknown cause. A 19-year-old female presented with gross hematuria and storage symptoms to the emergency. Contrast-enhanced computed tomography scan revealed a mass of 5 cm × 6 cm involving the dome and anterior wall of the bladder. Urachal carcinoma was kept as a possibility and transurethral biopsy of the aforementioned lesion was performed. The histopathology revealed inflammatory myofibroblastic tumor (IMT) of the bladder. A laparoscopic partial cystectomy was undertaken with adequate resection margins and the histopathology of the lesion confirmed IMT. When evaluating a mass in the genitourinary tract in a young individual, IMT should be considered as a possibility.

Organ Preservation in a Case of Retroperitoneal Ganglioneuroma: A Case Report and Review of Literature.

The retroperitoneum is a closed space harbouring vital organs including the great vessels, kidneys and adrenal glands, ureters, and the ascending and descending colon. Surgical management of retroperitoneal pathologies may need multiorgan resection in order to achieve complete surgical resection while preservation of surrounding organs should be attempted, especially in case of benign tumors. We present a case of 15-year-old girl with an 11 × 6 × 5 cm retroperitoneal ganglioneuroma displacing the right kidney, renal vein, and ureter and abutting the IVC which was excised in toto preserving the right kidney and ureter with careful dissection around the great vessels. We also attempt to review the various surgical options available while dealing with these benign retroperitoneal tumors which are often detected incidentally and usually surround important retroperitoneal organs and vessels.