Emphysematous pyelonephritis with progression to necrotising fasciitis of the posterior cervical region and the retropharyngeal space.

A man in his 50s with diabetes presented with backache, left flank pain and fever. On evaluation, he was found to have emphysematous pyelonephritis of the left kidney with a paranephric abscess extending into the posterior abdominal wall and superiorly up to the posterior chest wall and inferiorly extending up to the posterior superior iliac spine. The management involved the initiation of broad-spectrum antibiotics and percutaneous drainage of the abscess. However, as he continued to worsen symptoms-wise, he underwent computed-enhanced CT of the abdomen and thorax. The imaging revealed the presence of a purulent collection in the left lumbar region with an extension along the posterior cervical region and the retropharyngeal space. He underwent a fasciotomy of the lumbar region. The occurrence of emphysematous pyelonephritis along with necrotising fasciitis is uncommon and requires early aggressive management with broad-spectrum antibiotics and adequate drainage. This emphasises the need for early reimaging if the patient does not settle with antibiotics or percutaneous drainage.

Is low-dose tadalafil better than tamsulosin? A randomized controlled trial in shockwave lithotripsy for solitary upper tract calculi.

OBJECTIVE: To ascertain whether low-dose tadalafil (5 mg) is more efficient than tamsulosin (0.4 mg) in facilitating calculus expulsion in those receiving extracorporeal shockwave lithotripsy for solitary upper urinary tract calculi. PATIENTS AND METHODS: This was a triple-blinded, prospective, superiority, randomized controlled, single-centre trial. A total of 250 patients with solitary renal or ureteric calculus measuring 6-24 mm were randomized (1:1) to receive either 0.4 mg tamsulosin or 5 mg tadalafil daily for 30 days or until calculus clearance, whichever was earlier. RESULTS: There was no difference in the primary outcome, namely, calculus expulsion rate at 30 days (tamsulosin vs tadalafil, n (%) 99 [81.1%] vs 98 [80.3%] respectively, 95% confidence interval = 0.8% [-9.0, 10.7], P = 0.874). Similarly, a lack of difference was also noted in the secondary outcome, number of days to expulsion (tamsulosin vs tadalafil, geometric mean [SD] 13.59 [2.39] vs 13.74 [2.39] respectively, P = 0.928). Four patients discontinued the drug due to adverse drug reactions in the tadalafil group. CONCLUSIONS: Low-dose tadalafil is not superior to tamsulosin in improving calculus expulsion when used as an adjunct to shockwave lithotripsy. In this study, we also noted that tadalafil was less tolerated.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias

ABSTRACT Introduction To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. Material and methods Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. Results Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. Conclusions Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Vacuum physiotherapy after first stage buccal mucosa graft (BMG) urethroplasty in children with proximal hypospadias.

INTRODUCTION: To assess the feasibility of vacuum physiotherapy meant to decrease graft contraction and recurrent penile curvature (PC), hence successful tubularization and a straight penis in patients underwent two-stage buccal mucosa graft (BMG) urethroplasty, in proximal hypospadias repair. MATERIAL AND METHODS: Between January 2014 and July 2018, 59 two-stage BMG urethroplasties performed at our referral center, were included in the study. The parents were counseled to use the vacuum device between the two stages. An internal, self-administered, semiquantitative, non-validated questionnaire was designed to record parent and patient adherence to the vacuum physiotherapy and parent satisfaction. Success rate of graft tubularization, curvature correction rates, and status of early (4 months) postoperative urinary stream were evaluated. RESULTS: Of 45/59 (76.3%) who returned the questionnaire, 77.8% followed the recommended physiotherapy protocol using the vacuum device. 93.3% of parents replied that the use of the vacuum was easy or moderately easy. None of the parents interrupted the physiotherapy because of perceived difficulty or intolerability. 100% of parents would have repeated the physiotherapy, if they had to. Overall, success rate of tubularization was 98.3% (58/59), complete curvature correction was achieved in 88.2% (52/59) of patients, and 79.7% (47/59) of patients showed a straight and powerful early post-operative urinary stream. CONCLUSIONS: Physiotherapy with the vacuum device is safe, easy and practically feasible. Our vacuum physiotherapy protocol had high compliance rate. Vacuum physiotherapy should be considered for further assessment in patients undergoing two stage hypospadias repair using buccal mucosa.

Prevalence, assessment and surgical correction of penile curvature in hypospadias patients treated at one European Referral Center: description of the technique and surgical outcomes.

PURPOSE: Penile curvature (PC) is a common component of hypospadias, but its presence is inconstantly assessed. We aim to report prevalence of PC in hypospadias patients, as well as to report our method to assess and correct PC, with the associated postoperative outcomes. METHODS: We scrutinized 303 pediatric hypospadias patients operated (2013-2018) at our referral center. PC was routinely assessed and eventually corrected with dorsal plications (DP) as one-stage procedure, or ventral tunica attenuations ± DP as two-stage repair. PC severity and surgical treatment of PC were compared between primary and failed hypospadias. Finally, PC severity, failed repair and PC treatment were tested as predictors of perioperative complications. RESULTS: PC (> 10°) was identified in 274/303 (90.4%) patients, 86.1% with distal, 91.8% with midshaft, and 100% with proximal hypospadias, respectively. PC was found in 51/64 (79.7%) of failed hypospadias. One-stage and two-stage procedures were adopted in 211/274 (77%) and 63/274 (23%) children, respectively. PC severity (p = 0.1) and PC treatment (p = 0.4) did not differ between primary and failed hypospadias. PC severity (all p > 0.2), failed repair (p = 0.8), and PC treatment (all p > 0.09) were not predictors of perioperative complications. 95.6% of patients achieved a straight penis. CONCLUSION: Less than 1/10 patients did not require PC correction. High rate of residual PC in failed hypospadias and similar severity between failed and primary suggest that PC was usually under-corrected. It is possible to correct PC completely and the resulting complication would not be associated with PC severity, failed repair or treatment adopted.

Renal transplantation into optimized abnormal lower urinary tract - Impact on graft outcomes, patient survival, and complications.

INTRODUCTION: Literature regarding the outcomes of renal transplant in patients with abnormal lower urinary tracts (LUTs) is conflicting. The study aimed to determine the graft outcomes and complications of renal transplantation in an optimized abnormal LUT as compared to those with a normal LUT. MATERIALS AND METHODS: In this single-center retrospective-matched cohort study, we identified 31 patients with an optimized abnormal LUT in our transplant database between 2006 and 2016 (Group A) and selected an equal number of matched controls (Group B). The primary outcome was graft survival, and secondary outcomes were overall survival and complications. RESULTS: The median age was 24 years (range: 12-45), and the median duration of follow-up was 36 months in both groups. On Kaplan-Meier analysis, the estimated mean graft survival was 106 months (confidence interval [CI]: 91-120) in Group A versus 128 months (CI:117-139) in Group B (P = 0.47, log-rank analysis). On subgroup analysis of Group A, augmented bladders had the poorest mean survival (81 months, CI: 56-106), P = 0.09). The mean estimated patient survival was comparable between Group A and B (109 months, CI: 96-122 versus 139 months, CI: 134-144), P = 0.13). Infective complications (27 episodes vs. 1) and re-admissions (77 vs. 30) were significantly higher in Group A (P = 0.04 and P < 0.01). Clean intermittent catheterization was a risk factor for infections (63% vs. 37%, P = 0.033, odds ratio: 5). CONCLUSIONS: The graft and overall survival was comparable at 3 years in both groups. Infective complications were higher in Group A.

Is there a role for second transurethral resection in pTa high-grade urothelial bladder cancer?

INTRODUCTION: Evidence for second transurethral resection of bladder tumour (TURBT) for pTa high-grade lesions is limited. This study aims to examine the role of a second TURBT in the pTa high-grade group and to generate recurrence and progression data for this group. MATERIAL AND METHODS: We retrospectively studied the clinical profiles and outcomes of all patients diagnosed with high-grade pTa lesions at first TURBT, between the years 2006-2015. Firstly, in patients who underwent a complete first TURBT, we calculated the proportion of patients with positive findings on second TURBT. Secondly, we assessed whether those who underwent a second TURBT had a longer recurrence-free survival compared to those who underwent a single TURBT. RESULTS: One hundred and twelve patients had a pTa high-grade urothelial bladder tumor (WHO 2004 classification) at first TURBT, out of whom 43 (38.3%) had a second TURBT. Indications for second TURBT were high-grade lesions (n = 36), absence of detrusor muscle (n = 2), and incomplete resection (n = 5). Out of the 36 patients who had a complete first TURBT and underwent a second look TURBT, 7 patients had positive findings (3 carcinoma in situ, 2 pTa low-grade lesions and 2 pTa high-grade lesions) and there was no upstaging. Of the 5 patients with an incomplete first TURBT, one upstaged to pT1 on second TURBT. Of the 81 patients who followed up with us, 25.9% had a recurrence and 8.6% progressed. The estimated median recurrence free survival was 60 months (95% CI 29.2-90.7) for the whole group and 76 months vs. 45 months for the second and single TURBT group respectively - a difference that was clinically, though not statistically, significant. Multiple (≥2) tumours had a lower recurrence free survival (HR of 4.60, CI 1.67-12.63, p = 0.003). CONCLUSIONS: Of the patients with pTa high-grade tumours who had a second TURBT after a complete first TURBT, 19.4% had a positive finding. Multiple tumours are four times as likely to recur as solitary tumours. The role of a second TURBT in this group needs to be studied in larger patient cohorts before a recommendation regarding its lack of clinical utility can be made conclusively.

Urodynamic outcomes of tamsulosin in the treatment of primary bladder neck obstruction in men.

INTRODUCTION: Alpha blockers are widely used in the treatment of primary bladder neck obstruction; however, evidence for objective urodynamic efficacy is scarce. We studied the effect of the uroselective α1-blocker tamsulosin on urodynamic parameters in male patients with type I primary bladder neck obstruction. METHODS: A single center prospective observational study was carried out from July 2013 to February 2015. Male patients (18-50 years) with type 1 primary bladder neck obstruction were recruited. Selected patients were started on tablet tamsulosin 0.4 mg once daily for 3 months. International prostate symptom score (IPSS), uroflow and urodynamic studies were done pre- and post-treatment. Primary outcome was decreased in minimum detrusor pressure at maximum flow rate by 15%. Wilcoxon-matched pair signed-rank test was used. RESULTS: Of 39 patients recruited, 21 patients completed the follow-up as per protocol and were analyzed. Mean age was 41 years. 57% patients achieved the primary outcome (median detrusor pressure pre- and post-treatment were 71 and 56 cm of water, P < 0.001). Similarly, median values for bladder outlet obstruction index (BOOI) and IPSS decreased from 59 to 38 (P < 0.001) and 22 to 12 (P < 0.001), respectively. Median maximum flow rate increased from 8 to 10 ml (P = 0.05). Pretreatment BOOI of >60 was associated with poor outcomes. CONCLUSIONS: Tamsulosin 0.4 mg once a day is effective in reducing bladder outlet obstruction on pressure flow studies in patients with primary bladder neck obstruction type 1.

Does asymptomatic prostatic inflammation alter the outcome of transurethral resection of prostate?

INTRODUCTION: There is contradictory evidence in literature with respect to the association of asymptomatic prostatic inflammation on biopsy with complications of Transurethral Resection of Prostate. The aim of the present study was to evaluate the association of prostatitis in biopsy specimens of patients undergoing transurethral resection of prostate with bladder neck contracture (the primary end point) and other complications. MATERIAL AND METHODS: Patients who had undergone transurethral resection at a single centre between 2005 and 2010, with a minimum of 3 months follow-up were included. The study population was divided into two cohorts: those with inflammation on prostatic biopsy (Group A) and those without (Group B). These two groups were compared with respect to demographic data and pre-operative and intraoperative confounding factors. Immediate complications were documented using the modified Clavien-Dindo system and compared. Long term complications like bladder neck contracture, meatal stenosis, urethral stricture, and recurrent adenoma were also compared. RESULTS: Both groups were comparable except for Group A patients having a higher median resected weight (20 vs. 14 gms, p = 0.009). There was no significant difference between the groups with respect to the rate of bladder neck contracture and other long-term and short term complications on univariate and multivariate analysis. Larger resected weight of gland was associated with lower rate of bladder neck contracture on multivariate analysis (p = 0.019, Odds ratio: 0.937). CONCLUSIONS: Presence of histologically confirmed prostatic inflammation is not associated with bladder neck contracture or other complications following transurethral resection. Smaller resected prostatic weight was associated with higher incidence of bladder neck contracture.

Renal arteriovenous malformation with inferior vena caval extension mimicking renal cell carcinoma.

A young lady presented with complaints of right flank pain and a palpable mass. On contrast-enhanced tomography (CECT), a renal mass with extension into the inferior vena cava (IVC) - suggestive of renal cell carcinoma - was diagnosed and she underwent radical nephrectomy with en bloc excision of the IVC thrombus. Histopathology revealed a benign arteriovenous malformation that had extended into the IVC. Arteriovenous malformation should therefore be kept in the list of differentials for a renal mass with IVC extension.

Evaluation of the role of preoperative Double-J ureteral stenting in retroperitoneal laparoscopic pyelolithotomy.

BACKGROUND: Since the first retroperitoneal laparoscopic pyelolithotomy (RPPL) was reported by Gaur and associates in 1994, its technique has improved considerably. The applicability and indications of the procedure are expanding with advances in technology, expertise, and experience. To date, there has been no prospective study in the literature about the role of preoperative Double-J (D-J) ureteral stenting in patients who undergo RPPL. This study is an endeavor to evaluate the role of preoperative D-J stenting in RPPL. METHODS: The study included 184 patients, who were randomized into 2 groups. Group A included 95 patients, who underwent RPPL with D-J stenting. Group B included 89 patients, who underwent RPPL without D-J stenting. In group A, D-J stents were inserted under local anesthesia preoperatively, on the side of surgery. Complications during surgery and during the postoperative period were carefully recorded. RESULTS: The duration of drainage and volume in group A was significantly lower than in group B. The duration of postoperative stay was significantly reduced in group A (mean 3.3 vs. 5.74 days). The analgesic requirement in group A also was significantly lower than in group B (mean 378.95 vs. 558.99 mg). No statistically significant difference existed between the two groups, in terms of minor intraoperative and postoperative complications (25.3% vs. 29.2%; p < or = 0.547). CONCLUSIONS: D-J stenting and type of renal pelvis influenced the results, i.e., duration of drainage, analgesic requirement, and duration of stay, in patients undergoing RPPL. However, there was no significant difference in operative time, intraoperative blood loss, and postoperative complications. D-J stent group had significant increase in the rate of urinary tract infection postoperatively.