Pediatric urethrovaginal reflux: an underestimated cause of urinary incontinence and its successful management.

INTRODUCTION AND HYPOTHESIS: Urethrovaginal reflux (UVR) secondary to vaginal urine entrapment is an unnoticed cause of daytime urinary leakage in toilet-trained girls. Our aim is to emphasize the diagnosis of UVR as a cause of urinary incontinence, its predisposing factors, early detection, and treatment. METHODS: A total of 25 girls aged between 9 and 14 years presented with mixed daytime urinary incontinence from 2019 to 2021. They were evaluated by detailed history, vaginal examination, focused neurological examination, bladder diaries, urine analysis, uroflowmetry, and residual urine assessment. Micturating cystourethrography was also performed in those girls who did not show improvement with a conservative line of management. RESULTS: The parents of these girls were educated about the cause of leakage. They were treated with behavioral modifications, urotherapy, correcting toilet postures, and reverse sitting on the commode. Urethrovaginal reflux was found in 6 of the 25 girls (24%). Their ages were 9, 10, 10, 11, 12, and 14 years respectively. Two girls (10 and 14 years old) had a body mass index more than 25. They all had a typical history of a small quantity of urine leakage 5-10 min (post-micturition dribble) after every void. At follow-up after 12 months, all of them were free from urinary incontinence. CONCLUSIONS: Urethrovaginal reflux should be considered in the differential diagnoses of girls with day-time incontinence. The key to diagnosis is an appropriate and detailed history as it is common for parents or girls to ignore symptoms or fail to report them. Proper voiding instructions and behavioral therapy often resolve the problem.

Laparoscopy training status in India and a review of the current resident skill standards.

CONTEXT: The aim was to identify the current training standard of laparoscopy skills among the urology residents. AIMS: This paper presents the residents' subjective perception of their laparoscopy skills and evidence of an objective assessment of their actual skills. SETTINGS AND DESIGN: An online survey was mailed, and completed by urology residents in training. The residents' perception of laparoscopy training received, exposure to laparoscopy procedures, and training facilities were queried. The assessment was done on the skill levels of the residents presenting at an annual training program. SUBJECTS AND METHODS: 103 residents responded to the online survey and 115 residents were assessed at the training program. STATISTICAL ANALYSIS USED: Discrete data were compared using the t-test to test for significance of the means; P < 0.05 was considered significant. Pearson's correlation coefficient was used to obtain the relationship between variables. RESULTS: An overwhelming 91% rated their laparoscopy skill as just "satisfactory" or worse, and 60% did not have any training facilities in their department. 66% continue to be "assistants only" in conventional laparoscopy surgeries. Assessment of basic laparoscopy skills in the dry lab revealed 92% of residents having poor laparoscopy skills; similar to the subjective opinion in the survey. Only 6% (n = 5) of the residents showed a good or better skill score in the dry lab; similar to the survey. CONCLUSIONS: Based on the survey, a large number of residents have a poor opinion of their own laparoscopy skills, and the training facilities available to them. The data objectively prove the self-assessment of the residents on their laparoscopy skill level.

Objective assessment of mouth opening after buccal mucosal graft urethroplasty: A prospective study.

INTRODUCTION AND OBJECTIVES: Buccal mucosal graft (BMG) is frequently used for the reconstruction of urethral strictures with acceptable donor-site morbidity after graft harvest. There are only a few prospectively designed studies with a small number of patients reporting oral complications, particularly the mouth opening in the long terms. We did an objective assessment of mouth opening before and after 6 months of BMG urethroplasty as well as pain scores. MATERIALS AND METHODS: Fifty-eight patients who underwent BMG urethroplasty were included in the study between May 2013 and December 2014. Preoperative mouth opening (reference point between two incisors with the highest of three readings taken as final) was measured using a Vernier caliper. Harvest site was left open to heal by secondary intentions. Postoperatively, mouth opening and pain scores using self-administered (Visual Analog Scale [VAS]) assessed on day 1 and day 3, and follow-up at 1 week, 1 month, and 6 months. Data were analyzed as mean (standard deviation [SD]), proportion, and median (inter-quartile range [IQR]) with two-tailedP < 0.05 as statistically significant. RESULTS: The mean age was 39.6 years. The graft was harvested from a single cheek in 50% of patients. In remaining, it was taken from both cheeks, both cheeks with lip, and both cheeks with the tongue in 29.31%, 17.24%, and 3.5%, of patients, respectively. Preoperative mouth opening (5.13 cm [0.08]) was statistically significantly more than mouth opening on day 1 (4.34 cm [0.09]), day 3 (4.48 [0.09]), and day 7 (4.69 cm [0.09]). Mean difference became insignificant at the interval of 1 month (4.91 cm [0.09]) with 6 months' values showing marginal improvement over preoperative values (5.14 cm [0.07]). Pain was tolerable and patients reported low median VAS 2 (2-4) on day 1 and day 3 each. Reported median VAS became 0 (0-0) on day 7. CONCLUSION: Mouth opening restriction after BMG urethroplasty is a definite entity in the initial postoperative period, which becomes nonsignificant by 6 months. The pain has no effect on mouth opening.

A Prospective Study to Evaluate the Efficacy of Botulinum Toxin-A in the Management of Dysfunctional Voiding in Women.

OBJECTIVES: To assess the outcomes of Botulinum Toxin-A (BoNT-A) to the external urethral sphincter (EUS) in dysfunctional voiding (DV) refractory to standard urotherapy and bowel management. METHODS: Our criteria to diagnose DV in women included neurologically normal individuals with lower urinary tract symptoms, dilated proximal urethra on voiding cystourethrogram, and high detrusor pressure (PdetQmax > 20 cm H2O) associated with increased electromyography activity during voiding in urodynamic study (UDS). A total of 16 female patients with a median age of 36 years (5-60 years) received BoNT-A from June 2014 to December 2015. Patients below and above 10 years of age received 100 units and 200 units of BoNT-A to EUS, respectively. Patients were followed up till 6 months. RESULTS: Mean AUA (American Urological Association) symptom score decreased significantly from 11.75 ± 6.14 to 5.06 ± 5.1 and 4.25 ± 3.4 at day 14 and day 45 after BoNT-A, respectively (P < .0001). There were no significant improvements in maximal flow (Qmax) on uroflowmetry (UFM) and detrusor pressure at maximal flow (PdetQmax) in UDS. Significant reduction in post-void residual (PVR) from 69.31 ± 77.3 to 17.50 ± 22.3 mL at day 14 (P = .007) was observed, although the reduction was not significant at day 45. Although minor adverse effects were reported, none were serious or life-threatening. CONCLUSIONS: Our study showed that BoNT-A plays a role in improvement of urinary symptoms and reduces PVR at D14 in DV, but showed no improvement in UFM and urodynamic parameters, albeit with limited numbers and limited follow-up.

Dihydroxyadenine stone with adenine phosphoribosyltransferase deficiency: A case report.

Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive error of purine metabolism resulting in the generation of 2,8-dihydroxyadenine (DHA), a highly insoluble metabolite of adenine, which can cause radiolucent urolithiasis. This is the second case of DHA stone being reported in India and the first case in India to document the mutation of the APRT gene on blood DNA analysis.

Incidentally detected clear cell renal cell carcinoma with rhabdoid differentiation.

Renal cell carcinoma with rhabdoid differentiation (RCC-R) has an aggressive biologic behavior and poor prognosis. A recent consensus statement of the International Society of Urological Pathology (ISUP) proposed a nucleolar grading system (ISUP grade) for RCC to replace Fuhrman system and recommended reporting the presence of rhabdoid differentiation and considering tumors with rhabdoid differentiation to be ISUP Grade 4. We report a case of incidentally detected clear cell RCC-R in a 52-year-old man. This is one of the earliest cases of RCC-R (pT1b) detected and first such case from Indian subcontinent.

Use of Volume Rendered, Maximum Intensity Projection Images to Assess Whether the Medial Calyx Synonymous with the Posterior Calyx.

INTRODUCTION: This paper attempts to verify the anatomical veracity of the belief that in order to enter into a posterior calyx one must aim for the medial calyx during a percutaneous nephrolithotomy (PCNL). METHODS: Volume rendered and maximum intensity projection reconstructions of normal pelvicalyceal systems were assessed in various rotational planes. An experienced urologist decided the appropriate access for PCNL in the upper, interpole and lower calyx on each side. The selected calyx was then viewed on anteroposterior sections to decide whether they were projecting laterally or medially. RESULTS: Of the 508 calyces studied, the posterior calyx was projecting laterally in 72% and medially in 28%. In the upper calyx, the posterior calyx was projecting laterally in a majority of cases, 94% on the right and 89% on the left. In the right lower calyx, the posterior calyx was pointing laterally in 86%, whereas the distribution on the left was 64%. CONCLUSION: Our results refute the belief that the medial calyx is always synonymous with the lateral calyx.

Supracostal percutaneous nephrolithotomy: A prospective comparative study.

INTRODUCTION: A widely prevalent fear of thoracic complications with the supracostal approach has led to its underutilization in percutaneous nephrolithotomy (PCNL). We frequently use the supracostal approach and compared the efficacy and thoracic complications of infracostal, supra 12(th), and supra 11(th) punctures. MATERIALS AND METHODS: This was a prospective study of patients who underwent PCNL between January 2005 and December 2012. The patients were divided into three groups based on the access: infracostal, supra 12(th) (between the 11(th) and 12(th) ribs) and supra 11(th) (between the 10(th) and 11(th) ribs). Clearance rates, fall in hemoglobin levels, transfusion rates, perioperative analgesic requirements, hospital stay and thoracic complications were compared. RESULTS: Seven hundred patients were included for analysis. There were 179 (25.5%) patients in the supra 11(th) group, 187 (26.7%) patients in the supra 12(th) group and 334 (47.8%) patients in the infracostal group. The overall clearance rate was 78% with no difference in the three groups. The postoperative analgesic requirements were significantly higher in the supracostal groups and showed a graded increase from infracostal to supra 12(th) to supra 11(th). During the study period, only 2 patients required angioembolization (0.3%) and none required open exploration. The number of patients requiring intercostal chest drain insertion was extremely low, at 1.6% and 2.2% in the supra 12(th) and supra 11(th) groups, respectively. CONCLUSIONS: Our results confirm the feasibility of the supracostal approach including punctures above the 11(th) rib, albeit at the cost of an increase in thoracic complications. Staying in the line of the calyx has helped us to minimize the most dreaded complication of bleeding requiring angioembolization.

Use of a vegetable model as a training tool for PCNL puncture.

INTRODUCTION: Training residents to perform a PCNL puncture is hampered by the non-availability of a good inanimate model that can be used for demonstration and practice. The ethics of surgical training during actual surgeries is being questioned and the role of simulation is increasingly important. Virtual reality trainers, however, are prohibitively expensive and the use of animal models is fraught with regulatory and ethical concerns. We have devised a model that can be used to teach the concept of depth perception during a PCNL puncture. METHODS: A bottle gourd was used to mimic the posterior abdominal wall. Cotton pledgets dipped in intravenous contrast were fitted into 4 mm holes made at staggered levels in the bottle gourd which was strapped onto the operating table with the cotton pledgets facing away from the surgeon. Surgeons with varying degrees of experience made fluoroscopy-guided punctures onto the cotton pledgets. We recorded the time taken for puncture in seconds and the distance of the needle exit site from the center of the cotton ball. Speed was measured by recording the fluoroscopy time in seconds on the C-arm. Accuracy was documented by using a Vernier caliper to measure the distance from the edge of the target to the actual puncture. One second of fluoroscopy time and 0.1 mm distance were each given one point. The total points accumulated over a set of 10 punctures was added to give a total score. Longer fluoroscopy times and inaccurate punctures resulted in higher scores. RESULTS: A surgeon with more than 1000 PCNLs to his credit had a score of 99. The average score of five residents was 555. CONCLUSION: The bottle gourd model provides an ethically acceptable, inexpensive, easy to replicate model that can be used to train residents in the PCNL puncture.

An audit of suprapubic catheter insertion performed by a urological nurse specialist.

AIMS: To introduce the concept that a urological Nurse Specialist can perform Suprapubic Catheter (SPC) insertions independently without significant complications, if systematic training is given. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: A retrospective audit of Suprapubic Catheter insertions performed by a Urological Nurse Specialist was conducted between April 2009 and April 2011. RESULTS: Of the total 53 patients, in 49 (92.45%) the procedure was successful. Out of the remaining four, two (3.77%) were done by a urologist. One patient's (1.89 %) SPC did not drain after placement and ultrasonography reported that the Foley balloon was lying within the abdominal wall. The other patient's SPC drained well for a month and failed to drain after the first scheduled change in a month. Since the ultrasonography showed the Foley balloon to be anterior to the distended bladder, an exploration was performed and this revealed that the SPC tract had gone through a fold of peritoneum before reaching the bladder. None had bowel injury. CONCLUSIONS: If systematic training is given, a urological Nurse Specialist can perform SPC insertions independently without significant complications.

Results of urinary dissolution therapy for radiolucent calculi.

PURPOSE: In this paper we present our experience with dissolution therapy of radiolucent calculi. MATERIALS AND METHODS: This was a retrospective analysis of patients who were offered urinary dissolution therapy between January 2010 and June 2011. Patients were treated with tablets containing potassium citrate and magnesium oxide. Partial dissolution was defined as at least a 50% reduction in stone size. Patients with complete or partial dissolution were classified in the successful dissolution group. Patients with no change, inadequate reduction, increase in stone size and those unable to tolerate alkali therapy were classified as failures. Patient sex, stenting before alkalinization, stone size, urine pH at presentation and serum uric acid levels were analyzed using Fisher t-test for an association with successful dissolution. RESULTS: Out of 67, 48 patients reported for follow up. 10 (15%) had complete dissolution and 13 (19%) had partial dissolution. Alkalinization was unsuccessful in achieving dissolution in 25 (37%). Stenting before alkalinization, patient weight (< 60 vs. > 75kg) and serum uric acid levels (≤ 6 vs. > 6) were the only factors to significantly affected dissolution rates (p = 0.039, p 0.035, p 0.01 respectively). CONCLUSIONS: A policy of offering dissolution therapy to patients with radiolucent calculi had a successful outcome in 34% of patients.

Length of urethra in the Indian adult male population.

OBJECTIVE: The urethral length has not been measured in the Indian population. Even the international literature in this arena is very sparse. This paper is an attempt to develop a simple anatomical database for urethral length. MATERIALS AND METHODS: Between January 2010 and April 2011, the urethral lengths of 422 adult male patients who required catheterization as part of regular treatment at our hospital, were recorded after obtaining consent from the patients and from the scientific and ethics review boards of the institution. Patients with history of prostatic or urethral abnormalities were excluded. The balloon of a sterile Foley's catheter was inflated using 10 cc of saline. The length from the junction of the balloon to the 'Y' junction of the Foley was measured. The catheter was then passed into the bladder and re-inflated to same volume. The penis was gently straightened and the length of the catheter outside the penis was measured till the premarked point at the 'Y' junction. Subtracting this from the original length gave the length of the urethra. RESULTS: The mean length of the urethra was 17.55 + 1.42 cm with a range between 14 and 22.5 cm. CONCLUSIONS: Literature in which the length of the normal adult male urethra is recorded for a significant sample size is very scarce. Our data adds to basic anatomic information of the male urethra specific to the Indian population. STATISTICAL METHODS: Descriptive statistical analysis was performed. The non-linear regression analysis was employed to find the normative values of urethral length according to age class.

False urethral anastomosis.

We present images of three cases with false urethral anastomosis following urethroplasty. The likely causes are inadequate posterior urethral dissection and blind use of Hey Grove dilator. We recommend use of antegrade flexible cystoscopy to prevent this complication.

Functional recovery after transplantation of bone marrow-derived human mesenchymal stromal cells in a rat model of spinal cord injury.

BACKGROUND AIMS: Spinal cord injury (SCI) is a medically untreatable condition for which stem cells have created hope. Pre-clinical and clinical studies have established that these cells are safe for transplantation. The dose dependency, survivability, route of administration, cell migration to injury site and effect on sensory and motor behavior in an SCI-induced paraplegic model were studied. METHODS: A spinal cord contusion injury model was established in rats. Bone marrow (BM) mesenchymal stromal cells (MSC) were tagged to facilitate tracing in vivo. Two different doses (2 and 5 million cells/kg body weight) and two different routes of infusion (site of injury and lumbar puncture) were tested during and after the spinal shock period. The animals were tested post-transplantation for locomotor capacity, motor control, sensory reflex, posture and body position. Stem cell migration was observed 1 month post-transplantation in spinal cord sections. RESULTS: The overall results demonstrated that transplantation of BM MSC significantly improved the locomotor and sensory behavior score in the experimental group compared with the sham control group, and these results were dose dependent. All the infused stem cells could be visualized at the site of injury and none was visualized at the injected site. This indicated that the cells had survived in vivo, were probably chemoattracted and had migrated to the lesion site. CONCLUSIONS: MSC transplanted with a lumbar puncture method migrate to the site of injury and are the most suitable for SCI healing. These cells demonstrate a dose-dependent effect and promote functional recovery when injected during or after the spinal shock period.