Confronting urethrorrhagia after Otis urethrotomy: a case report.

BACKGROUND: Otis urethrotomy can sometimes lead to troublesome bleeding after seemingly uneventful procedures. This case report highlights one such case which went unnoticed initially; the bleeding was erroneously ascribed to the prostate, thereby falsely indicting the "decoy" prostate. CASE PRESENTATION: A 78-year-old Asian gentleman was referred to our hospital with complaint of intractable bleeding after undergoing laser enucleation of prostate at another institute, wherein he further underwent unsuccessful bilateral angioembolization of pudendal arteries. On endoscopy (for hemostasis), we found a spurting vessel in the navicular fossa, which was effectively controlled. CONCLUSIONS: This case report highlights the importance of performing prompt endoscopy in case of uncontrolled bleeding after prostate endoscopic surgery.

Germ cell tumors with neuroglial differentiation do not show molecular features akin to their central nervous system counterpart: experience from extra-gynecological sites.

Teratomas with secondary somatic malignancy showing neuroglial differentiation (central nervous system (CNS)-type tumors) arising from a glial or neuroepithelial component is a very uncommon event and primarily described in the ovary. We aimed to describe the morphological spectrum and molecular features of CNS type of neuroepithelial tumors arising from the germ cell tumors (GCT) in the extra-gynecological sites. All cases of teratoma and mixed GCT arising from the non-gynecological sites over 7 years were screened for CNS type of neuroepithelial tumors. Detailed histological and immunohistochemical analysis was performed. IDH1 and 2 sequencings were performed in the glial tumors. Fluorescent in situ hybridization (FISH) was performed for EWSR1 rearrangement, 19/19q co-deletion, CDKN2A homozygous deletion, EGFR amplification, and C19MC amplification, wherever required. Out of 302 GCTs examined, the neuroglial tumor was detected in 15 cases. It included nine cases of glial tumors (including one pilocytic astrocytoma (grade I), two diffuse astrocytomas (grade II), one oligodendroglioma (grade II), one gemistocytic astrocytoma (grade II), three anaplastic astrocytomas (grade III), and one case of glioblastoma (grade IV)) and six cases of the embryonal tumor with multilayered rosettes (ETMR). None of the gliomas showed IDH mutation by immunohistochemistry or sequencing. The ETMR cases did not show Lin28 expression or C19MC amplification. To conclude, the spectrum of neuroglial tumors arising from teratoma in the extragonadal sites is vast and most commonly includes glial neoplasms and embryonal tumors. Our findings indicate that the genotype and pathogenesis of tumors with neuroglial differentiation in teratoma are distinct from their CNS counterpart.

Toxic epidermal necrolysis-like presentation of toxic erythema of chemotherapy.

Toxic erythema of chemotherapy is an umbrella term encompassing a range of reactions characterized by symmetric erythematous to dusky patches, which can develop oedema, desquamation and/or purpura. We describe an elderly patient with prostate cancer who developed this complication while receiving docetaxel chemotherapy, presenting with prominent mucosal and periorificial involvement, along with epidermal necrosis, closely mimicking toxic epidermal necrolysis.

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.

Rare Presentation of Metastatic Endometrioid Adenocarcinoma of Uterus Mimicking as Second Primary in Urinary Bladder on 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography.

We present a case of endometrioid carcinoma metastasis in the bladder mimicking as the second primary of urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT). The presentations of bladder lesions on 18F-FDG PET/CT are varied, and rare presentations of common malignancies can pose a significant diagnostic challenge as in the index case and highlight the importance of histopathological examination to confirm any unusual FDG uptake confounding the diagnosis.

Bladder Leiomyoma: A Rare Differential and a Potential Pitfall in the Evaluation for a Bladder Mass in 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography.

18F-Fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG PET/CT) has shown an increasing role in the evaluation of urinary bladder cancer, though benign pathological processes of the urinary bladder can also result in increased FDG uptake. Leiomyomas of urinary bladder are benign mesenchymal neoplasms and a very rare bladder tumor comprising <0.5% of all bladder tumors. Here, we present the low-grade 18FDG uptake in urinary bladder leiomyoma on PET/CT done for the clinical suspicion of bladder cancer, which can be a rare differential for bladder carcinoma.

Perioperative outcomes of minimally invasive versus open radical cystectomy: A single-center experience.

INTRODUCTION: Open radical cystectomy (RC) is associated with significant morbidity and the role of minimally invasive surgery (MIS) in reducing morbidity of RC is controversial A direct comparison of various surgical modalities on perioperative outcomes is lacking in the Indian literature. We evaluated outcomes of minimally invasive (robotic and laparoscopic) versus open RC with pelvic lymph node dissection (PLND) performed at our institute from 2014 to 2016. METHODS: Eighty-three patients of RC with PLND were prospectively analyzed from December 2014 to February 2016. All patients of muscle invasive urothelial cancer of the bladder undergoing RC (open or MIS) were included in the study. Based on patients preference they were assigned to one of the three groups (Open RC, robot-assisted RC, or laparoscopic RC). Their demographic profile, preoperative disease stage, operative data like operative time, blood loss, intraoperative complications, histopathological data like pathological stage, lymph-node yield etc., postoperative complications if any and total duration of stay were recorded. These data of laparoscopic, open, and robotic cystectomies were compared in terms of various demographic, histopathologic parameters and perioperative outcomes. RESULTS: Twenty-nine patients (34.93%) underwent minimally invasive RC with PLND (5 laparoscopic and 24 robotic). The median age of patients was 58 years. Mean number of lymph nodes removed was 22.5 ± 14.6. The total number of lymph nodes removed in laparoscopic surgery was 104 with a yield of 20.6 per patient, in robotic surgery were 627 with a yield of 26.1 per patient, and in open surgery were 1119 with a yield of 20.7 per patient (P = 0.004). Clavien-Dindo Grade 2 and 3 complications were seen in 37.5% of robotic, 60% of laparoscopic, and 55.54% of open RC. Average blood loss and operative time in laparoscopic, robotic, and open RC were 511.53 ± 311.02 ml, 552.08 ± 267.63 ml, and 512.05 ± 213.9 ml and 8.23 ± 1.36 h (hrs), 7.53 ± 1.92 h, and 5.85 ± 1.76 h, respectively (P = 0.68 and <0.001, respectively). CONCLUSIONS: MIS is associated with significantly longer operative time than open RC. Robotic RC has significantly higher lymph node yield than open or laparoscopic RC. Minimally invasive RC is equivalent to open surgery in terms of perioperative morbidity, mortality, and blood loss.

Needle in a haystack: lost in transition.

A lost needle during minimally invasive surgery is a cause of undue anxiety to the entire surgical team and also causes prolongation of surgical time. There is no literature reporting follow-up of any patient with needle left behind as they are considered as a 'never event' during a surgical procedure. Preventing such events needs vigilance on part of the surgeon and assistant. Here, we report a case of lost needle during performance of a robot-assisted nephron sparing surgery. The robot needed to be de-docked and converted to laparoscopy. After a thorough search, the needle was found to be lodged at an unusual place. A brief review of available literature is also provided alongside.

A comparative randomized prospective study to evaluate efficacy and safety of combination of tamsulosin and tadalafil vs. tamsulosin or tadalafil alone in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.

INTRODUCTION: Lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) and erectile dysfunction are common disorders of advancing age. AIM: To evaluate the efficacy and safety of tamsulosin and tadalafil in patients with LUTS due to BPH. METHODS: In this prospective randomized study, 133 men complaining of LUTS due to BPH were included. Forty-five patients received tamsulosin 0.4 mg/day alone (Group A), 44 patients received tadalafil 10 mg/day (Group B), and combination therapy (tamsulosin and tadalafil both) was instituted in 44 patients (Group C). After a 2-week medication free run-in period, they were evaluated for International Prostatic Symptom Score (IPSS), International Index of Erectile Function score (IIEF5), quality of life (IPSS QoL), maximum urinary flow rate (Qmax), post-void residual urine (PVR) volume, and safety parameters before and at 3 months of treatment. MAIN OUTCOME MEASURES: There were primary (IPSS, IPSS QoL index, Qmax, and PVR) and secondary (erectile function [EF] domain scores from IIEF5) efficacy end points. Safety assessment included laboratory tests and patient's reporting of adverse event. RESULTS: A significant improvement in IPSS score was observed in all the 3 groups A, B, and C (-50.90%, P < 0.05; -33.50%, P < 0.05; and -53.90%, P < 0.05, respectively). IIEF5 score increased significantly in these three groups (+39.28%, P < 0.05; +45.96%, P < 0.05; and +60.23%, P < 0.05, respectively). A significant increase in Qmax and decrease in PVR were also observed (33.99%, P < 0.05; 29.78%, P < 0.05; and 37.04%, P < 0.05) and (-60.90%, P < 0.05; -49.45%, P < 0.05; and -62.97%, P < 0.05, respectively). The QoL scores improved significantly (-73.35%, P < 0.05; -70.26%, P < 0.05; and -79.65%, P < 0.05, respectively). Side effects were dyspepsia, heartburn, headache, flushing, myalgia, and backache. Adverse effect dropout was 3.7%. No participant experienced any severe or serious adverse events. CONCLUSIONS: In patients with LUTS due to BPH, tamsulosin and tadalafil alone or in combination cause a significant improvement in patients with LUTS. Their EF also improves with these medications. The improvement is better with combination therapy compared with single agent alone.

Comparison of 18F fluoride PET/CT and 99mTc-MDP bone scan in the detection of skeletal metastases in urinary bladder carcinoma.

AIM: The aim of this study was to compare (18)F-fluoride PET/CT and (99m)Tc-MDP bone scintigraphy in the detection of skeletal metastases in urinary bladder carcinoma. PATIENTS AND METHODS: In this prospective study, 48 patients with urinary bladder carcinoma (44 male and 4 female patients, aged 35-80 years) underwent (99m)Tc-MDP planar and SPECT/CT bone scan (BS) followed by (18)F-fluoride PET/CT within 48 hours. Skeletal metastasis diagnosed on each of these techniques was compared against a final diagnosis based on contrast-enhanced CT, MRI, skeletal survey, clinical follow-up, and histological correlation. RESULTS: (18)F-fluoride PET/CT identified bony metastases and changed the management in 17 of 48 patients (35%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of (99m)Tc-MDP planar BS were 82.35%, 64.51%, 56%, 86.95%, and 70.83%; of (99m)Tc-MDP SPECT/CT were 88.23%, 74.19%, 65.21%, 92%, and 79.16%; and of (18)F-fluoride PET/CT were 100%, 87.09%, 80.95%, 100%, and 91.66%, respectively. Fair agreement between (99m)Tc-MDP planar BS and F-fluoride PET/CT (κ = 0.42) and excellent agreement between SPECT/CT and (18)F-fluoride PET/CT (κ = 0.74) were found. CONCLUSIONS: ( 18)F-fluoride PET/CT has higher sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in detecting bone metastases in urinary bladder carcinoma than conventional (99m)Tc-MDP planar BS. SPECT/CT improves all these parameters compared with planar BS and may serve as a cost-effective screening procedure for the detection of skeletal metastases in high-risk patients.

Incidental detection of a vesicocolonic fistula on renal scintigraphy with SPECT/CT.

Urinary-enteric fistula is a rare cause of recurrent urinary tract infection (UTI). Therefore, delayed/incidental diagnosis is the rule. The authors present an image of a vesicocolonic fistula incidentally detected during SPECT/CT renal scintigraphy with 99mTc-DTPA in a female patient with recurrent UTI. The diagnosis was subsequently confirmed by cystoscopy and surgery.

F-18 fluorodeoxy glucose positron emission tomography/computed tomography findings in a rare case of penile leiomyosarcoma.

Penile cancer is a rare entity accounting for only 0.4% all male malignancies. Penile leiomyosarcomas are even rarer with only around 35 cases reported in literature. We report a rare case of penile leiomyosarcoma illustrating F-18 Fluorodeoxy glucose (FDG) positron emission tomography/computed tomography (PET/CT) features and histopathology correlation.

Uroflowmetry in healthy women: Development and validation of flow-volume and corrected flow-age nomograms.

INTRODUCTION: Voiding dysfunction is common among women. However, unlike men, no universally accepted nomogram is available for them. This study was undertaken to establish normal reference values of urinary flow parameters for healthy Indian female population in menstrual age group. MATERIALS AND METHODS: Women volunteers of menstrual age group, including hospital staff, nursing students, visitors and relatives of patients, underwent free uroflowmetry using digital uroflowmeter (Solar Silver, Medical Measurement System, The Netherlands). Women with voiding symptoms, urinary tract infection within last 4 weeks, neurological/non-neurological diseases or medication affecting voiding function and abnormal uroflows were excluded. One micturition was obtained per proband in a sitting position to determine various uroflow variables. RESULTS: Of total 343 women enrolled in the study, data of 308 was available for final analysis. Their mean (+/-SD) age was 33 +/- 8.63 years, voided volume 289.79 +/- 166.52 ml, maximum flow-rate (Q(max)) 23.06 +/- 9.40 ml/sec, average flow-rate (Q(ave)) 13.08 +/- 6.00 ml/sec, voiding time 23.50 +/- 12.52 sec, time to Q(max) 8.56 +/- 6.55 sec, and post-void residue 2.92 +/- 3.69 ml. Corrected Q(max) and corrected Q(ave) were computed to be 1.41 +/- 0.43 and 0.80 +/- 0.27, respectively. Confidence limit flow-volume nomograms were developed and validated using data of asymptomatic (n = 25) as well as symptomatic women (n = 22). Corrected Q(max) and corrected Q(ave) to age nomograms were also introduced. CONCLUSION: These nomograms would help clinicians evaluate flow rates over a wide-range of voided volume as well as age, enabling effective screening of women for voiding dysfunction, and evaluating response to medical or surgical treatment.