A 17-year-old indwelling ureteral stent with large vesical calculus at one end: The tombstone of a forgotten Double "J" stent.

Objective: To highlight the presentation and management of a 17-year-old forgotten ureteral stent with a large vesical calculus at one end, a very rare yet devastating complication of ureteral stenting. Case Presentation: A 65-year-old gentleman presented with complaints of lower urinary tract symptoms for two years with a history of ureterolithotomy done 17 years ago. Imaging revealed a forgotten ureteral stent embedded in a large vesical calculus. He underwent a percutaneous cystolithotomy with removal of the forgotten stent. Conclusion: DJ stent is commonly used in urologic practice. It is a double-edged sword as it can lead to severe morbidity in patients who have forgotten stent. Knowledge of DJ stent-related complications and need of timely removal will help primary care physician in providing better health care. Proper counselling of patients before and after the placement of stent and maintenance of stent registries play a major role in avoiding this dreadful complication.

Management strategies and outcome of ureterovaginal fistulae: A systematic review and meta-analysis.

BACKGROUND: Genitourinary fistula is a distressful condition involving mental, social, marital, and financial repercussions. OBJECTIVE: The objective of this study is to systematically evaluate etiology, clinical presentation, diagnosis, the timing of repair, and perform a meta-analysis evaluating the success rate of various treatment modalities with respect to time taken to seek treatment. SEARCH STRATEGY: We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in April 2020 according to the PRISMA statement. Seventeen studies were included in the final analysis and all were retrospective in design. SELECTION CRITERIA: Each article was rated by the evidence-based medicine levels of evidence scale and the Methodological Index for Nonrandomized Studies scale for assessment of bias among nonrandomized studies. MAIN RESULTS: Of the 799 fistulae reported in 17 studies, endoscopic management was done in 35.6% (12 studies), whereas surgical management was preferred in 85.6% fistulae (15 studies). The pooled success of endoscopic stenting was 32% (95% confidence interval [CI]: 7-64) and 100% (95% CI: 98-100) in operated patients. Patients who underwent stenting within 2 weeks (20%), 2-6 weeks (21%), and >6 weeks (40%) had pooled success rates of 95% (95% CI: 87-100), 46% (95% CI: 0-100), and 20% (95% CI: 1-49), respectively. Patients who underwent surgical management <6 weeks (15.9%) and >6 weeks (22%) of diagnosis had pooled success rates of 100% (95% CI: 99-100) and 100% (95% CI: 99-100), respectively. CONCLUSIONS: Stent placement as early as <6 weeks (preferably < 2 weeks) had better outcomes as compared to >6 weeks. Proceeding to surgery regardless of timing in cases of stent failure seems to be a feasible option.

Subcapsular Renal Hematoma Following Ureteroscopic Lithotripsy: An Uncommon Complication of a Common Procedure-A Report of Two Cases.

Objective: To highlight the unusual complication of subcapsular renal hematoma (SRH) after a seemingly simple ureteroscopic lithotripsy (URSL), to try and identify the predisposing factors that lead to this complication, and steps that can be taken to further decrease the incidence of this rare but potential life-threatening complication. Methods: We highlight two cases of obstructed ureteral stones with upstream hydronephrosis who presented with colicky pain. Both underwent URSL with 8F/9.8F semirigid ureteroscope and were found to have postprocedure SRH. Results: Both our patients were managed conservatively with culture-directed intravenous antibiotics. One patient needed intervention in the form of aspiration of the hematoma. Follow-up ultrasound revealed complete resolution of the hematoma in both the cases and are doing fine on follow-up. Conclusion: Various risk factors have been identified, which predispose an individual to this complication and all endourologists must take certain precautionary measures such as decreased operative time and perfusion pressures, treating urinary tract infections and preoperative optimization of hypertension, diabetes, and chronic kidney disease (CKD) to further decrease the incidence of SRH. Management is conservative in majority of cases with percutaneous drainage and antibiotics, with surgery being reserved for hemodynamically unstable patients.

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario.

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.

Spontaneous Large Urinoma Secondary to Obstructing Ureteral Calculus: A Kidney Pop-Off Mechanism.

Introduction and Background: Spontaneous rupture of the urinary collecting system with extravasation of urine is a rare complication of obstructive stone disease. Most of the cases are caused by obstructive ureteral stones. We herein present a case of a spontaneous caliceal rupture with a large perirenal urinoma formation that was silent on presentation and managed with endoscopic stenting and percutaneous catheter drainage. Case Presentation: A 56-year-old man presented with complaints of vague right flank discomfort. A noncontrast CT scan revealed a 9.4 mm right mid ureteral obstructive calculus with a 14 cm collection in the perirenal space communicating with the lower calix of the right kidney. Retrograde insertion of 6F Double-J stent was done endoscopically and a pigtail catheter was placed in the right perinephric collection. Initially the catheter drained 100 mL clear urine and decreased progressively. A repeat ultrasonography revealed no collection and the catheter was removed after 10 days. The patient underwent clearance of stones after 8 weeks. On table, retrograde pyelogram showed no leak. The patient is doing well 2 weeks postoperatively. Conclusions: Obstructive ureteral stone presenting with spontaneous forniceal rupture and large perinephric collection in a silent manner. Although endoscopic management alone offers excellent results in small ruptures, diversion of the collecting system with drainage of the collection remains the mainstay of treatment in large urinomas to prevent complications. Definitive management of the cause of obstruction is paramount and should be done after complete healing of the rupture.

Da Vinci Walks the Pebbled Streets of a Primary Obstructed Megaureter with Ureterocele.

Introduction: Primary obstructed megaureter (POM) usually refers to primary dilated ureters in which vesicoureteral reflux and other secondary causes of lower ureteral obstruction have been ruled out. We herein present a case of obstructed megaureter with a dilated saccular lower end representing an ureterocele and concomitant multiple multifaceted stones almost completely filling the dilated tortuous ureter of a normally functioning and excreting kidney. Materials and Methods: Our index case was a 45-year-old lady with intermittent right flank pain for a year with acute colic since a week. Imaging revealed a grossly dilated tortuous ureter with >50 multifaceted stones all along its length, an ureterocele, and mild hydronephrosis. She underwent a robot-assisted ureterolithotomy and complete stone clearance followed by ureteral reimplantation over an ureteral stent. Results: Postoperative course was uneventful and on follow-up at 3 weeks, stent was removed after checking a cystogram. The da Vinci system with its minimally invasive approach and better ergonomics made it quite convenient to remove all 52 stones, ensuring an excellent postoperative recuperation and incomparable cosmesis. Conclusion: POM in adults is usually symptomatic and associated with complications, and surgery remains the mainstay of treatment when it is associated with calculi. Ureteral tailoring and ureteroneocystostomy with extraction of stones were done for at-risk kidneys and to prevent further renal deterioration. However, these efforts appear futile when the severe renal impairment has set in and nephroureterectomy is thus required. The robotic approach for reconstruction is a safe, effective, and feasible option with excellent perioperative results.