Our experience with genitourinary fistulae.

INTRODUCTION: Our objective was to analyze the incidence, etiopathology, diagnosis and therapeutic aspects of the genitourinary fistula in an Indian population. METHODS: This is a retrospective analysis of the genitourinary fistulae repaired at the Department of Urology, Institute of Medical Sciences, Banaras Hindu University, between January 1990 and December 2006. The surgical approach varied in each patient. Interposition grafts or flaps were used as and when required. The main outcomes analyzed were the incidence, etiology, surgical approaches, accessory procedure required, need for tissue interposition, cure rate per repair and overall success rate. RESULTS: Out of 558 cases, 403 were vesicovaginal, 84 ureterovaginal, 43 urethrovaginal and 28 vesicouterine fistulae. The most common etiology was obstructed labor (72.2%), followed by hysterectomy. The transvaginal route was preferred for repair wherever possible. The transabdominal route was adopted for the repair of supratrigonal vesicovaginal, ureterovaginal and vesicouterine fistulae and if bladder augmentation was required. Conservative management was successful in 1.9% of the vesicovaginal fistulae and in 8 cases of ureterovaginal fistula. The remaining cases were managed surgically with excellent results. CONCLUSION: Genitourinary fistulae are not life-threatening but are socially debilitating. Surgical repair provides the definitive cure, but expectant treatment can be tried in selective patients.

Urethral reconstruction in balanitis xerotica obliterans.

OBJECTIVES: To review the results of utilizing different grafts for substitution urethroplasty for anterior urethral stricture caused by balanitis xerotica obliterans (BXO). METHODS: 153 patients who underwent substitution urethroplasty for anterior urethral strictures were included in this study. The stricture length varied from 3.8 to 16.4 cm (mean 10.2 cm). In 32% of the patients (49), local genital, penile (18), perineal (16) and scrotal (15) skin grafts were used. Over the 3 years our standard treatment policy has been to utilize a free mucosal graft from a non-genital area. Buccal mucosa was the most preferred, utilized in 74 (48.3%) patients and bladder mucosa in 12 (7.8%). Recently we have used lingual mucosal grafts in 18 (11.7%) patients for substitution urethroplasty. RESULTS: The overall success rate for non-genital mucosal graft was 92.2%. The remaining 8 patients required more than one supplementary procedure postoperatively but none required a second urethroplasty. Of 49 patients who underwent substitution urethroplasty utilizing genital skin, the success rate was only 4%. 16.3% required one and 14.3% required multiple auxiliary procedures postoperatively. 34 patients (69.4%) required subsequent urethral reconstruction. CONCLUSIONS: A free graft urethroplasty using non-genital skin is recommended for anterior urethral stricture related to BXO.

Oral complications after lingual mucosal graft harvest for urethroplasty.

BACKGROUND: The aim of this study was to assess the complications at donor site after lingual mucosal graft harvesting for urethroplasty. METHODS: From March 2006 to December 2006, 30 patients of anterior urethral stricture underwent lingual mucosal graft urethroplasty. The site of the harvest graft was lateral mucosal lining of the tongue. Donor site complications, that is, pain, slurring of speech, pain during speech, salivatory changes and difficulty in protrusion of tongue were noted. RESULTS: The mean (range) age of patients was 36.2 years (22-52 years). The mean (range) stricture length was 8.4 cm (4.8-16 cm) and graft length was 8.5 cm (4.2-16.2 cm). Mean duration of follow up was 3.8 months. At the first postoperative day, 90% of the patients experienced pain at donor site and 20% had slurring of speech. Pain was mild to discomforting in 80% and distressing to horrible in 13% of the patients. By third postoperative day, two-thirds were pain free, one-thirds had mild pain only and none had slurring of speech. By day 6 of surgery, all patients were pain free. Six per cent of the patients reported numbness over ventral aspect of anterior half of tongue, which persisted in the first follow up and subsided by second follow up. There was no bleeding, haematoma or infection at donor site. All patients were able to resume oral fluid within 24 h, eat soft solid diet in 48-72 h and return to normal diet after 4-5 days of surgery. No patient complained of difficulty in opening the mouth, salivation disturbances, perioral numbness or difficulty in protrusion of tongue. No long-term functional or aesthetic complications were reported. CONCLUSION: Lingual mucosal graft harvesting is feasible, provides a long graft, is easy to carry out and is the least morbid procedure.

Surgical complications of radical retropubic prostatectomy: A single institutional experience of seven years.

AIM: To determine the surgical complications of open retropubic radical prostatectomy. MATERIALS AND METHODS: Fifty-nine cases of localized prostate cancer underwent retropubic radical prostatectomy in our department in the last seven years. Standard technique of open retropubic radical prostatectomy as described by Walsh was used. During follow-up cancer control and quality of life indices (potency and urinary continence) were noted. RESULT: Postoperative recovery of all patients except one was excellent. This patient required cardio-respiratory support and nine units of blood transfusion. Forty-nine out of 52 patients were continent, two had stress incontinence and one was totally incontinent at one year. Bladder neck contracture was present in eight out of 52 patients at one year. Forty-five patients were impotent at one year with or without oral tablet sildenafil. Cancer control was present in 45 out of 52 cases. Seven cases had biochemical failure at one year. CONCLUSION: Though retropubic radical prostatectomy is the standard treatment for early prostate cancer it is not without complications. It has a steep learning curve. More number of cases and refinement in technique is required to achieve world-class results.

Xanthogranulomatous pyelonephritis: our experience with review of published reports.

BACKGROUND: The aim of this study was to analyse the cases of xanthogranulomatous pyelonephritis with review of published reports. METHODS: We retrospectively reviewed all nephrectomy specimens during February 1995 to January 2006. We found 26 cases of xanthogranulomatous pyelonephritis. We prepared a chart of these cases consisting of preoperative symptoms, laboratory findings, radiological imaging results and preoperative diagnosis. Open nephrectomy was carried out in all cases. RESULTS: Age group of the patients was 6-65 years and male : female ratio was 1.6:1. Twenty-two patients presented to us with intermittent high-grade fever, 21 with flank pain, 18 with loin mass, 2 with haematuria and 1 was detected during screening of vague gastrointestinal symptoms. Twenty-five patients had pyuria and only 10 had sterile urine culture. In all patients, only one kidney was affected. All patients had renal calculi 10-42 mm in size with bilaterally enlarged kidneys. Ipsilateral kidney was enlarged because of hydronephrosis or pyonephrosis in all cases and contralateral kidney was enlarged because of compensatory hypertrophy in 13 cases. Ipsilateral kidney had severely compromised renal function in all cases. Associated psoas abscess was present in one and tuberculosis in another. CONCLUSION: Xanthogranulomatous pyelonephritis is a relatively rare entity that is associated with obstruction, stones and infection of the urinary tract. Late presentation leads to loss of renal parenchyma. It cannot be differentiated preoperatively with renal tumours (renal cell carcinoma and Wilms' tumour), pyonephrosis, infected hydronephrosis and renal lymphoma. Nephrectomy and antibiotics are the treatment of choice.

Lycopene as a chemopreventive agent in the treatment of high-grade prostate intraepithelial neoplasia.

OBJECTIVE: Because of its long latency, slow growing nature, and high prevalence, prostate cancer is the best model for chemoprevention. High-grade prostate intraepithelial neoplasia (HGPIN) is a precursor of prostate cancer. Chemoprevention with lycopene has shown definite results in prostate cancer. We undertook a study to use lycopene as a chemopreventive agent in the treatment of HGPIN for preventing prostate cancer from developing in this vulnerable group of patients. MATERIALS AND METHODS: A total of 40 patients with HGPIN were randomized into 2 groups: one received 4 mg lycopene twice a day for one year, and the other was periodically followed up. Total follow-up was one year. RESULTS: Our results show that lycopene can delay or prevent HGPIN from developing into occult prostate cancer, and there exists an inverse relationship between lycopene and prostate-specific antigen. Being a vegetable carotenoid, lycopene is a safe drug to be used for a longer period without any adverse reaction. CONCLUSION: Lycopene is an effective chemopreventive agent in the treatment of HGPIN, with no toxicity and good patient tolerance.

Anterior vesical hitch--a step to enhance safety of percutaneous access to bladder.

PURPOSE: To describe the novel technique of anterior vesical hitch to enhance the efficacy and safety of percutaneous bladder surgery. MATERIALS AND METHODS: The anterior bladder wall is anchored to the anterior abdominal wall with the help of a prolene suture passed slightly lateral to the midline midway between the pubic symphysis and umbilicus. Percutaneous cystolitholapaxy and antegrade posterior urethral valve ablation were performed after anterior vesical hitch in five pediatric male patients. Data collected included operative parameters and complications related to the technique. RESULTS: Mean patient age was 2.9 years (range 1.5-6 years). Three patients had bladder stones and two had posterior urethral valves. Mean time to achieve bilateral parietal fixation of the bladder was 7 min 20 s. There was no intraoperative slippage of Amplatz sheath or suture cut through. No bleeding from the puncture site was encountered. No postoperative complication related to the percutaneous access tract was noted in any patient. CONCLUSIONS: The anterior vesical hitch procedure is safe and easy. It prevents slippage of Amplatz sheath during percutaneous access to the bladder lumen.

"Bilateral Double J Stent Removal: The way to do it!".

There are many urological and non-urological indications which require bilateral double J stenting. We describe a point of technique for simultaneous removal of both the Double J stents. Both the stents are held by stent removing forceps at a point where they cross each other and then removed in one go with the help of cystoscope. Medline search did not reveal any techniques of removing two DJ stents in one go.

A comparative study of artificial neural network and multivariate regression analysis to analyze optimum renal stone fragmentation by extracorporeal shock wave lithotripsy.

To compare the accuracy of artificial neural network (ANN) analysis and multi-variate regression analysis (MVRA) for renal stone fragmentation by extracorporeal shock wave lithotripsy (ESWL). A total of 276 patients with renal calculus were treated by ESWL during December 2001 to December 2006. Of them, the data of 196 patients were used for training the ANN. The predictability of trained ANN was tested on 80 subsequent patients. The input data include age of patient, stone size, stone burden, number of sittings and urinary pH. The output values (predicted values) were number of shocks and shock power. Of these 80 patients, the input was analyzed and output was also calculated by MVRA. The output values (predicted values) from both the methods were compared and the results were drawn. The predicted and observed values of shock power and number of shocks were compared using 1:1 slope line. The results were calculated as coefficient of correlation (COC) (r2 ). For prediction of power, the MVRA COC was 0.0195 and ANN COC was 0.8343. For prediction of number of shocks, the MVRA COC was 0.5726 and ANN COC was 0.9329. In conclusion, ANN gives better COC than MVRA, hence could be a better tool to analyze the optimum renal stone fragmentation by ESWL.

Renal transplantation using live donors with vascular anomalies: a salvageable surgical challenge.

Renal transplantation is an established mode of management for patients with end-stage renal disease (ESRD). In India, majority of the patients with ESRD depend upon live donors for renal transplantation and renal vascular anomalies are commonly seen in these potential donors. We present our experience in renal transplantation using donors with vascular anomalies. During the period between 2001 and 2004, we performed 36 live related donor renal transplantations. All study patients had only one donor each, with compatible blood group. Ten of the donors had vascular anomalies. Three had bilateral double arteries, one had double left and single right renal artery, one had bilateral triple arteries, one had triple arteries on left and double arteries on right side, of which one had early branching, two had bilateral early branching of arteries, and two other cases had double renal veins. Open donor nephrectomy was performed in all the cases. End-to-side anastomosis with external iliac vein and artery of the recipient was performed by the parachuting technique. Eight kidneys had immediate diuresis after transplantation. In two kidneys, diuresis started 2-3 hours after administration of 120 mg of furosemide. All patients had serum creatinine ranging between 0.9 and 1.8 mg/dl by the 10th post-operative day. Follow-up of these cases have varied from one month to two years. In the current scenario, multiple arteries in the donor are no longer considered relative contraindications for renal transplantation. With good surgical skill and experience in bench surgery, all such donors can be accepted. Use of external iliac artery for anastomosis with the technique of parachuting makes the procedure easy and safe.

A decade's experience with vesicovaginal fistula in India.

A retrospective analysis of 252 cases of vesicovaginal fistulae was done to analyse its etio-pathology and management in an Indian population. After a thorough evaluation, different techniques of fistula closure were used for repair and the results were listed. The main outcome measures were the etiology of the fistula, need for tissue interposition and cure rate per repair as well as the overall cure rate. We compared our results with literature and concluded that simple and small fistulae should be repaired with layered closure. All complicated fistulae should be repaired with tissue interposition or tissue graft. This is the first study from India compiling 10 years of experience on vesicovaginal fistula.