Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder.

PURPOSE: We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up. MATERIALS AND METHODS: We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function. RESULTS: We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52 months (IQR 31-103 months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45 ml/min. CONCLUSIONS: Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45 ml/min are at greater risk of a decline in renal function following reconstruction.

A randomised controlled trial comparing two protocols of preoperative antibiotics in patients with positive urine culture undergoing percutaneous nephrolithotomy.

AIM: To compare the outcomes of two different protocols of antibiotic prophylaxis in patients with positive urine culture undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Patients were prospectively enrolled for the randomised study to either group A which included patients where an attempt to sterilise the urine was made with a 1 week course of sensitive antibiotics or group B that included patients who received a shorter duration of prophylaxis using sensitive antibiotics for 48 h prior to procedure which was continued for 48 h postoperatively. Enrolled patients had stones requiring percutaneous nephrolithotomy and had a positive preoperative urine culture. Primary outcome was difference in sepsis rates between the groups. RESULTS: A total of 80 patients randomised into two groups of 40 each based on the antibiotic protocol used were analysed in the study. There was no difference in infectious complication rates between groups on univariate analysis. The rate of SIRS in Group A and Group B was found to be 20% (N = 8) and 22.5% (N = 9) respectively. The rate of septic shock in Group A and Group B was 7.5% and 5% respectively. On multivariate analysis, longer duration of antibiotics did not decrease the risk of sepsis compared to shorter antibiotic course (p = 0.79). CONCLUSION: Attempts to sterilise urine before PCNL may not decrease the risk of sepsis in patients with positive urine culture undergoing PCNL and may only result in unnecessary prolonging of antibiotic usage thereby increasing the chances of antibiotic resistance.

Complex circumferential obstetric fistula-a urologist's worst nightmare.

INTRODUCTION AND HYPOTHESIS: Circumferential vesicourethrovaginal fistula is a severe form of obstetric injury that is challenging to repair and carries a poor prognosis related to eventual continence. Here, we report the successful repair of a circumferential vesicovaginal fistula associated with near total loss of the urethra. The use the anterior bladder flap technique along with an autologous rectus sheath sling resulted in the creation of an effective continence unit. METHODS: A 31-year-old woman had a history of obstructed labor resulting in intrauterine death followed by trans-abdominal hysterectomy for postpartum hemorrhage. Since then she had had total urinary incontinence. She had an attempted repair through the vaginal route, which had failed. Physical examination and endoscopic evaluation revealed a large vesicourethrovaginal fistula with near total loss of the urethra leaving only the meatus. Intraoperatively, we found that it was a large circumferential defect in the infratrigonal region with no anterior bladder wall left at the site of the fistula. RESULTS: We performed an anterior bladder flap procedure as described by Tanagho along with an autologous rectus sheath sling for additional support. Postoperatively, the patient was completely continent. CONCLUSIONS: The anterior bladder onlay flap technique, which has been used extensively for female urethral reconstruction in developed countries, along with an autologous rectus sheath sling is an effective technique for management of circumferential fistulas allowing good continence. Incorporation of this technique into the armamentarium of surgeons managing fistulas in developing countries will go a long way toward helping this unfortunate group of women with this morbid complication of obstructed labor.

Posterior urethral mini-valves causing urinary tract infection: A report of 3 cases.

Posterior urethral valves have myriad presentations based on the severity of obstruction with the milder end of spectrum often termed as mini-valves. The simultaneous occurrence of ureteropelvic junction obstruction and urethral valves has not been described before and is most likely coincidental. Herein, we discuss the management of three boys who had febrile urinary tract infection following pyeloplasty and on evaluation were found to have valves. This article highlights the need for considering these mini-valves as a possibility in boys presenting with symptoms following pyeloplasty so as to avoid delay in diagnosis and unnecessary morbidity in these children.

An interesting presentation of invasive bladder carcinoma as pseudo renal failure.

Ascites and oliguria with an increasing serum creatinine level are often observed in patients with acute renal failure. However, these symptoms are also noted in individuals with intraperitoneal urinary leakage and can be mistaken for acute renal failure. This rise in creatinine in such patients is called pseudo renal failure and it happens by a process of reverse peritoneal dialysis. In literature, the most commonly described condition that leads to this clinical picture is following a spontaneous or missed bladder perforation. We, herein, report a case of carcinoma of the bladder that presented with features resembling acute renal failure, which later turned out to be pseudo renal failure due to intraperitoneal urinary extravasation from a forniceal rupture. The patient was managed with emergency with a percutaneous drain followed by a percutaneous nephrostomy, which led to normalization of creatinine. Cystoscopy revealed the bladder growth in an intact small capacity bladder and biopsy confirmed it as a muscle invasive squamous cell carcinoma. Due to advanced nature of his malignancy, he underwent a palliative ileal conduit diversion but he later developed chest metastasis and ultimately succumbed to the disease. Intraperitoneal urinary leakage due to forniceal rupture presenting as pseudo renal failure is a rare presentation of carcinoma bladder. Sudden onset abdominal discomfort, increasing ascites, hematuria, and oliguria with elevated renal parameters needs consideration and exclusion of this entity. The diagnostic dilemma associated with this rare presentation along with the management and prognosis in such patients of carcinoma bladder are discussed.

Presentation, management and outcomes of pediatric urogenital tuberculosis: 20 years' experience from a tertiary center.

BACKGROUND: Urogenital tuberculosis (UGTB) has traditionally being a diagnosis of adulthood and is supposed to be rare in children, as it is believed that the symptoms of renal tuberculosis do not appear for 10 or more years after the primary infection. While this may be true in developed countries, where childhood pulmonary tuberculosis is a rarity nowadays. In developing countries, childhood pulmonary tuberculosis is still a major issue and hence, UGTB is not an uncommon diagnosis in younger children and adolescents in these countries. Considering this dearth of data on childhood UGTB, we retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery. OBJECTIVE: To analyze the clinical presentation, management strategies and outcomes of pediatric UGTB managed in a tertiary care center. MATERIALS AND METHODS: Case records of children and adolescents ≤18 years diagnosed with UGTB during the period July 1998 to June 2018 at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 41 children and adolescents (M: F = 22:19) identified, with a mean age of 14.8 ± 3.9 years who fulfilled the inclusion criteria. The most common presentation was flank pain and irritative storage symptoms. Mycobacterium tuberculosis was identified on urinary examination in only 17 (41.5%) cases. Six patients were lost to follow up after initial diagnosis. A total of 45 procedures (35 primary and 10 secondary) were performed in 35 children. Initial diversion in the form of PCN and DJS were done in 11 and 12 patients respectively, of which 8 were managed with stenting alone. Surgical management was done mostly in the form of nephrectomy (15), nephrectomy along with reconstruction (5) and reconstruction only (6). On univariate analysis, factors associated with nephrectomy were poor initial function and nephrostomy as initial diversion. Overall median follow-up was 25 (IQR 15.5-74.25) months. During follow up, chronic renal failure developed in nearly 53.8% of patients who underwent major reconstruction. CONCLUSIONS: Urogenital tuberculosis presents with a wide spectrum of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of minimally invasive diversions and surgery (both ablative and reconstructive) achieve satisfactory results in the majority of cases. Children undergoing major surgical reconstruction in particular need to be followed up rigorously and counselled about possibility of development of renal failure.

When the Good Old X Ray Saved the Day.

Internal ureteral stents have become an integral part of urologic practice to relieve intrinsic as well as extrinsic upper urinary tract obstruction. Missed internal ureteral stents is a serious potential complication that is associated with increased patient morbidity and is especially a problem in developing countries due to poor patient compliance, lack of understanding, and poor administration of stent registry. Diagnosis of forgotten ureteral stents is usually straight forward on usual imaging. Here, we report a case where the forgotten stent was missed on ultrasound and computed tomography and was picked up on plain radiograph thereby, emphasizing the still relevant role of plain radiograph in evaluation of stone disease.

Remember the "Putty Kidney"-A Reminder of Days Gone by.

The term ''putty kidney'' was first used in 1906 by Dr. F. Tilden Brown, a genitourinary surgeon, to describe a well-defined density seen in kidney region on standard radiograph which is caused by a ''putty-like'' substance that had formed a cast inside a tuberculous kidney. The putty kidney is a classic imaging sign, rarely seen nowadays which represents a nonfunctioning autonephrectomized kidney seen in end stage renal tuberculosis.1-5 Here, we describe a 45-year-old female with left flank pain who on imaging had a classic putty kidney which led to an evaluation and later confirmation of a diagnosis of renal tuberculosis.

Herniation of the Right Renal Pelvis through a Posterolateral Diaphragmatic Defect (Bochdalek Hernia).

Diaphragmatic herniations are the rarest form of ureteral herniations with only around 9 cases reported since 1958.1-10 Though uncommon, it should be considered in the differential diagnosis of a posterior diaphragmatic or paraspinal opacity with associated hydronephrosis. Correct diagnosis is of paramount importance and can be easily established by noninvasive imaging technique. In symptomatic individuals, laparoscopic intervention can be offered with good results in fit patients with ureteral stenting reserved for poor surgical candidates. Here we present a successful laparoscopic management of an elderly female who presented with right flank pain and was diagnosed with a right sided diaphragmatic ureteral herniation.

Persistent Incontinence Following Surgery for Ureteric Triplication With Contralateral Duplication-A Management Dilemma.

Ureteral triplication is a rare congenital anomaly of urinary tract with wide spectrum of presentation. The presentation with incontinence has usually been taken as a sign of ureteral ectopia in these cases. However, ectopia cannot explain all cases with incontinence. We report a case of a 14-year-old girl with ureteral triplication with contralateral duplication and vesicoureteral reflux of the upper moiety on the triplicate side and dysplastic upper moiety on duplicated side, who had persistent incontinence following a left ureteroureterostomy and right heminephrectomy. The clinical features of this rare case and the management of this peculiar postoperative situation is discussed herewith.

An interesting presentation of invasive bladder carcinoma as pseudo renal failure / Uma apresentação interessante do carcinoma invasivo de bexiga como pseudo insuficiência renal

Abstract Ascites and oliguria with an increasing serum creatinine level are often observed in patients with acute renal failure. However, these symptoms are also noted in individuals with intraperitoneal urinary leakage and can be mistaken for acute renal failure. This rise in creatinine in such patients is called pseudo renal failure and it happens by a process of reverse peritoneal dialysis. In literature, the most commonly described condition that leads to this clinical picture is following a spontaneous or missed bladder perforation. We, herein, report a case of carcinoma of the bladder that presented with features resembling acute renal failure, which later turned out to be pseudo renal failure due to intraperitoneal urinary extravasation from a forniceal rupture. The patient was managed with emergency with a percutaneous drain followed by a percutaneous nephrostomy, which led to normalization of creatinine. Cystoscopy revealed the bladder growth in an intact small capacity bladder and biopsy confirmed it as a muscle invasive squamous cell carcinoma. Due to advanced nature of his malignancy, he underwent a palliative ileal conduit diversion but he later developed chest metastasis and ultimately succumbed to the disease. Intraperitoneal urinary leakage due to forniceal rupture presenting as pseudo renal failure is a rare presentation of carcinoma bladder. Sudden onset abdominal discomfort, increasing ascites, hematuria, and oliguria with elevated renal parameters needs consideration and exclusion of this entity. The diagnostic dilemma associated with this rare presentation along with the management and prognosis in such patients of carcinoma bladder are discussed.

Resumo Ascite e oligúria com um nível crescente de creatinina sérica são frequentemente observadas em pacientes com insuficiência renal aguda. Entretanto, esses sintomas também são notados em indivíduos com extravasamento urinário intraperitoneal e podem ser diagnosticados como lesão renal aguda erroneamente. Este aumento de creatinina em tais pacientes é chamado de pseudo insuficiência renal e ocorre por um processo de diálise peritoneal reversa. Na literatura, a condição mais comumente descrita que leva a este quadro clínico se dá após uma perfuração vesical espontânea ou perdida. Relatamos aqui um caso de carcinoma de bexiga que apresentou características semelhantes à insuficiência renal aguda, e mais tarde se revelou uma pseudo insuficiência renal devido a extravasamento urinário intraperitoneal de uma ruptura de fórnice renal. O paciente foi tratado com emergência com um dreno percutâneo seguido por uma nefrostomia percutânea, que levou à normalização da creatinina. A cistoscopia revelou o crescimento da bexiga em uma bexiga intacta, de pequena capacidade e que a biópsia confirmou como um carcinoma escamoso invasivo muscular. Devido à natureza avançada de sua malignidade, ele foi submetido a um desvio de conduto ileal paliativo, mas posteriormente desenvolveu metástase torácica e acabou sucumbindo à doença. O vazamento urinário intraperitoneal devido à ruptura do fórnice renal que se apresenta como pseudo insuficiência renal é uma apresentação rara do carcinoma vesical. Desconforto abdominal de início súbito, ascite crescente, hematúria e oligúria com elevados parâmetros renais precisam de consideração e exclusão desta entidade. O dilema diagnóstico associado a esta rara apresentação, juntamente com o controle e prognóstico em tais pacientes de carcinoma vesicular, são discutidos.