Renal artery pseudoaneurysm post-COVID-19 infection: An unusual delayed complication.

This case report discusses a rare and severe complication of COVID-19 recovery - renal mucormycosis leading to right renal artery pseudoaneurysm. A 59-year-old patient, previously treated for COVID-19, presented with dry cough, flank pain, and hematuria. He was diagnosed with renal artery pseudoaneurysm with renal mucormycosis. Successful management included urgent angioembolization, systemic liposomal amphotericin B, and subsequent radical nephrectomy post-stabilization. The case underscores the importance of vigilant post-COVID-19 follow-up, particularly in patients treated with steroids, and highlights the need for a multidisciplinary approach for timely diagnosis and effective management of mucormycosis related complications.

Sleep quality and obstructive sleep apnea among male patients with lower urinary tract symptoms: A prospective observational study.

Introduction: Apart from nocturia, few reports have been published on the relationship between lower urinary tract symptoms (LUTS) and sleep disturbances in patients visiting urology outpatient clinics. This study assessed the association between our population's LUTS and sleep disturbances. Methods: This was a prospective observational study. A total of 123 male patients with a history of LUTS aged more than 40 years were recruited from urology outpatient clinic. International Prostate Symptom Score was utilized to assess LUTS. To determine the quality of sleep, the Pittsburgh Sleep Quality Index (PSQI) was used. Berlin questionnaire (BQ) was used for screening obstructive sleep apnea. Results: A total of 123 participants were enrolled in this study. The mean age of the participants was 61 ± 11.1 years. Nocturia >3 episodes were significantly more in patients with PSQI >5 (P < 0.05). There was a greater prevalence of severe LUTS in patients with PSQI >5 (P < 0.05). The association between LUTS and BQ score showed an increased prevalence of severe symptoms in patients with high BQ. Patients with PSQI >5 had more severe LUTS (53% of patients) compared to patients with PSQI ≤5 (5% of patients) (P = 0.000). Patients with PSQI >5 had overall poorer quality of life (QOL) scores, with QOL being 5 and 6 in 18% and 4.8% of the patients, respectively. Conclusions: There is a significant association between the prevalence of nocturia, moderate-to-severe LUTS, and the existence of sleep disorders. Therefore, screening for sleep disturbances may be performed on male patients who present with LUTS.

Recurrent vesico-cervical fistula: our experience.

INTRODUCTION AND HYPOTHESIS: Vesico-cervical (VCxF) is an uncommon entity among the gamut of genitourinary fistulas. The common causes include prolonged labor, previous lower-segment cesarean sections (LSCS), difficult vaginal deliveries, and traumatic injuries. METHODS: A 31-year-old woman presented with a history of LSCS for prolonged labor 4 years ago followed by a failed robotic repair for diagnosed VCxF and vesico-uterine fistula (VUtF) 1 year ago. The patient developed a recurrence 4 weeks after catheter removal. The patient underwent cystoscopic fulguration 6 months after the robotic surgery, but this failed after 2 weeks. Now, the patient presented with continuous urine leakage through the vagina for 6 months. On evaluation, she was diagnosed with recurrent VCxF and a repeat transabdominal repair was planned. On cystovaginoscopy, there was difficulty in negotiating the fistulous tract from either end. With great difficulty, we placed the guidewire from the vaginal end, which reached a false paracervical passage. Although in the false tract, the guidewire helped with localization of the intraoperative fistula site. After docking, port placement, and localization of the fistula site (tug on the guide wire), a mini cystostomy was performed. A plane was created between the bladder and cervicovaginal layer and dissected up to 1 cm beyond the fistula. The cervicovaginal layer was closed. An omental tissue interposition was followed by cystotomy closure and drain placement. RESULTS: The postoperative period was uneventful, and the patient was discharged on the 2nd day after drain removal. The catheter was removed after 3 weeks and the patient is doing fine under regular follow-up for 6 months. CONCLUSIONS: It is challenging to diagnose and repair VCxF. Transabdominal repair is better than transvaginal repair owing to its location. Patients can opt for open or minimally invasive (laparoscopic/robotic) surgery, with better postoperative outcomes in minimally invasive techniques.

Inner ear barotrauma: A case report of rare post-operative complication following robot-assisted radical prostatectomy.

To highlight a rare case of inner ear barotrauma as a post-operative complication following robot-assisted radical prostatectomy (RARP). A 65-year-old man diagnosed with localised prostate carcinoma underwent elective RARP in a steep Trendelenburg position. Postoperatively, the patient complained of bothersome dizziness and spinning of surroundings associated with nausea. The patient was diagnosed to have vestibular symptoms secondary to inner ear barotrauma. He was started on prochlorperazine 12.5 mg and antibiotics, following which the patient improved. Vestibular rehabilitation exercises were taught to the patient. After 3 days of treatment, the patient did well with no episodes of dizziness. The patient was discharged on tablet cinnarizine 25 mg thrice daily for a week. On follow-up, the patient is asymptomatic. Inner ear barotrauma can be a rare complication of a combination of prolonged steep Trendelenburg during robotic surgery and pneumoperitoneum. Only further reporting of such incidents can help determine predisposing factors and precautions for preventing such incidents.

Urodynamics in the evaluation of lower urinary tract symptoms in young adult men: A systematic review.

Introduction: This review aims to systematically evaluate the available evidence on the different urodynamic diagnoses of lower urinary tract symptoms (LUTS) in young adult men aged 18-50 years and to summarize the various urodynamic parameters based on these diagnoses. Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement and the search was performed in PubMed, Embase, and Cochrane library from inception till September 2021. A total of 295 records were identified using a combination of keywords such as LUTS, urodynamics (UDS), and young males. The review was registered in PROSPERO (CRD42021214045). Results: All the ten studies, which were included in this analysis, categorised the patients into either of the four primary diagnoses after the UDS - primary bladder neck obstruction (PBNO), dysfunctional voiding, detrusor underactivity (DU), or detrusor overactivity. Five of these studies used the conventional UDS, and in the other five a video UDS was performed. The most common abnormality on the conventional UDS was DU with a pooled estimate of 0.24 (95% confidence interval [CI] - 0.104-0.463, I2-95.35, (τ2-1.07). The most common abnormality on the video UDS was PBNO with a pooled estimate of 0.49 (95% CI - 0.413-0.580, I2-66.59, 2-0.09). The point estimates of various UDS parameters were also recorded. Conclusion: A urodynamic diagnosis was possible in 79% and 98% of the young men who underwent a conventional UDS or a video UDS, respectively. However, the men subjected to the conventional UDS and the video UDS had significant differences in their primary urodynamic diagnostic label. These results will help to plan future trials for the evaluation and management of LUTS in young men.

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.

Deciphering the enigma of female urethral strictures: A systematic review and meta-analysis of management modalities.

OBJECTIVE: To evaluate the management methods of female urethral stricture (FUS) and analyze the outcomes of surgical treatments. A meta-analysis was done in an attempt to identify the best approach of urethroplasty and the graft-of-choice. MATERIALS AND METHODS: A systematic search of Pubmed/Medline and Embase databases was performed according to the Preferred Reporting Items For Systematic Review And Meta-Analysis statement, for articles reporting on FUS management in the last decade. The Newcastle-Ottawa scale was used to assess the quality of 28 included non-randomized studies. The data on FUS management was summarized and pooled success rates (taken as symptom improvement and no need for further instrumentation) were compared. The secondary outcome was to establish a diagnostic modality of choice and define a "successful-outcome" of repair. RESULTS: The outcome was separately reported for 554 women undergoing surgical intervention for FUS in the literature. The criteria defining FUS were varied. A combination of tests was used for diagnosis as none was singularly conclusive. A total of 301 patients had previous urethral instrumentations. The pooled success rate of urethral dilatation (234 women) was 49% at a mean follow-up of 32 months; flap urethroplasty (108 cases) was 92% at a mean follow-up of 42 months; buccal mucosal graft (BMG) urethroplasty (133 cases) was 89% at a mean follow-up of 19 months; vaginal graft augmentation (44 cases) was 87% at a mean follow-up of 15 months; and labial graft reconstruction (19 cases) was 89% at a mean follow-up of 18.4 months. The dorsal approach of graft augmentation met with 88% (95% confidence interval [CI] 0.79-0.95) success compared with 95% (95% CI 0.86-1) for the ventral approach. CONCLUSION: FUS is a rare condition requiring a meticulous diagnostic workup using multiple tests. All urethroplasties have shown better pooled success rates (86%-93%) compared with dilatation (49%). BMG is equally effective as vaginal graft urethroplasty.

Meatal-sparing dorsal onlay vaginal graft urethroplasty: widening the surgical horizons of female urethral stricture.

AIM OF THE VIDEO: Female urethral stricture is an uncommon but challenging entity in the spectrum of female pelvic dysfunctions. There are various reconstructive techniques but none can be recommended over another. We present a case of meatal-sparing dorsal onlay vaginal graft urethroplasty as a surgical variation of the standard dorsal approach. This is a step to improve the results of the dorsal approach and overcome its limitations. PATIENTS AND METHODS: In this video we present meatal-sparing dorsal onlay vaginal graft urethroplasty as a modification of the conventional dorsal approach. RESULTS: Sexual function can be preserved by dorsal plane dissection away from the clitoral neurovascular bundle. Excessive blood loss is avoided by limited mobilisation and dissection of the urethra. Meatal reconstruction is avoided by slitting the urethra directly over the strictured mid-urethral segment, thus averting a widened meatus and spraying of the urinary stream. CONCLUSION: Female urethroplasty provides excellent cure rates. Meatal-sparing dorsal onlay vaginal graft urethroplasty can be considered in mid- and proximal urethral strictures. This simple and effective approach can widen the surgical horizons in the treatment of female urethral stricture and reduce its complications.

Ganglioneuroma presenting as an adrenal incidentaloma: Feasibility of adrenal-sparing surgery.

Adrenal ganglioneuromas (GNs) are very rare tumours that originate from neural crest cells. Most of the time, they are diagnosed incidentally as they are usually non-functional and remain asymptomatic. Nowadays, they are being detected more often due to better availability of imaging facilities such as computed tomography (CT)/magnetic resonance imaging (MRI). Minimally invasive adrenalectomy (laparoscopic or robotic) remains the standard of care for such lesions. Hereby, we report a case of a 15-year-old young girl with right adrenal incidentaloma which was diagnosed on CT with the features suggestive of GN. She underwent robot-assisted excision of the mass with adrenal-sparing surgery. Histopathology revealed benign GN and no adjuvant treatment was required. As GN is not known for recurrence or metastasis, minimal invasive adrenal-sparing surgery should be a preferred modality of choice.

Priapism with penile gangrene: An unusual presentation of multiple myeloma.

Penile gangrene is very rare sequel of ischemic priapism. Previous published reports have shown its occurrence in patients with sickle cell disease, urethral carcinoma, bladder carcinoma, thrombotic thrombocytopenic purpura, idiopathic, traumatic, etc. Ischemic priapism with penile gangrene as an initial presentation of multiple myeloma has not been reported. We present a 44-year-old patient of multiple myeloma presenting with ischemic priapism and penile gangrene requiring partial penectomy.

Navigating the complexities of a forgotten double J stent.

Double-J (DJ) stents are most commonly used urological tools these days. Serious complications may occur when stents are left in place for longer duration. We present a case of a woman in her 40s with a forgotten DJ stent for 4 years, leading to complications such as encrustations, bladder and renal stone formation. The patient underwent a comprehensive endourological approach, including endoscopic cystolithotomy and left-sided percutaneous nephrolithotomy. The case highlights the importance of timely stent removal to prevent complications such as encrustations and stone formation. Patient education and counselling are crucial to avoid poor compliance and the associated risks of forgotten stents. This case underscores the significance of a multidisciplinary approach and emphasises the need for proactive measures to prevent such complications, including the implementation of a stent placement registry.

Management Modalities of Primary Bladder Neck Obstruction in Young Adult Men: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review was done to critically appraise the various evidence available in the literature for the presenting symptoms, diagnosis, and management modalities for primary bladder neck obstruction diagnosed on invasive urodynamics in young adult men 18-50 years of age. METHODS: A search was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials databases until July 2022 to find English-language studies relevant to the topic. RESULTS: A total of 10 studies were included. The estimated difference in International Prostate Symptom Score between baseline and 3 months in the subgroup of medical and surgical treatment was found to be -8.82 and -11.25, respectively (P = .37), and after 12 months, it was found to be -7.69 and -17.70 respectively (P .001). The pooled estimate for the difference in Qmax between baseline and 3 months after medical and surgical treatments in the subgroup was found to be 2.92 and 7.03, respectively (P = .18), and after 12 months, it was found to be 4.54 and 7.74, respectively (P .001). The pooled estimate of the difference in post-void residue before and after 3 months of medical and surgical treatments in a subgroup was found to be -31.15 and -70, respectively (P .001), and after 12 months, it was found to be -31.49 and -156.00, respectively (P .001). Quality of life scores improved in both subgroups. CONCLUSION: The alpha-blockers are effective in managing primary bladder neck obstruction in the short term, while bladder neck incision is preferred for better longterm outcomes.

Management of a Patient With Ankylosing Spondylitis and Multiple Comorbidities Who Underwent a Percutaneous Nephrolithotomy Using an Innovative Positioning Strategy.

Ankylosing spondylitis (AS) is a chronic inflammatory disorder leading to bony ankylosis, ossification, and fibrosis of the spine. Airway management is difficult in these patients due to restricted head and neck movement as well as a stiff body posture. This also poses challenges in lying down supine as well as surgical positioning. We report a case of a patient with AS and multiple co-morbidities who underwent a percutaneous nephrolithotomy for renal calculi, and the customisations made in anaesthetic and surgical techniques to safely perform the procedure.

Female Urethral Stricture Caused by Lichen Sclerosus: An Uncommon Presentation.

Lichen sclerosus is an inflammatory disease of the mucocutaneous region. The etiology of lichen sclerosus is not well explained. Lichen sclerosus is more common in females and generally involves the genital area. Urethral involvement in lichen sclerosus is uncommon in females. Males have a higher propensity for urethral involvement in lichen sclerosus. Here we report a case of a 50-year-old female with lichen sclerosus and urethral stricture. Buccal mucosal graft urethroplasty was done. The success rate of urethroplasty is low in patients with lichen sclerosus. Meatal sparing urethroplasty is usually not recommended in females with urethral strictures associated with lichen sclerosus. Our patient was asymptomatic at six months of follow-up.

Interruption of BCG Therapy for NMIBC During COVID-19 Crisis, Dilemma in Its Continuation: a Review of Available Evidence and Suggested Management Strategies.

The COVID-19 disease, caused by SARS-CoV-2 virus, has been one of the worst pandemics ever to hit the human mankind. Undoubtedly the start of the second wave of COVID-19 has literally ripped apart the hearts of millions of people. Cancer patients have been left of the beaten track to their fate, with no access to treatments. Intravesical BCG instillation is the standard of care for patients with non-muscle invasive bladder cancer (NMIBC). Several patients were in the middle of their treatment regimen when this pandemic struck. As slowly the word is recuperating from concussion effect of this pandemic and routine health services are being restored, uro-oncologist will face a unique scenario with respect to intravesical BCG therapy i.e., whether to restart the course of BCG therapy or to continue course from where it was interrupted. There are no studies in literature to directly answer this peculiar question and to resolve this dilemma. So, we in this review article propose to explore the literature for the most appropriate therapeutic regimen for these patients with interruption of intravesical BCG therapy. We plan to divide the patients with interruption to BCG therapy into the following three groups:Group 1: Patients who had interruption during the induction period.Group 2: Patients who completed the induction course but maintenance course could not be started.Group 3: Patients who had interruption during maintenance phase of BCG therapy. We will compile the recent recommendations by NCCN, AUA, and EAU for the administration of intravesical BCG in non-muscle invasive bladder cancer. We herein want to review the literature to propose the most appropriate strategy, its safety profile for these subsets of patients. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-023-01742-8.

Cyanoacrylate Glue Masquerading as an Obstructive Calculus: Rare Sequelae of Angioembolization for Renal Pseudoaneurysm.

Renal pseudoaneurysm is a well-known albeit rare vascular complication following renal trauma, percutaneous interventions, renal biopsy, and partial nephrectomy. Angioembolization has become an effective treatment option for pseudoaneurysm using Cyanoacrylate glue, Gel-foams, Micro-coils, polyvinyl alcohol, etc. We herein present a 20-year-old gentleman with infected left hydroureteronephrosis secondary to an impacted foreign body in a ureter, specifically, down-migrated cyanoacrylate glue. This is two weeks following glue angioembolization for a left upper polar segmental renal artery pseudoaneurysm secondary to stab injury. He underwent a successful left-side ureteroscopic extraction of this polymerized glue, following which his symptoms subsided. These complications of glue migration following angioembolization are infrequent, and reports of it are scarce in the literature. Stringent follow-up and timely intervention are essential to mitigate disastrous outcomes.

Small Tumor, Major Complication: A Case of Spontaneous Perinephric Hematoma From a Small Renal Angiomyolipoma.

A renal angiomyolipoma is a benign kidney tumor composed of muscle, fat, and blood vessels. It is the most common benign kidney tumor, and it affects women more frequently than men. Angiomyolipomas can be small and asymptomatic, or they can be large, presenting with symptoms such as discomfort, hematuria, and hypertension. Occasionally, the rupture of an angiomyolipoma can cause a perinephric hematoma. This case report discusses a patient who developed a spontaneous large perinephric hematoma alongside a small renal angiomyolipoma. Aneurysm was seen on imaging. Angioembolization was successfully used for treatment. We explore the significance of the presence or absence of an aneurysm in predicting the risk of hemorrhage, particularly in association with small lesions. Angioembolization is an excellent choice for treating angiomyolipomas associated with significant hematomas.

Metabolic evaluation of first-time uncomplicated renal stone formers: A prospective study.

Background: Nephrolithiasis is a global health problem. The recurrence rate after the first stone clearance is approximately 50% at 5 years. Metabolic abnormalities are an important factor responsible for stone recurrence. Our prevalidated study aimed to evaluate metabolic abnormalities associated with first-time uncomplicated renal stone formers (FTURSF). Materials and methods: In this prospective, exploratory, time-bound, descriptive study, 30 first-time renal stone formers were evaluated for metabolic abnormalities. High-risk stone formers were excluded from the study. Data were collected in a predefined proforma, transferred to an Excel sheet, and analyzed using the Statistical Package for Social Sciences 20 and Epi Info 7. Fisher exact test, Mann-Whitney U test, paired t test, and Pearson correlation coefficient were used for statistical analyses. Results: The mean age of the participants was 35.57 ± 11.07 years, with a male-to-female ratio of 1.72. The most common abnormality was a 24-hour urine volume of <2.5 L in 73.33% of the participants. One or more metabolic abnormalities were detected in 76.67% of the participants. Other common metabolic abnormalities detected were hypocitraturia (60%), hypercalciuria (16.67%), hyperoxaluria (13.33%), and hyperuricosuria (3.33%). Parathyroid adenoma was detected in one participant (3.33%). Conclusions: Our study documented significant metabolic abnormalities in FTURSF. Therefore, a simplified metabolic evaluation protocol should be adopted while evaluating FTURSF. Detection of an underlying metabolic abnormality would enable the early institution of preventive measures to reduce stone recurrence and related complications.

Acute Pyelonephritis With Cullen's Sign Masquerading As Pancreatitis.

Cullen's sign is well described in the literature as subcutaneous ecchymosis in the periumbilical region. It is most commonly represented with acute pancreatitis. Recently, there have been many case reports associated with this sign to different clinical scenarios. A 61-year-old gentleman reported to the ED with left flank pain, intermittent fever, and a periumbilical ecchymosis on abdominal examination. Numerous tests were performed to rule out the likelihood of acute pancreatitis. The patient was diagnosed with acute pyelonephritis and received appropriate treatment. Cullen's sign should raise suspicions of retroperitoneal or intraabdominal abnormalities. While the pathophysiological process underlying the emergence of this symptom frequently signals retroperitoneal bleed, this is not always the case.

Urological Manifestations of Kindler Syndrome: A Case Report.

Kindler syndrome is a rare autosomal recessive skin disorder. It results from mutation of the FERM domain containing kindlin-1 (FERMT1) that leads to loss of function of kindlin-1, which plays a role in keratinocyte adhesion, polarization, proliferation, and migration. It is characterized by skin blistering, photosensitivity, progressive poikiloderma, and skin atrophy. The mucosae genitourinary system is commonly affected. The urological manifestations include meatal stenosis, urethral stricture, phimosis, and scarring of the glans penis. Skin biopsy with genetic analysis is the gold standard for diagnosis. Genetic counseling and a multidisciplinary approach are the mainstays of treatment.