Long-term Outcomes of Augmentation Cystoplasty in Genitourinary Tuberculosis in Adults: A 12-year Follow-up Experience at a Tertiary Care Center.

OBJECTIVE: To evaluate the long-term effectiveness and consequences of augmentation cystoplasty in adult patients with small capacity bladder due to genitourinary tuberculosis (GUTB). METHODS: After approval of the institutional ethical committee, we retrospectively analyzed the database of adult patients with small capacity bladder due to GUTB treated by augmentation cystoplasty from January 2010 to December 2022 at our center. The patients were followed up at 6 weeks postoperatively, then every 3 months for first year and 6 months in second year, and then annually. Patients were assessed for symptoms, renal function, blood biochemistry levels, and ultrasound KUB at each follow-up visit. RESULTS: A total of 40 patients underwent augmentation cystoplasty were included. All patients underwent augmentation cystoplasty either with ileum (n = 35) or sigmoid colon (n = 5). On long-term follow-up, there was statistically significant improvement in bladder capacity, decrease in voiding frequency (P = .00), decrease in eGFR (P = .02) and increase in serum creatinine (P = .02). Significant complications were wound infection 4 (10%), intestinal obstruction 1(2.5%), urinary tract infection 6 (15%), bladder stone 2 (5%), mucus retention 3 (7.5%), hypocalcemia with metabolic acidosis 2 (5%) and need of intermittent catheterization in 11 (27.5%) patients. CONCLUSION: Multidrug therapy with judicious reconstructive surgery is the optimal treatment modality for GUTB with cicatrization sequelae. In GUTB, augmentation cystoplasty is a safe procedure and strict long-term follow-up is needed to prevent complications.

Anatomical approach to PCNL: concept of ideal puncture zone in a 3D perspective.

To describe a concept of ideal 'puncture zone' as against any single ideal 'puncture tract' for percutaneous nephro-lithotomy (PCNL) and present our results. Through this narrative, we aim to reduce the gaps in inter-understanding of an erstwhile description of ideal tract and real-life puncture making. The puncture zone principle was applied for our novel puncture making technique during PCNL. The largest imaginary cone that can fit into a respective calyx, with its tip in the pelvis defines the 'puncture zone' for that calyx. This concept allows fine-tuning of the ideal puncture tract based upon the desired corresponding manipulation zone and also shifts the focus of puncture making to infundibulum anatomy from the tip of calyx. The surgical technique and retrospective review of 136 cases done between 2015 and 2021 using this concept are presented. Primary outcome included stone-free rate, pseudo-aneurysm and blood transfusion at 3 months of follow-up. 33 cases had multiple (> 3) stones, 21 only calyceal/infundibular stones, eight partial staghorn and 12 were complete staghorn stones. Mean stone size was 29 ± 15 (Range: 5-53) mm. Complete clearance was achieved in 127 cases, four of which required two tracts. Blood transfusion was required in one case. No pseudo-aneurysms were encountered. The puncture zone concept has provided good results in our hands. It may help easier understanding of PCN puncture making and provides a background for reconciliation between description of an ideal tract and practical puncturing techniques used by different surgeons.

Peri-operative antibiotic usage during endourological surgery: A multi-institutional, national-level, cross-sectional audit of prevalent practice pattern in India.

Introduction: Antibiotic use during endourological procedures is often discordant from the reported guidelines, despite the potential risks of antibiotic resistance, adverse effects, and health-care costs. A nationwide audit was conducted, with the support of the Urological Society of India, to ascertain the current antibiotic prescription practices for the endourological procedures and the reasons associated with them. Methods: A multi-institutional, national-level, cross-sectional audit analyzing elective endourological procedures was performed. The data regarding the disease profile; risk factors for infectious complications; urine culture; pre-, per-, and post-operative antibiotic use; additional antibiotic use; and patient demographics were collected in a standardized pro forma. Reasons for prescribing antibiotics divergent from the guideline recommendations were also noted. Any infectious complication that necessitated the antibiotic use was also noted prospectively up to 1 month. All the data were entered into a single centralized and customized online portal on a real-time basis. Results: One thousand five hundred and thirty-eight cases were recruited from 20 hospitals. A single-dose prophylaxis was prescribed in only 319 (20.7%) of the cases, and the majority received a multi-day prophylaxis. A combination of two or more antibiotics was prescribed as the prophylaxis in 51% of the cases. One thousand three hundred and fifty-six (88.2%) cases were continued on a long-duration prophylaxis after the discharge, with 1191 (77.4%) receiving it for > 3 days. One thousand one hundred and sixty (75.4%) cases received a guideline-discordant prophylaxis solely on the basis of the surgeon's or institution's protocol, rather than any specific case based need. Ninety eight (6.4%) cases developed postoperative urinary tract infection. Conclusions: Multi-dose, combination and post-discharge antibiotic prophylaxis for endourological surgeries is highly prevalent in India. This audit highlights the huge potential to reduce such guideline-discordant overuse of antibiotics during the endourological procedures.

A Large Contemporary Experience of Renal Tumors in Young: Clinico-pathological Profile and Long-Term Survival Patterns.

Renal tumors in young population are relatively rare. We reviewed our experience with renal masses in patients below 45 years of age. Our objective was to analyze clinico-pathological and survival characteristics of renal malignancy in young adults in contemporary era. The medical records of patients below 45 years of age who underwent surgery for renal mass at our tertiary care center between 2009 and 2019 were retrospectively analyzed. Pertinent clinical information was compiled, including age, gender, year and type of surgery, histopathology and survival data. A total of 194 patients who underwent nephrectomy for suspicious renal masses were included. Mean age was 35.5 (14-45) years and males were 125 (64.4%). A total of 29/198 (14.6%) specimens had benign disease. In addition, 155 (91.7%) out of 169 malignant tumors were renal cell carcinomas, clear cell variant being the most common type (51%). Compared to RCC, non-RCC tumors were more common in females (27.7 vs 78.6%, p < 0.0001), had an early age of diagnosis (27.2 vs 36.9 year, p < 0.00001) and poorer progression-free (58.3 vs 72.0%, p = 0.03) and overall survival (63.6 vs 84.2%, p = 0.02) at 6 years of follow-up. Renal masses in young adults are most commonly RCC but can also include other diverse types. RCC in young adults is usually organ confined and has good prognosis. As compared to RCC, non-RCC malignant tumors occur in young age, are more in females, and have worse prognosis. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01643-2.

Cutaneous Ureterostomy or Ileal Conduit Urinary Diversion: Can We Spare the Bowel Following Radical Cystectomy in Patients with Solitary Functioning Kidney?

To compare the outcomes between cutaneous ureterostomy and ileal conduit urinary diversion in patients with solitary functioning kidney, undergoing radical cystectomy. This study was a retrospective analysis of the patients, with solitary functioning kidney, who underwent radical cystectomy with either cutaneous ureterostomy or ileal conduit from January 2014 to May 2019. Baseline characteristics, perioperative outcomes, and follow-up renal function were evaluated and compared. For renal function outcomes, we assessed the estimated glomerular filtration rate (eGFR) and included patients with a follow-up of at least 2 years. A total of 43 patients were included in the study, 23 of them underwent cutaneous ureterostomy and 20 underwent ileal conduit urinary diversion. The two groups were similar with respect to their baseline demographic and clinical characteristics. Operative time (p < 0.001), time to drain removal (p = 0.016), postoperative length of hospital stay (p = 0.018), and bowel-related complications (p = 0.047) were significantly lower in patients who underwent cutaneous ureterostomy. The eGFR was comparable at baseline, and till 1 year of follow-up. But, there was a greater decline in eGFR over 2 years, in patients who received cutaneous ureterostomy (p = 0.039). The present study shows that cutaneous ureterostomy has better perioperative, and comparable short-term renal function outcomes over ileal conduit urinary diversion. However, over 2 years of follow-up, there was an increased likelihood, and greater degree of decline in eGFR in patients who received cutaneous ureterostomy.

Prospective evaluation of PI-RADS v2 and quantitative MRI for clinically significant prostate cancer detection in Indian men - East meets West.

Purpose: To validate the detection of clinically significant prostate cancer (Gleason's score ≥7) by PI-RADS v2 and to assess the ability of quantitative MRI parameters to detect clinically significant prostate cancer (CSPCa) in Indian men. Methods: Adult men (n = 95) with serum PSA >4 ng/ml were prospectively evaluated with multiparametric MRI (mpMRI) followed by histopathological evaluation using systematic 12-core prostate biopsy in 69 patients and prostatectomy specimens in 26 patients, performed within six weeks of mpMRI. The imaging and the pathology were divided into 12 sectors per prostate. For the validation of PI-RADS v2, a cut-off of PI-RADS v2 score ≥ 3 and PI-RADS v2 score ≥ 4 were compared to histopathology as a reference standard. Further, quantitative parameters, apparent diffusion coefficient (ADC), Ktrans, and Kep were correlated with the Gleason score and evaluated for their ability to distinguish between sectors with CSPCa and sectors without CSPCa. Results: PI-RADS score ≥ 4 showed higher specificity (89%) than PI-RADS score ≥ 3 (72.2%) at the cost of mild but not significant reduction of sensitivity (sensitivity-87.6% vs 91.9), (n = 1,140 sectors, 95 patients). PI-RADS v2 and quantitative parameters demonstrated the ability to discriminate sectors positive vs negative for CSPCa: AUC (area under the curve) for ADC was 0.928, PI-RADS v2 was 0.903, Ktrans was 0.897 and Kep was 0.695. Gleason score correlated well with PI-RADS (r = 0.74), ADC (r = -0.73) and Ktrans (r = 0.69). Conclusion: PI-RADS v2 is a reliable method for the detection and localization of clinically significant prostate cancer in Indian men, suggesting applicability beyond European or American demographics. Quantitative mpMRI parameters can detect clinically significant prostate cancer with similar test characteristics as PI-RADS v2.

Postoperative dengue haemorrhagic shock and Trichosporon fungal sepsis: a multidisciplinary rescue.

A woman in her 30s had robotic pyeloplasty done for right ureteropelvic junction obstruction. Incidentally she developed dengue viral fever starting on postoperative day 1 itself, which progressed to dengue haemorrhagic shock by 1 week, complicating pyeloplasty due to pelvicalyceal haematoma. Dengue associated shock was superimposed with subsequent gram-negative bacterial sepsis, further complicated later with Trichosporon fungal sepsis. She was managed under multidisciplinary care, involving urology, infectious disease and ICU care. Her diagnostic and difficult management issues due to these rare sequential medical issues in an otherwise usually uncomplicated postsurgical phase are discussed along with short review of literature. This case highlights the importance of early diagnosis, timely supportive care and appropriate management in such tropical infections with significant associated mortality.

Ureter-first Approach and Reduction of Pelvis: Standardizing Handling of Ureteropelvic Junction During Pyeloplasty.

OBJECTIVE: To present our "ureter-first" approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes' pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors. METHODS: A standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented. RESULTS: Fifty-one consecutive cases were done using ureter-first approach. UPJ was >1 cm in eight cases. Three of these had UPJ >2 cm. Eight other cases had a low-insertion below level of kidney while three had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months. CONCLUSION: A uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.

Survival analysis and predictors of long-term outcomes following radical nephrectomy with inferior vena cava (IVC) thrombectomy in renal cell carcinoma.

Background: Renal cell carcinoma (RCC) presents with inferior vena cava (IVC) thrombus in 10%-30% cases and surgical management forms the mainstay of the treatment. The objective of this study is to assess the outcomes of the patients undergoing radical nephrectomy with IVC thrombectomy. Methods: A retrospective analysis of patients undergoing open radical nephrectomy with IVC thrombectomy between 2006 till 2018 was done. Results: A total of 56 patients were included. The mean (±standard deviation) age was 57.1 (±12.2) years. The number of patients with levels I, II, III, and IV thrombus were 4, 29,10, and 13, respectively. The mean blood loss was 1851.8 mL, and the mean operative time was 303.3 minutes. Overall, the complication rate was 51.7%, while the perioperative mortality rate was 8.9%. The mean duration of hospital stay was 10.6 ± 6.4 days. The majority of the patients had clear cell carcinoma (87.5%). There was a significant association between grade and stage of thrombus (P = 0.011). Using Kaplan-Meier survival analysis, the median overall survival (OS) was 75 (95% confidence interval [CI] = 43.5-106.5) months, and the median recurrence-free survival (RFS) was 48 (95% CI = 33.1-62.3) months. Age (P = 0.03), presence of systemic symptoms (P = 0.01), radiological size (P = 0.04), histopathological grade (P = 0.01), level of thrombus (P = 0.04), and invasion of thrombus into IVC wall (P = 0.01) were found to be significant predictors of OS. Conclusion: The management of RCC with IVC thrombus poses a major surgical challenge. Experience of a center along with high-volume and multidisciplinary facility particularly cardiothoracic facility provides better perioperative outcome. Though surgically challenging, it offers good overall-survival and recurrence-free survival.

Effects of horizontal versus vertical bolster alignment on anatomical orientation of kidney as applied to prone percutaneous nephrolithotomy.

PURPOSE: To evaluate the anatomical changes in kidney orientation in prone position with use of horizontal or vertical bolster alignment. METHODS: Patients having renal stone(s) on ultrasonogram or X-ray underwent split bolus computed-tomo-urography (CTU) in prone position with horizontal and vertical bolster positions. CTUs were read by a single radiologist to quantify the cranio-caudal, antero-posterior, side to side and rotational movements of kidneys as relevant to prone percutaneous nephrolithotomy. RESULTS: 19 adult patients with 38 renal units and mean basal metabolic index of 25.6 kg/m2 underwent CTU. Greater inferior displacement of both kidneys was seen with horizontal bolsters as compared to vertical bolsters. The right upper calyceal-diaphragm distance was 2.1 ± 1.5 cm and the lower calyceal-diaphragm distance was 2.0 ± 1.6 cm greater with the horizontal bolsters (p < 0.01). Similarly, the displacement on the left side was 1.5 ± 0.8 cm and 1.4 ± 0.8 cm, respectively (p < 0.01). Horizontal bolsters also result in significantly longer calyceal-skin distance at both poles of both kidneys [right upper: 0.4 ± 0.5 cm (p < 0.01), right lower: 0.8 ± 0.7 cm (p < 0.01), left upper: 0.4 ± 0.6 cm (p = 0.02), left lower: 0.8 ± 1.1 cm (p < 0.01)] and wider erector spinae-mid posterior calyceal-colon angle (124.8 v/s 110.0 on the right and 96.2 v/s 85.7 on the left) (p < 0.01). CONCLUSION: Horizontal bolsters provide significantly more caudal displacement of the kidneys; the right kidney being displaced more as compared to the left. However, there is also an increase in the skin-calyceal distance with horizontal as compared to the vertical bolsters. These assessments may help the surgeons decide optimal bolster position individualized to the patient.

Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center.

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Systemic dissemination of tumor cells during transurethral resection in patients with bladder tumor and its clinical relevance: A follow up study.

OBJECTIVE: Tumor cells are shed during transurethral resection of bladder tumor (TURBT) and form the basis for use of single dose immediate chemotherapy instillation to reduce recurrences. Systemic dissemination of these cells along with the irrigation fluid is also possible but not consistently proven. In this study, we evaluated such dissemination of tumor cells into the circulation during TURBT and its clinical impact. METHODS: Patients with primary presentation of bladder tumor who underwent TURBT were included. Peripheral venous blood samples before and after TURBT were analyzed for circulating tumor cells (CTCs) using flow-cytometry. A CD45 negative cell with positive expression of cytokeratin 18, 19, and EpCam was defined as CTC. The CTC counts, pre and post TURBT, were compared and correlated with final histopathology. The patients were also followed up for any local and/or systemic recurrences. RESULTS: Nine (16.98%) out of 53 patients developed a measurable rise in CTCs after TURBT. All of these patients had high grade and muscle invasive disease. Overall, a measurable rise in CTCs was seen in 9 out of 17 (52.94%) patients with muscle invasive disease. There was no difference in the clinico-pathological stage or the status of cystectomy and/or chemotherapy between those who did or did not show a rise in CTCs. On follow up, 7 patients with muscle invasive disease developed local and/or systemic recurrences and the rise in CTCs was not found to be associated with adverse oncological outcomes. CONCLUSIONS: This study confirms the hypothesis of inadvertent dissemination of tumor cells into the circulation during TURBT, especially in patients with high grade and muscle invasive disease. The long-term oncological impact of such dissemination remains to be confirmed.

Clinical Value of Patient-Specific Three-Dimensional Printing of Kidney Before Partial Nephrectomy: A Qualitative Assessment.

Objectives: To qualitatively assess the clinical usefulness of patient-specific high-fidelity three-dimensional (3D) print model of kidney before partial nephrectomy (PN) and to identify subset domains where it may help in clinical terms. Materials and Methods: Thirteen 3D models were printed for tumors having RENAL nephrometry score of ≥8. Their usage for PN was assessed prospectively using a qualitative questionnaire to be answered on a Likert scale of 1-10. The questions focused on realistic resemblance, preoperative dry surgical run, intertest comparison, surgical impact, and overall beneficence domains as perceived by primary surgeons with respect to surgical conduct during PN. Results: Mean RENAL score was 9.15 (8-11). Models were rated high (9.07 ± 0.86) for realistic resemblance domain and were rated better than contrast-enhanced computed tomography (CECT) (8.38 ± 0.87) and intraoperative ultrasonography (8.07 ± 1.26) for orientation regarding resection margins. A further marginal improvement to 8.2 ± 0.84 was noted against ultrasound where surgeon did a dry cut preoperatively. Use of superselective arterial approach in four, precise awareness about dissection of a major vessel in four, retroperitoneoscopic approach in one, and surgical margin awareness in three were directly attributed to the model. Overall utility of having a model printed was rated high (8.23 ± 1.3). Conclusion: The 3D print models of complex renal tumors have high realistic resemblance to actual patient's anatomy. They were rated better than preoperative CECT or intraoperative ultrasonography for orientation regarding surgical resection margins. It may also help change or modify the surgical plan in a subset of patients with a potential to improve overall outcomes in these complex cases.

Impact of vesicovaginal fistula repair on urinary and sexual function: patient-reported outcomes over long-term follow-up.

INTRODUCTION AND HYPOTHESIS: While the anatomical closure rates of vesicovaginal fistula (VVF) following transabdominal (TA) and transvaginal (TV) repairs seem comparable, studies comparing urinary and sexual outcomes following successful repair are lacking. We aimed to report patient-reported outcomes on sexual and urinary functions after long-term follow-up with successful repair. METHODS: We retrospectively reviewed 81 women who had successful VVF repair at our institute. Pre-, intra- and post-operative details were retrieved from electronic data software. Patient-reported sexual and urinary function outcomes were assessed using the Female Sexual Function Index (FSFI) questionnaire and International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF), respectively, at last follow-up. We also compared such outcomes among TA and TV repairs. RESULTS: Of 81 women, 28 (34.6%) had TA and 53 (65.4%) had TV repairs. Mean age was 37.5 years and mean fistula diameter was 12.9 mm. The most common aetiology was hysterectomy. Thirty-three patients (40.7%) had previous failed repairs. At a mean follow-up of 29.8 months, 24 (34.3%) women had sexual dysfunction and 15 (18.5%) women experienced urinary dysfunction. The TA and TV groups had comparable mean FSFI scores (28.7 ± 6.1 vs. 30.9 ± 5.2, p = 0.13) and ICIQ-SF scores (0.7 ± 1.7 vs. 0.5 ± 1.4, p = 0.59). In multivariate analysis, fistula size and site were significant predictors of urinary dysfunction whereas multiparity was the most significant predictor of sexual dysfunction. CONCLUSIONS: Sexual and urinary dysfunction is found in a considerable number of women after VVF repair. However, our data suggest comparable long-term sexual and continence outcomes between TA and TV repairs.

Primary urethral small cell melanoma with neuroendocrine differentiation: a case report.

BACKGROUND: Primary malignant melanoma of the female urethra is an exceedingly rare tumor. It represents 0.2% of all malignant melanomas. Divergent differentiation towards non-melanocytic lineages has not been reported in urethral melanoma. CASE PRESENTATION: We report a rare case of neuroendocrine differentiation in a large primary small cell malignant melanoma involving the urethra, in a 62-year-old lady, who presented with obstructive urinary symptoms. Clinical and radiological workup revealed a large urethral mass with liver and lymph nodal metastases. A biopsy was performed from the urethral and liver lesions which showed poorly differentiated tumor cells with small cell morphology and presence of melanin pigment. These cells were immunopositive for melanocytic and neuroendocrine markers. Ultrastructural examination showed presence of melanosomes and neurosecretory granules in the tumor cells. CONCLUSIONS: Although malignant melanoma with neuroendocrine differentiation is exceptionally rare, it needs to be recognized among the other well-known variants of malignant melanoma.

Management of Untreated Classical Bladder Exstrophy in Adults: A Single-Institutional Experience.

OBJECTIVES: To report our single center experience in the management of untreated adult classical bladder exstrophy. MATERIALS AND METHODS: A retrospective review of 25 adults aged ≥18 years who underwent repair of the classical bladder exstrophy from April 2000 to February 2020 was performed. Patients with prior repair and neoplastic changes in the exposed bladder mucosa were excluded. The patients and primary caretakers were actively involved in the decision-making of the surgical procedures best suited them. Work-up included upper tract evaluation and random bladder mucosal biopsy. RESULTS: The mean age of presentation was 25 years. Primary schooling was completed by only 32% patients. The majority (72%) of the patients opted continent catheterizable pouch. Penn pouch was the most common pouch performed. In 3 patients, a complete primary repair was done in a single setting. In 4 patients with lack of education and difficult access to nearby health care settings, ileal conduit was performed. In all except 3 (13.1%), abdominal wall closed primarily. None of the patients required osteotomy. At a mean follow-up of 6.5 years, all patients with continent pouches were continent. One patient required revision of left ureteroneocystostomy at 20 months follow-up. All except one patient, who had complete primary repair were continent at a mean follow-up of 6 years. CONCLUSION: Management of adult classical bladder exstrophy is challenging. The various pouches extend the surgical options. Ileal conduit may be a simple alternative to complex reconstructions in unmotivated patients with poor access to the hospital.

"Stalagnate in Bladder": Synechiae Post Anti-Incontinence Surgery in Women.

Background: Anti-incontinence suspension procedures in women include Burch colposuspension or needle suspension procedures. Even though bladder injury is a known complication of any needle urethral or colposuspension procedure in women, it is rare. Delayed presentation may occur with lower urinary tract symptoms or hematuria. However, synechiae formations in bladder have rarely been reported. In this study, we report two cases presenting late with synechiae formation inside the bladder as a result of the suspension suture actually passing through the bladder and thus sewing the posterior and anterior walls of bladder together. Case Presentation: Two ladies presented late after Burch colposuspension with nonresolving urinary symptoms. Both these ladies demonstrated a "smiley bladder sign" caused by a filling defect on cystogram. Cystoscopy revealed a synechial pillar attaching the anterior and the posterior walls, reminiscent of stalagnate-like column in the bladder cavity in both cases. Both cases were managed endoscopically with laser incision avoiding injury to the ureteral orifices. Conclusion: A rare previously undescribed complication of Burch colposuspension and its typical appearance on cystogram is reported along with its endoscopic management. These cases highlight the use of intraoperative cystoscopy to prevent such complications.