Clinicopathological study of adrenal pheochromocytoma and extra-adrenal paragangliomas with reference to GAPP and PASS scoring systems.

BACKGROUND: The presence of distant metastasis is known to drastically reduce survival of adrenal pheochromocytoma (PH) and extra-adrenal paraganglioma (PGL). Therefore, predicting malignant potential has an immense impact on prognosis. Pheochtomocytoma of adrenal gland scaled score (PASS) and the grading of adrenal pheochromocytoma and paraganglioma (GAPP) score are two histological algorithms used to predict metastatic potential, but neither has been regarded as 'gold-standard'. Both these scoring systems are yet to be validated. Here, we tried to validate the association of GAPP/PASS scores with disease outcome and strength of association between individual GAPP/PASS parameters with prognosis. MATERIALS AND METHODS: This was a prospective study comprising 22 pheochromocytomas and eight paragangliomas. GAPP score was calculated in paraganglioma cases, and both GAPP/PASS scores were calculated for pheochromocytomas. Disease outcome was then tallied with risk stratification of the GAPP/PASS scoring system. Succinate dehydrogenase B (SDHB) immunohistochemistry was done in 15 cases to see its impact on prognosis. RESULTS: The common PASS parameters associated with malignancy were 'high cellularity', 'tumor cell spindling' and 'extension into adipose tissue'. PASS score showed high sensitivity and negative predictive value but low specificity and positive predictive value. Similarly, GAPP score also showed high sensitivity and negative predictive value but low specificity and positive predictive value. CONCLUSION: In our study, GAPP/PASS scores successfully segregated tumor with low malignant potential from tumor with higher risk of metastasis, although specificity of GAPP was more than PASS. We also found that addition of objective parameters like SDHB immunohistochemistry may further increase the specificity of the existing scoring system.

Low Serum Testosterone as a Poor Prognostic Marker in Urethral Stricture: A Single-Center Prospective Longitudinal Study.

Introduction Androgens play a key role in modulating periurethral and preputial vascularity, cavernosal smooth muscle integrity, and penile growth. As a result, low testosterone may adversely affect the severity and outcome of urethral stricture patients. So, to find out the hormonal influence on the clinical outcome of urethral stricture we conducted a prospective longitudinal study at our institute. Methods The study was conducted at the Department of Urology, Institute of Post Graduate Medical Education & Research (IPGMER), Kolkata, India, from February 2023 to September 2023. This study was approved by the Institutional Ethics Committee at IPGMER, Kolkata with the approval number IPGMER/IEC/2023/436. Hormonal levels in patients with diagnosed non-traumatic urethral stricture were compared with patients without stricture. Patients with any overt hormonal abnormality or androgen-secreting tumor were excluded. A morning 10 cc blood sample was collected for testosterone, follicle-stimulating hormone, luteinizing hormone, and thyroid-stimulating hormone. The association of hormonal levels was measured in both groups and compared statistically. Any association of hypogonadism (testosterone <300 ng/dL) with respect to length, severity, and recurrence of urethral stricture was also studied. Results Forty patients with urethral stricture and same number of patients without stricture were included in the study. The mean testosterone level was found to be significantly low in patients with stricture (386 ng/dL vs 660 ng/dL). The age-wise distribution also showed low mean testosterone compared to patients without stricture. The incidence of hypogonadism is also found to be higher in stricture patients (47.5% vs 27.5%). It was also observed low testosterone is more prevalent in pan-anterior stricture (10/40) and long-segment stricture(>2 cm). Patients with stricture were also followed up for 6 months for recurrence of symptoms. Thirteen patients had recurrence. Patients with recurrence had significantly low serum testosterone (272 ng/dL vs 440 ng/dL). Conclusion Our study documented stricture patients with low serum testosterone have poor outcomes. Low testosterone level is strongly associated with longer stricture and increased risk of stricture recurrence.

A Prospective, Randomized Study Comparing the Outcome After Thulium Laser Enucleation of the Prostate with Conventional Monopolar TURP for the Treatment of Symptomatic Benign Prostatic Hyperplasia.

OBJECTIVE: This is a prospective randomized study with the aim of comparing (thulium laser enucleation of the prostate (ThuLEP) and transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) treatment. METHODS: Patients are assessed preoperatively and up to 6 months postoperatively. International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rates (Qmax), international index of erectile function-5 (IIEF-5) and post-void residual volume (PVR) are collected on each follow-up. RESULTS: In comparison to TURP, the ThuLEP group has significantly less need for catheter traction and less need for postoperative irrigation. The operative time is significantly higher in ThuLEP compared to TURP. ThuLEP is significantly superior to TURP in terms of early catheter removal, less drop in haemoglobin, less fall in serum sodium level, and early hospital discharge. ThuLEP and TURP resulted in a significant improvement from baseline in terms of IPSS, PVR, Qmax, and QoL, but there was no significant difference between the 2 groups. The IIEF-5 is the same as the baseline in both groups. Early and late complications are also comparable. CONCLUSION: The ThuLEP outperforms TURP in terms of blood loss, significantly less need for postoperative catheter traction, bladder irrigations, early catheter removal, and less hospital stay. Transurethral resection of the prostate takes longer operative time in the early stages of experience. The results of both surgeries are comparable in terms of PVR, Qmax, and subjective scoring systems (IPSS, QoL). Transurethral resection of the prostate is a safe and efficient BPH treatment method comparable to the monopolar TURP.

A single-stage dorsal inlay buccal mucosal graft placement through subcoronal vertical sagittal ventral urethrotomy without glansplasty for reconstruction of meatal stenosis, fossa navicularis, and distal penile urethral stricture: Our initial experience.

Introduction: Reconstruction of fossa navicularis stricture (FNS) poses a challenge in providing acceptable functional and cosmetic outcomes. We describe our novel surgical technique and its short-term results. Methods: This urethroplasty technique is a single-stage dorsal inlay buccal mucosal graft placement with subcoronal vertical sagittal ventral urethrotomy without glansplasty. Twenty-one operated patients were followed up at 2 months and 6 months postoperatively. We studied the functional outcome of the International Prostate Symptom Score, quality of life (QoL) score, maximum flow rate, postvoid residual (PVR) urine, and reconstructed urethral luminal caliber. Sexual function was studied via a brief male sexual function inventory. Hypospadias objective score evaluation (HOSE) was used to assess the cosmesis. Patient satisfaction was evaluated using the global response assessment score (GRA). Results: FNS is seen commonly associated with lichen sclerosus (n = 12). Nine patients had stricture that extended into the distal penile urethra. The mean stricture length was 2.76 cm. At the end of the study, a significant improvement in mean IPPS (18.81), mean QoL score (2.25), mean Qmax (20.94 mL/s), mean PVR (103.05 mL), and mean urethral caliber (16.06 Fr) were noted. No difference in sexual drive and erectile function but significant improvement in ejaculation was noted. All patients had single-stream urine, reconstructed urethral caliber ≥16Fr, HOSE ≥14, and GRA ≥2 at 6 months. Except for two patients, all had vertical slit-like meatus. Conclusion: This technique is feasible, with good cosmetic, functional, and subjective outcomes with marked patient' satisfaction.

Evaluation of psychosocial status of CKD patients on renal replacement therapy and post renal transplant patients: An observational study.

INTRODUCTION: Recent studies have shown a high prevalence of depression and anxiety in patients with end-stage renal disease (ERSD) and renal transplant recipients. AIM: The aim of this observational study is to asses prevalence of depression and anxiety symptoms in CKD patients and post renal transplant patients. METHODS: In this study 100 patients divided in 50-50 each group. Group 1 with CKD patients on dialysis and group 2 with post renal transplant patients. Each group evaluated for depression and anxiety symptoms using BDI (Beck's Depression Inventory) and STAI (State-Trait Anxiety Inventory) score which is divided into STAI-X1 and STAI-X2, respectively. RESULTS: Our study revealed in group 1 48% patient versus group 2 34% patients present with depressive symptoms whereas in case of anxiety symptoms STAI-X1 and STAI-X2. Group 1 24% and 18% whereas group 2 34% and 28% patients, respectively. CONCLUSION: It is observed that depressive symptoms are more common in CKD patients on dialysis whereas anxiety symptoms observed more in patients after renal transplant. The obtained results indicate that screening tests and monitoring of the emotional state of patients with CKD are necessary, regardless of the disease stage and treatment; this includes patients after kidney transplantation.

Comprehensive study of anxiety and depression in females with urinary incontinence.

BACKGROUND: Anxiety and depression are commonly seen with urinary incontinence (UI) and its association is strongest for urgency and mixed UI. It affects the quality of life and functional status. AIMS: To assess the prevalence and severity of anxiety and depression in SUI (Stress urinary incontinence) and UUI/MUI (Urge or mixed urinary incontinence), to assess the severity of SUI and UUI/MUI and its association with anxiety and depression and to identify various factors associated with anxiety and depression. MATERIALS AND METHODS: An observational study using various tools as history regarding urinary incontinence, history of other prior events which can lead to anxiety or depression, age, educational level, BMI (Body mass index), HADS scale (Hospital anxiety and depression scale) for anxiety and depression and ICIQ-UI-SF score (International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form). RESULTS: The Prevalence of anxiety and depression in UUI/MUI was higher. More women were overweight (BMI > 25) in the UUI/MUI group. Higher prevalence of anxiety and depression in the very severe urinary incontinence group. No association of the level of education with anxiety and depression in women with urinary incontinence. CONCLUSION: Anxiety and depression are more in UUI/MUI patients compared to SUI. In obese ladies, UUI is more prevalent compared to SUI. Anxiety and depression are more with increasing severity of incontinence. Anxiety and depression have no association with the educational status of the patients.

A prospective comparative evaluation of preoperative stone scoring systems with respect to stone free rate and complications in percutaneous nephrolithotomy.

BACKGROUND: PCNL outcomes among urologists are different because of the vast heterogeneity in the methods for clinical, academic characterisation and evaluation of surgical outcomes of nephrolithiasis. So assessing the preoperative factors that affect SFR (Stone Free Rate) and complications is critical. Heterogeneity in reporting of PCNL outcomes among different centres has led to the invention of nephrolithotomy scoring systems based on preoperative parameters to better counsel patients contemplating PCNL. The Guy's stone score, CROES nomogram and the S.T.O.N.E score are seen as predictors of stone-free status (SFS) and complications after PCNL. No universally accepted stone scoring system for predicting SFR and complications after PCNL exists. This is a prospective observational study to compare and analyse the existing stone scoring systems (SSS) and to assess the best parameters to predict PCNL outcomes concerning SFR and complications. METHODS: This study is done in a tertiary level institute in eastern India which included 200 patients who underwent PCNL from November 2019 to November 2021. The relevant operative parameters were documented and compared to the preoperative factors with the help of nephrolithotomy scoring systems. RESULTS: The Guy score, CROES nomogram and S.T.O.N.E. score were accurate in predicting the SFR in patients undergoing PCNL. A new IPGMER preoperative stone scoring system based on the most relevant parameters could be used as an alternative to predict SFR and complications in PCNL. CONCLUSION: The Nephrolithometry scoring systems are simple, straightforward and easily reproducible systems to classify the severity of nephrolithiasis and to stratify the complexity of PCNL.

Efficacy of supine trans-abdominal pronated shock head ESWL for treatment of distal ureteric stones: A pilot study.

OBJECTIVE: To evaluate the efficacy of extracorporeal shockwave lithotripsy (ESWL) in supine trans-abdominal approach for distal ureteric calculi and to determine the variables that could affect the outcome results. MATERIALS AND METHODS: Between November 2019 and January 2021, 172 patients with a solitary distal ureteric calculus were treated with ESWL in supine position with a pronated shock wave head against the anterior abdominal wall. The outcome of treatment evaluated and the clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone-free rate (SFR). RESULTS: Overall SFR was 84.84% (140/165). Those with stone clearance, 83.57% (117/140) cleared after one session and 16.42% (23/140) needed more than one session. Only three factors had a significant impact on SFR, that is stone length, stone width, stone attenuation. For stone length ⩽ 9 mm SFR was 93.44% (114/122) compared to 60.46% (26/43) for stone length of 10-12 mm (p < 0.00001). There were statistically significant increased SFR for stones with attenuation of <0.0001 and for the mean stone width of 8.02 mm (p < 0.00001). Stone localisation was easy with good patient comfort. CONCLUSION: Supine trans-abdominal ESWL is a new, effective and safe form of treatment for distal ureteric calculi. The stone length, stone width along with stone attenuation were the only significant predictors of stone free status in supine position.

Emergency extracorporeal shock wave lithotripsy: A study on feasibility and efficacy in stone clearance and reducing morbidity in ureteric and renal stones with colic.

OBJECTIVES: Evaluation of safety, efficacy, and feasibility of emergency extracorporeal shockwave lithotripsy (eESWL) in combating obstructing stones with colic on emergency basis. MATERIALS AND METHODS: From November 2019 to November 2021, 102 subjects underwent emergency ESWL for obstructing ureteric and renal stones with colic within 24 h of presentation. RESULTS: Patients in this study belonged to age group of 18-67 years with mean being 39 years consisting of 85 males and 22 females (M:F = 85:22). Mean stone dimensions were 8.26 mm in length and 7.65 mm in width. A total of 42 patients had their stone in kidney or upper ureter while 24 patients had stone in mid ureter and remaining patients (n = 36) had stone in lower ureter. About 65 patients had their stone completely cleared after single ESWL session while 20 patients required multiple sessions to achieve complete clearance. Of these 17 patients (16.67%) were not rendered stone free even after three sessions and had to undergo ureteroscopic lithotripsy (URSL). Overall Stone Free Rate (SFR) was 83.33%. For stone attenuation of ⩽900 HU, SFR was 97.18% while for >900 HU it was only 51.61%. CONCLUSION: eESWL is safe, feasible, and efficacious noninvasive alternative for definitive management of obstructing ureteral and renal stones with colic as far as stone clearance and rapid and definitive pain relief are concerned and that too with very minimal morbidity without the need for admission and hence can reduce the prolonged waiting period for endoscopic stone surgery in any high-volume tertiary care hospital. Length, width, and attenuation of stone were found to be the main factors dictating the success of eESWL.

Expression of HER2/NEU in newly diagnosed metastatic carcinoma prostate on TRUS biopsy specimen and its clinical correlation and progression.

BACKGROUND: Prostate cancer development and progression to androgen-independent disease is correlated with increased expression of growth factors and receptors capable of establishing autocrine and/or paracrine growth-stimulatory loops. Overexpression of the Her2/neu receptor tyrosine kinase has been associated with the progression to androgen independence in prostate cancer cells. OBJECTIVE: Our primary aim was to investigate the frequency of HER2/neu amplification in prostate biopsy specimens in newly diagnosed metastatic carcinoma prostate and its correlation to progression of androgen independent carcinoma. MATERIALS AND METHODS: In our study, expression of HER2/neu was carried out by immunohistochemical analysis in TRUS biopsy specimen of newly diagnosed metastatic carcinoma prostate. RESULTS: Out of 36 patients, seven (19.4%) showed her2neu overexpression on immunohistochemical staining. Five out of seven (71%) were associated with higher histological grade >7 at diagnosis (p < 0.05). Her2neu overexpression was not significantly associated with age and serum PSA at diagnosis. However progression to castration resistant stage was not dependant on Her2/neu status (p > 0.05). CONCLUSION: Overexpression of her2/neu was associated with high grade carcinoma prostate at diagnosis, however progression to castration resistant stage was not related with her2neu expression.

Correlation of digital rectal examination and serum prostate-specific antigen levels for detection of prostate cancer: Retrospective analysis results from a tertiary care urology center.

Objective: The objective of our study was to evaluate the detection rate of prostate cancer by digital rectal examination (DRE) and serum prostate-specific antigen (PSA) levels followed by standard 12-core transrectal ultrasound (TRUS)-guided prostate biopsy. Materials and Methods: After screening of patients presenting with lower urinary tract symptoms (LUTS) using DRE and serum PSA level, we enrolled patients for TRUS-guided 12-core prostate biopsy. Indications included PSA level ≥4 ng/ml and/or suspicious DRE findings. A retrospective analysis was done to find out the correlation between suspicious rectal examination and various serum PSA levels in detection of cancer prostate. Results: A total of 847 patients were screened for cancer prostate during our study period (May 2012-February 2020). Among them, 823 patients who underwent prostate biopsy were analyzed. Prostate cancer was detected in 330 cases (40.09%). Mean age of patient (years) with and without prostate cancer was 66.25 ± 9.45 and 64.3 ± 8.96 years, respectively. Median value of serum PSA in patients positive for cancer was 33 ± 260 ng/ml compared to patients without cancer, who had a median value of 9 ± 64 ng/ml (P-value of <0.0001). The detection rate of cancer based on suspicious DRE findings irrespective of PSA was 52.18% (251/481), compared to 45.46% (311/684) using a PSA cut-off of ≥4.0 ng/ml alone. Among 330 patients with positive biopsy, 19 (5.75%) had a PSA level <4 ng/ml and they were identified based on suspicious DRE alone. Conclusion: Suspicious DRE was significantly associated with detection of prostate cancer across all PSA levels. Patients with PSA <4 can harbor prostate malignancy and such cases can be detected by use of DRE in screening of all patients with LUTS.

Diagnostic and prognostic utility of SF-1 in adrenal cortical tumours.

Background and Aims: Superior imaging techniques have increased the recognition of adrenal pathology. Distinguishing benign from malignant adrenocortical tumors is not always easy. Several criteria and immunohistochemical markers have been discovered which help to differentiate between adrenocortical adenoma (ACA) and adrenocortical carcinoma (ACC). Our aim here was to evaluate the diagnostic and prognostic role of steroidogenic factor-1 (SF-1) in adult adrenocortical tumors (ACT) diagnosed using the Weiss criteria. In this cohort, we have also analyzed Ki67 and p53 expression and the extent of agreement between SF-1 and Ki-67. Methodology: This was a retrospective, observational study comprising 24 cases of adult ACT over 10 years. Immunohistochemical staining for SF-1, Ki67, and p53 was done in all the cases, and the results correlated with the morphological diagnosis made using Weiss criteria. Results: SF-1 was 100% sensitive and 80% specific as a marker of malignancy. Increased SF-1 expression correlated with worse survival. There was a moderate degree of agreement between Ki-67 labeling-index and SF-1 as a marker of malignancy with the kappa coefficient being 0.75. The sensitivity of p53 was lower than Ki67 in diagnosing ACC. Conclusion: In adult ACTs, SF-1 has diagnostic significance and prognostic implication. SF-1 is a crucial, dosage-dependent survival factor in ACC. There is a moderate extent of agreement between Ki-67 and SF-1 as a marker of malignancy.

Composite phaeochromocytoma with malignant peripheral nerve sheath tumour: A case report with summary of prior published cases.

Composite phaeochromocytomas (CP) are extremely uncommon adrenal medullary tumours where phaeochromocytoma coexists with another adrenal medullary tumour also of neural crest origin. CP includes combination of phaeochromocytoma along with a component of neuroblastoma, ganglioneuroblastoma, ganglioneuroma, benign nerve sheath tumour or a malignant peripheral nerve sheath tumour (MPNST). Here we describe the morphological and immunohistochemical details of a case of CP with MPNST in a 30 years old lady, without history of neurofibromatosis. Only 6 cases of CP with MPNST have been reported so far. We have tabulated a summary of these prior published cases of phaeochromocytoma with MPNST. To our knowledge, this is the first literature review describing the clinico-pathological characteristics of these rare tumours.

Clinical assessment of stabilisation of renal function after nephrectomy.

INTRODUCTION AND OBJECTIVE: Nephrectomy leads to derangement of renal function and various adaptive changes by the remaining kidney over a period of time. This study is performed to evaluate the amount of derangement of renal function in donor and radical nephrectomy, how much the remaining kidney adapts over a period of time and the time taken for stabilisation of renal function. METHOD: A total of 60 patients who underwent nephrectomy (Radical/Donor) were followed up for 12 months with serial estimation of renal function and was compared with preoperative renal function. Data was analysed with statistical analysis. RESULT: Patients who underwent radical nephrectomy had 37% initial decline in renal function which was later stabilised at 19% lower than baseline value. Patient who underwent donor nephrectomy had initially 39% decline in renal function which was later stabilised at 24% lower than normal. CONCLUSION: Removal of functional renal tissue led to reduction of renal function. This decline is more evident in the initial post-operative period and then begin to stabilise over months. The greater is the amount of normal tissue removed, the greater is the reduction of renal function and more time it will take to stabilise, increasing overall morbidity of the patient. This study suggests that even patients with normal GFRs should be followed up postoperatively to determine their ultimate renal functional outcomes.

Bladder teratoma with pilimiction in a male adolescent.

Teratomas are tumors consisting of two or three germ layers, seen commonly during childhood. Mature teratomas are benign and demonstrate well differentiated tissues such as sebaceous glands, hair, and teeth. Bladder is a very rare extragonadal site for teratoma, moreover so in adults. Presentation may vary from with irritative lower urinary tract symptoms or urinary retention to pilimiction (passage of hair in the urine). We hereby present a case of mature teratoma of the urinary bladder, with a classical symptom of pilimiction, in a 22-year-old male patient, which to our knowledge is the first male case reported in the literature.

Monthly maintenance protocol Bacillus Calmette-Guerin as a viable alternative to Southwest Oncology Group maintenance protocol in nonmuscle-invasive bladder cancer: A prospective randomized study.

INTRODUCTION: Bladder cancer is the most common malignancy of the urinary tract, and recurrence following transurethral resection poses the biggest challenge. Intravesical Bacillus Calmette-Guerin (BCG) maintenance with the Southwest Oncology Group (SWOG) protocol remains the gold standard but with poor patient compliance. MATERIALS AND METHODS: The present study aims to compare the SWOG maintenance protocol with a monthly maintenance protocol comprising 12 monthly doses of intravesical BCG. Patients are included in the study only if induction BCG is completed and cystoscopy at 3 months is negative. All patients receive 80 mg BCG in each dose with strict cystoscopic surveillance every 3 months. RESULTS: Patient demographics and tumor characteristics were similar in the two groups. There were no statistically significant differences in outcome in terms of recurrence, progression, and adverse reactions in both the groups. Although a larger number of patients in the SWOG maintenance group were lost to follow-up, the difference was not statistically significant proportions. CONCLUSION: From this study, we can conclude that monthly maintenance BCG for 1 year is comparable in terms of outcome with SWOG protocol maintenance BCG. A greater percentage of patients in the monthly maintenance protocol completed the treatment as planned.

Pain and anxiety assessment during cystourethroscopy in males using voiding instruction: A prospective, randomized controlled study.

INTRODUCTION: Office cystourethroscopy is one of the common and most frequent urological procedures. Pain and anxiety during the procedure might lead to noncompliance and incomplete cystoscopic examination. Negotiating cystoscope through external sphincter is the most painful and uncomfortable distressing part of cystoscopy. To overcome this, manual compression of irrigation bag during cystoscopy has been used and found to be helpful. Numerous other methods were also studied. Despite these, cystoscopy is still painful and causes anxiety in patients. External sphincter gets relaxed naturally during the act of micturition. Based on this principle, pain and anxiety were studied with voiding instruction during cystourethroscopy. OBJECTIVE: To study the effect of voiding instruction on anxiety and pain during cystourethroscopy using the Hamilton Anxiety Rating Scale (HAM-A) and visual analogue scale (VAS), in a well-matched Eastern Indian male patient population in a prospective, randomized pattern. METHODS: A total of 100 male patients were recruited from those who underwent cystourethroscopy examination in SSKM Hospital and were prospectively randomized into two groups: cystoscopy with or without voiding instruction. Pre- and postprocedure HAM-A score and postprocedure VAS score were recorded. RESULTS: The mean postprocedural pain (VAS) score between voiding instructed and noninstructed groups reached statistical significance: 3.06 ± 1.98 (Range, 2-5) and 5.16 ± 2.86 (Range, 4-8), respectively (P < 0.001). Preprocedure HAM-A score was similar between both groups. Postprocedure median HAM-A score was statistically significantly lower (mean 17.86 ± 2.8 vs. 19.76 ± 3.12; P < 0.001) in voiding instructed group. CONCLUSION: Pain and anxiety level during cystourethroscopy examination in males can be significantly reduced when the patient is instructed to void during cystourethroscopy examination.

Penile strangulation by different objects and its removal by the modified string method: Management of four cases with review of literature.

Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Penile strangulation by a nonmetallic or thin metallic ring is easily overcome by severing/cutting the object; however, a heavy and long metal ring causing penile strangulation is not only difficult to sever but also it may worsen the scenario if removal is tried with inappropriate method. Here, we report four cases of penile strangulation by different objects which were successfully removed by aspiration and string method. We found that instead of using heavy cutting instruments and other surgical methods, string and aspiration technique is much better.

Rare cases of ectopic ureter: Analysis from a single centre with review of the literature.

OBJECTIVE: Purpose of our study was to aggregate and analyse rare cases of Ectopic Ureter (EU), their association with other anomalies, clinical features, diagnosis and management. MATERIAL AND METHODS: A total of nine patients with rare presentation of EU were evaluated. Combination of endoscopic and imaging modalities was used as required to define the anatomy and devise the best surgical approach in these cases. RESULTS: Among six females and three males with EU, four cases had bilateral EU, four unilateral EU and one case had EU of a solitary kidney. Urinary incontinence was encountered in five cases including one male patient whilst other cases presented with varied clinical features and associated anomalies. Two patients had anorectal malformations, and two had uterine anomalies in the form of bicornuate uterus. Other patients had multiple rare associations such as triplication of ureter, bilateral absence of seminal vesicles with infertility, multicystic dysplastic kidney, ureter draining in uterus, renal failure, absence of bladder trigone, and hypospadias etc. Ureteric reimplantation was performed in four cases, two required ureteroureterostomy, another two had undergone upper pole nephrectomy and in one case renal transplant had been carried out owing to chronic renal failure. CONCLUSION: EU is among group of those congenital entities which remain shrouded until adulthood, when symptoms become distressing. Fortunately, prognosis is favourable after surgical correction, in spite of its rarity. Complexity arises when other associated anomalies are identified.

Unexplained occurrence of multiple de novo pseudoaneurysms in patients with chronic kidney disease undergoing angioembolization for bleeding following percutaneous renal intervention: Are we dealing with infection or vasculitis?

BACKGROUND AND OBJECTIVES: Patients with chronic kidney disease (CKD) are more prone for bleeding following percutaneous renal intervention, as compared to those with normal renal function. Causes are multi-factorial. Finding multiple aneurysms away from the site of renal intervention following initial angioembolization for hemorrhage is very unusual in these patients. MATERIALS AND METHODS: Clinical and radiological findings of all the patients who underwent renal angiography for post-intervention bleed for a period of 5 years were reviewed and analyzed. RESULTS: A total of 29 patients required angiography for post-intervention hemorrhage. Six patients had recurrence of hemorrhage for which they underwent repeat angiography. Four of these patients had appearance of multiple new aneurysms away from the site of percutaneous nephrostomy (PCN)/percutaneous nephrolithotomy (PNL) puncture and the site of previous bleeding. All the patients had CKD (creatinine >2.5 mg/dl). They were on prolonged preoperative urinary diversion and had polymicrobial urinary infection. Three patients had candiduria. None of these patients had re-bleeding after repeat embolization and treatment with antibacterial and antifungal agents. CONCLUSIONS: Development of multiple aneurysms away from the sites of punctures in patients with CKD following percutaneous intervention is very unusual. Its causation including infection with bacteria and fungus, reaction of embolizing material, and angiopathy needs to be explored.