Bilateral Single-System Ectopic Ureter: When Can We Avoid Bladder Neck Reconstruction?

Bilateral single-system ectopic ureter (BSSEU) is often associated with underdeveloped incompetent bladder neck; hence, to achieve continence, bladder neck reconstruction (BNR) is usually advocated with ureteric reimplantation. Presented here is a 14-year-old girl with BSSEU who achieved continence without BNR. An attempt is made to look at factors that could identify patients in whom BNR could be avoided.

Sexual dysfunction in Indian men undergoing Double J ureteral stenting following ureteroscopy-A prospective analysis.

This prospective study was aimed to evaluate the impact of an indwelling ureteral double-J stent on the sexual health of Indian men undergoing ureteroscopy. The first phase of the study included 30 men who were not counselled prior to stenting about possible sexual dysfunction, while in the next phase, 60 men were counselled about this. These 60 patients were assessed by a 6-point questionnaire: five questions from the International Index of Erectile Function-5 (IIEF-5) and an additional 6th question to assess pain during erection/ejaculation. Patients answered the questionnaire prior to ureteroscopy, at the time of stent removal and then 4 weeks after stent removal. A higher proportion of men in the second phase attempted sexual activity (68.3% vs. 26.7%; p < .001). Significant changes were noted in the total IIEF-5 score (mean 23.16 before vs. 15.65 after, p < .001) and individual IIEF-5 components: erection confidence (4.59 vs. 2.76, p = .017), maintenance ability (4.67 vs. 2.43, p = .006) and intercourse satisfaction (4.61 vs. 2.31, p < .001) and also the 'pain' question (2.83 post-stenting vs. 0.37 pre-stenting, p < .001). Most patients had a recovery of scores at 4 weeks after stent removal. Thus, ureteral DJ stenting leads to significant but temporary sexual dysfunction and patients need to be counselled regarding this.

A global knowledge, attitudes and practices survey on anatomical endoscopic enucleation of prostate for benign prostatic hyperplasia among urologists.

There is an increasing use of the procedure, anatomical endoscopic enucleation of the prostate, as an alternative to conventional transurethral resection of prostate for surgical treatment of benign prostatic hyperplasia. However, barriers to adoption of this procedure remain and no prior studies explored this important aspect till date. The aim of this study is to identify the predictors and barriers of surgeon-related practices in this area. The study findings may also provide valuable insight into current practice trends worldwide. To achieve the objectives, we conducted an online, cross-sectional, questionnaire-based study between 1st September 2019 and 5th October 2019 to investigate the knowledge, attitudes and practices among urologists worldwide. Our findings showed that the main barriers for adoption of the procedure were lack of mentorship, a steep learning curve, and unavailability of morcellator, bipolar or laser energy sources. Fear of urinary incontinence, bleeding and bladder injury were not major hindrance to adoption of this technique. The results also demonstrated that there will be continued increase in utility of the procedure in the future.

Safety, feasibility, and quality of holmium laser en-bloc resection of nonmuscle invasive bladder tumors - A single-center experience.

INTRODUCTION: Conventional transurethral resection of bladder tumor (cTURBT), despite its piecemeal resection and associated limitations, remains the most widely practiced technique of TURBT. Resecting the tumor in a single piece would avoid most of the drawbacks of cTURBT. Our objective was to assess the feasibility, safety, and quality of Holmium (Ho) laser en-bloc resection (ERBT) for nonmuscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively studied 67 patients who underwent Ho laser EBRT for primary NMIBC. Data were collected regarding tumor size, number and location, intraoperative complications, and postoperative course. Patients were grouped as first 20, next 20 (21-40), and last 27 cases to assess how the quality of resection improved with increasing experience. RESULTS: The mean tumor size was 28.7 ± 7.9 mm, with 34.3% of the patients having a tumor larger than 3 cm. While 43 patients (64.17%) had a single tumor, the rest had multiple tumors, ranging from 2 to 9 in number. The mean total duration of resection was 38.7 ± 11.6 min. No case required conversion to cTURBT. No patient experienced obturator reflex or bladder perforation. Detrusor muscle was present in 85.07% of the resections. With increasing experience, requirement for bladder irrigation and the incidence of postoperative clot evacuation decreased (P < 0.0001 and P = 0.31, respectively), and the detrusor-positive rate in the specimen increased (P = 0.24). The mean duration of catheterization was 1.76 ± 0.54 days. CONCLUSION: Ho laser ERBT is safe and feasible for complete resection of NMIBCs with no risk of obturator-nerve reflex and a high rate of detrusor-positive specimens.

Transurethral En bloc Excision of Pediatric Bladder Tumor using Holmium Laser.

A 12-year-old male child, during evaluation of chronic constipation, was incidentally diagnosed to have a fronded bladder growth. Transurethral en bloc excision of the tumor was achieved using holmium laser. Histopathology confirmed it to be an inflammatory pseudotumor. This case is reported for its unusual presentation and management by holmium laser.

Lumbar artery injury: A rare source of perirenal hematoma following percutaneous renal procedures.

Vascular complications are the most feared complication of percutaneous renal procedures. Hematuria and perirenal hematomas, if they occur, usually arise from injury to renal arteries or its branches. Lumbar artery injury after percutaneous renal procedures is a rare occurrence. We report two cases of lumbar artery injury: one after antegrade ureteric stenting and the other after percutaneous renal biopsy. Both were successfully treated by transcatheter embolization.

Symmetrical peripheral gangrene of all four limbs: An unusual complication of ureteroscopy.

Ureteroscopy (URS) is a commonly performed and a safe urological intervention. However, potentially serious infective complications are possible after URS. A young nondiabetic woman developed severe Gram-negative septicemia after ureteroscopy for a lower ureteric calculus. The sepsis progressed to symmetrical peripheral gangrene of all the four limbs. She required left below-elbow amputation, right below-knee amputation, and loss of all toes and digits of the other two limbs.

Comparison of the efficiency and complications of Lumenis and Wolf morcellators after holmium laser enucleation of the prostate.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is a recognized option for the surgical management of benign prostatic hyperplasia. While the laser parameters and enucleation techniques have been widely studied, the morcellation techniques still remain under-evaluated. The current study evaluates the two commonly used morcellation devices for their in vivo efficiency and patient safety. MATERIALS AND METHODS: A total of 222 patients who underwent HoLEP at two medical centres between January 2011 to December 2013 by a single surgeon were included. Of these 222 patients, the Richard Wolf Piranha Morcellation System, Germany (WM), was used on 140 patients, while on the remaining 82, the Lumenis® VersaCut™ Morcellator, Yokneam, Israel (LM), was used. These devices were compared for safety parameters such as the incidence of bladder mucosal injury, deep muscle injury, bladder perforation, and bleeding requiring electrocoagulation. The morcellation efficiency (ME) defined as the ratio of the weight of morcellated tissue in grams to the time required for morcellation in minutes was also compared. RESULTS: The incidence of bladder mucosal injury, deep muscle injury, and bleeding requiring electrocoagulation was statistically significantly lower for the WM than the LM. None of the patients had a full-thickness bladder perforation with either of the morcellators. The ME was higher for the LM. In eight patients, hard, smooth rounded adenomatous nodules could not be morcellated by the WM and had to be crushed by a stone grasping forceps before morcellation. CONCLUSIONS: While the LM is a faster morcellator, WM has a better safety profile.

Cystoscopic stent removal using a guidewire loop.

Stent removal is a simple procedure performed with a rigid cystoscope and a stent removal forceps. In the rare event when the stent removal forceps does not work or breaks down, a guidewire loop can be used to remove the stent.

A double J stent misplaced in the inferior vena cava during Boari flap repair.

A 30-year-old lady underwent a Boari flap repair for post-hysterectomy mid-ureteric stricture. The upper end of the double J stent inserted during the procedure was misplaced in the supra-renal inferior venal cava. Cystoscopic stent removal could be performed uneventfully, while the stricture was managed by endoureterotomy.

Best laser for prostatectomy in the year 2013.

Lasers have come a long way in the management of benign prostatic hyperplasia. Over last nearly two decades, various different lasers have been utilized for prostatectomy. Neodymium: yttrium-aluminum-garnet laser that started this journey, is no longer used for prostatectomy. Holmium laser can achieve transurethral enucleation of the prostatic adenoma producing a fossa that can be compared with the fossa after Freyer's prostatectomy. Green light laser has a short learning curve, is nearly blood-less with good immediate results. Thulium laser is a faster cutting laser while diode laser is a portable laser device. Often laser prostatectomy is considered as a replacement for the standard transurethral resection of prostate (TURP). To be comparable, laser should reduce or avoid the immediate and long-term complications of TURP, especially bleeding and need for blood transfusion. It should also be safe in the ever increasing patient population on antiplatelet and anticoagulant drugs. We need to take stock of the situation and identify, which among the present day lasers has stood the test of time. A review of the literature was performed to see if any of these lasers could be called the "best laser for prostatectomy in 2013."

Use of Anabolic-Androgenic Steroids and Male Fertility: A Systematic Review and Meta-analysis.

Background: Anabolic-androgenic steroids (AASs) are often used by men for bodybuilding and to improve sports performance. The use is not limited to professional competitive athletes, but many amateur men. Objective: The objective of this study was to assess and systematically review the effects of AAS on male fertility parameters, spermiogram, testosterone, follicle-stimulating hormone (FSH) and luteinising hormone (LH) and to review reversibility and other morbidity impacting fertility. Methods: Eligibility criteria - We included studies mentioning data about adult males using supraphysiologic doses of AAS for sports performance or appearance enhancement, with comparison data from general population or matched controls if available reporting fertility parameters and sexual performance. Information sources - A systematic literature search was performed using PubMed, MEDLINE, EMBASE, Google Scholar and World of Science. Controlled clinical trials randomised or nonrandomised (if available), case series with or without matched controls, case reports, cross-sectional surveys, reports on follow-up of subjects caught in doping test and their fertility parameters when reported. Risk of bias/quality assessment - The quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. Results: Included studies - Thirty-two studies were included. There were 12 cohort studies, 5 case-control studies, 9 cross-sectional surveys and 6 case reports. The study population comprised 9371 individuals, of which 2671 were AAS users. Synthesis of results - AAS users had reduced levels of FSH and LH than the naïve population. These levels remained low for 3-6 months after stopping AAS. One year after stopping AAS, the users and naïve population had insignificant differences in FSH and LH values. The total testosterone (TT) levels were comparable in users and naïve populations at baseline, 3 months and 6 months after stopping, but at 1 year, TT values were lower in AAS users. Sperm concentration in AAS users and naïve population was similar, but sperm motility was lower in AAS users. The testicular size was lower in AAS users. The erectile function improved with AAS use, but on withdrawal, there was decreased libido and erectile dysfunction. Most AAS users need additional medications to mitigate detrimental effects on fertility. Description of the effect - AAS use negatively impacted the gonadotrophin levels and had lower sperm motility and testicular size. Strength - Comprehensive review of 32 publications, study population of 9371 individuals, of which 2671 were AAS users, meta-analysis of reproductive hormones, semen parameters and testis size. Limitations: The limitations are small sample size of most of the studies, polypharmacy, lack of information on dosing and high heterogeneity. Interpretation: AAS use is detrimental for sperm motility and has a partially reversible negative impact on male fertility. Users must be cautioned about its negative impact on libido and erectile function.Registration: PROSPERO Registration No. CRD42023411294.

Evaluating factors associated with the risk of hydrothorax following standard supracostal percutaneous nephrolithotomy.

Objective: To report our experience with supracostal percutaneous nephrolithotomy (SC-PNL) and evaluate factors which could predict the risk of hydrothorax following SC-PNL. Methods: We reviewed 347 patients who underwent SC-PNL from January 2011 to December 2019. Patients were assessed for demographic characteristics, indication for the supracostal access, level of supracostal access, anatomy of the kidney (normal or malrotated), site of the puncture in relation to the mid-scapular line (medial or lateral), and whether another subcostal tract for stone clearance was required or not. Patients were assessed for the incidence of hydrothorax and requirement of intercostal drain depending on the level of percutaneous access. In addition, a multivariable logistic regression analysis model was developed to identify factors which could predict the occurrence of hydrothorax following SC-PNL. Results: Of the 347 patients with SC-PNL, 248 (71.5%) underwent a supra-12th rib approach, while the rest needed a supra-11th (n=85; 24.5%) or a supra-10th (n=14; 4.0%) rib tract. Overall, 17 (4.9%) patients developed a hydrothorax, while an intercostal-drain was required in seven of these 17 patients for 48 h. None of the patients with a supra-12th rib puncture required an intercostal-drain. More than a third of the patients with a supra-10th puncture developed a hydrothorax (35.7%) and all of them required an intercostal drain. Factors such as anteriorly malrotated kidney (odds ratio [OR]=2.722; 95% confidence interval [CI]=1.042-5.617, p=0.03), puncture medial to the mid-scapular line (OR=1.669; CI=0.542-1.578, p=0.03), and an access higher than the supra-12th level (OR=5.265; CI=1.292-9.342, p<0.001) proved to be independent predictors of hydrothorax following a SC-PCNL on multivariable analysis. Conclusion: Incidence of clinically significant hydrothorax requiring an intercostal-drain after SC-PNL is very low. Knowledge of the predicting factors will help to anticipate the risk of hydrothorax in a particular patient and take necessary peri-operative measures.