Saline nasal irrigation and gargling in COVID-19: a multidisciplinary review of effects on viral load, mucosal dynamics, and patient outcomes.

With unrelenting SARS-CoV-2 variants, additional COVID-19 mitigation strategies are needed. Oral and nasal saline irrigation (SI) is a traditional approach for respiratory infections/diseases. As a multidisciplinary network with expertise/experience with saline, we conducted a narrative review to examine mechanisms of action and clinical outcomes associated with nasal SI, gargling, spray, or nebulization in COVID-19. SI was found to reduce SARS-CoV-2 nasopharyngeal loads and hasten viral clearance. Other mechanisms may involve inhibition of viral replication, bioaerosol reduction, improved mucociliary clearance, modulation of ENaC, and neutrophil responses. Prophylaxis was documented adjunctive to personal protective equipment. COVID-19 patients experienced significant symptom relief, while overall data suggest lower hospitalization risk. We found no harm and hence recommend SI use, as safe, inexpensive, and easy-to-use hygiene measure, complementary to hand washing or mask-wearing. In view of mainly small studies, large well-controlled or surveillance studies can help to further validate the outcomes and to implement its use.

Overlooked Factors Causing Renal Damage in Vesicoureteric Reflux!

Introduction: Vesicoureteric reflux (VUR), recurrent urinary tract infection (RUTI), febrile urinary tract infection (FUTI), renal scarring, and renal damage are intimately related. Key factors of renal damage in VUR are suspected to be RUTI and FUTI. Hence, conventional treatments are targeted toward the prevention of RUTI and FUTI. However, literatures have witnessed that control of infection is not sufficient enough. That means we are missing some hidden, enigmatic, or overlooked factors which are essentially responsible for renal damage. We know RUTI occurs from the stasis of urine in system and stasis might occur from obstruction somewhere in system. Moreover, obstruction builds up back pressure in the bladder and ureters, and ultimately in kidneys; that pressure is independently harmful to renal function. Pressure is further harmful if this joins together with infection. We know that RUTI and FUTI along with pressure in the urinary tract are harmful to renal parenchyma. Nevertheless, search for the nexus of obstruction, pressure, stasis, infection, and damage (OPSID) of renal function is not yet focused on in VUR research. In this retrospective study on secondary VUR, we would like to find the overlooked factors or nexus of OPSID associated with VUR causing renal damage. Patients and Methods: A total of 170 renal units of 135 patients with VUR resulted from the posterior urethral valve and from repaired bladder exstrophy, from March 2005 to April 2019, had adequate data regarding control/correction of obstruction and urodynamic studies. The mean patient's age was 2.8 years (range 1 day-14 years). The diagnosis of VURs was made with postnatal cystogram in patients of the posterior urethral valve and of repaired continent augmented bladder exstrophy. We do cystogram not micturating cystogram following ultrasonography if showing dilated ureter/s. If we find no residual in ureter/s after 30 min in cystogram, we label it as "rise and fall" VUR (raf_VUR), i.e., without obstruction. On the other hand, if there is post void residual in ureter/s for more than 30 min, we label it as "rise and stasis" VUR (ras_VUR) means combination of VUR with uretero vesical junction obstruction (UVJO). Along with this, all patients were followed up with albumin creatinine ratio, creatinine clearance, USG Renometry, DTPA renal scan, uroflowmetry, and urodynamic study (UDS). Repeat cystoscopy, if necessary, was done following UDS for secondary bladder neck incision (BNI) or for repeat BNI if necessary. Results: Mean duration of follow-up was 7.2 years (range 3-14 years). Out of 170 renal units, 132 renal units had VUR without VUJO, i.e., raf_VUR and 38 renal units had ras_VUR. All patients of UVJO were relieved either with anticholinergics or with DJ stenting or by re-implantations. Twenty-nine patients out of 135 had high pressure on UDS, and they needed BNI. We were able to prevent upstaging of chronic kidney disease (USCKD) in all 135 patients. Conclusions: Our tangible goal of treatment in VUR is the prevention of USCKD. We differentiated raf_VUR from ras_VUR with cystogram. Patients with ras_VUR and patients with raf_VUR with high bladder pressure were actively treated. This particular subset VUR was treated with prophylactic antibiotic and surgical corrections. We prevented renal damage by eliminating obstruction and stasis which helped to prevent RUTI and FUTI. Possibly, similar management might also help to manage "primary VUR." Possibly those overlooked factors which are essentially responsible for renal damage are veiled in nexus OPSID of the kidney.

How We Made Exstrophy Bladder Continent and Preserved the Renal Functions.

Purpose: Crucial requirement of exstrophy bladder repair is to make patients continent as well as to preserve kidney functions. We analyzed our patients' data retrospectively to study their continence and to find out the justification behind continence and preservation of renal functions. Patients and Methods: We selected files of 18 fully continent patients from 52 patients operated. Eleven out of 18 patients were presented from beginning and 7 were referred after around 8 to 14 years, as incontinent bladder following good repair of bladder neck and posterior urethra. Eleven were operated with complete primary repair of exstrophy along with pubic osteotomy minimal and were kept on cystostomy track (CT) till augmentation to vent out vesical pressure. In seven patients, we did reduction of caliber of posterior urethra and bladder neck along with CT followed by augmentation after 6 months. Results: All 18 patients are maintaining dry period for 24 h. Two patients had enuresis but are manageable with partial fluid restriction from evening. Seventeen out of 18 patients are maintaining their renal functions. Conclusion: No tension abdominal wall closure with rectus muscle apposition is essential to preserve repaired bladder exstrophy. Osteotomy prevents lateral drag to overcome failure of whole reconstruction. Increased "systolic" vesical pressure from contraction of small bladder might destroy the mechanism of continence and renal functions. Hence, venting of vesical pressure through CT is obligatory till augmentation which is of necessity to be done as early as possible to create a low-pressure continent system.

Extended Ulaanbaatar Procedure with Preputial Skin Graft for Proximal Hypospadias.

Background: Two stage urethroplasty for proximal penile hypospadias is time consuming, expensive and; traumatic both for parents and phallus. On the other hand, single stage procedure technically demanding. We would like to describe Extended Ulaanbaatar Procedure (EUP) which is not a two stage procedure. Rather, might be called as 'extended single stage' procedure. In EUP we have done orthoplasty along with urethroplasty with preputial skin graft at same sitting as primary procedure keeping urination diverted through proximal hypospadiac meatus as "controlled fistula" which was closed after six months as secondary procedure. Methods: We operated on 35 patients of proximal penile hypospadias with moderate to severe chordee. Chordee was excised till correction of curvature. Two distracted cut ends of native plate was bridged with preputial skin graft (PSG) in between. Following that, silastic tube was placed over glandular plate as scaffold, on both cut ends of native plate and PSG. All the urethral plates and PSG were buried with tunica vaginalis flap before glanuloplasty. After six months, proximal "controlled fistula" was closed with scrotal dartos fascia and skin to join distal to proximal urethra. Results: Vertical meatus in glans was found in 32 patients. One patient had glans dehiscence, two patients had medium sized fistula, another two patients had stenosis in neourethra and six had suture track fistula. Twenty-nine patients had satisfactory curve with good flow in uroflowmetry as per nomogram at sixth month of follow up. Conclusion: In classic Ulaanbaatar procedure authors do distal urethroplasty and glanuloplsaty in 1st stage following orthoplasty to avoid repeat trauma in glans in repeat procedures. Left over urethroplasty in classic Ulaanbaatar was done in 2nd stage. However, in EUP; we did urethroplasty for full length following orthoplasty as primary procedure. This procedure is less invasive than two staged as we avoided repeat degloving and repeat dissection on operated tissues. Urethroplasty done as primary procedure shunned the need of repeat degloving, decreased the period of morbidity, stay, and cost of surgery. We also avoided problems of urination through not matured, long, neo-urethra. Similarly complications i.e disruption, stenosis in neo-urethra can be managed utilizing the advantages of urinary diversion.

Studies on Reproductive Development and Breeding Habit of the Commercially Important Bamboo Bambusa tulda Roxb.

Compared to other grasses, flowering in bamboo is quite divergent, yet complex with respect to time to flower, number of individual culms in a population that have been induced at a time (sporadic vs. gregarious), nature of monocarpy, morphology of inflorescences (solitary spikelet vs. pseudospikelet), biology of pollen and nature of genetic compatibility. Wide diversity exists even across species and genotypes. However, due to the rarity of flowering and inaccessibility, few studies have been done to systematically analyse diverse aspects of the reproductive behaviour of bamboo. In this study, four recurrently occurring, sporadic flowering populations of Bambusa tulda have been closely observed over the last seven years. Detailed inflorescence and floral morphology and development of reproductive organs have been studied. Pollen viability was assessed by staining and in vitro germination. Self and cross pollination experiments were performed in a plantation site to assess the genetic nature of pollen-pistil interaction. The study identifies interesting reproductive features, that are not common in other grasses. A few important observations include the early appearance of a solitary spikelet vs. late appearance of a pseudospikelet in the flowering cycle, low rate of pollen germination, protandry, self-incompatibility and higher rate of seed setting by the pseudospikelet as compared to the solitary spikelet. The findings will not only be useful to understand the reproductive behaviour of this non-woody timber plant, but will also be useful for forest management and sustainable use of bamboo bioresources.

Abdominoperineal Tunnel Crafted with Alken's Telescopic Dilators: A Novel Technique!

BACKGROUND: Abdomino-perineal pull through procedure needs perineal dissection and for that swap of supine to prone may be necessary. To avoid that as well as to avoid neuro-muscular damage; we are describing a simple minimal invasive procedure with help of Alken's telescopic dilators. PATIENTS & METHODS: We created abdomino-perineal tunnel with Alken's telescopic dilators to bring down the lumen of intestine in perineum in eight patients. RESULTS: Operative time happened to be less and procedure found to be less traumatic. All the eight patients had satisfactory outcome. CONCLUSIONS: Actually, we have repurposed the Alken's dilator for creation of abdomino-perineal tunnel or track to get benefit of minimal dissection of perineum during pull-through procedure as well as to avoid neuro-muscular damage.

Percutaneous Cystolithotomy in Augmented Bladders.

AIMS: Incidence and recurrence of bladder stone in augmented exstrophy bladder rate is high. So, recurrent open cystolithotomy is not a preferred procedure; particularly through scarred tissues, consequence of previous surgeries. Percutaneous cystolithotomy (PCCL) is an old but standard procedure for retrieval of bladder stones in adults. We extrapolated PCCL for bladder stone in augmented bladders in children. PATIENTS AND METHODS: In three patients, we made suprapubic (SP) needle track with initial puncture (IP) needle under cystoscopic guidance. Following that laparoscopic cannula was placed through dilated SP track that was crafted with Alken's dilators and bladder stones were removed with grasper. RESULTS: On cystoscopy, we also observed the patches of skin tissues in native bladders. Continence and bladder capacity were not affected following PCCL. CONCLUSION: PCCL in augmented bladder showed good outcome. High recurrence of bladder stone is possibly due to presence of keratin in dermal tissue; invaded mucosa in open bladder plate. It seems shaving or fulguration of those dermal elements during bladder reconstruction might decrease incidence of stone formation. However, we haven't attempted fulguration during PCCL.

Needling for Suture Track Fistula.

A day care procedure for ablation of epithelium of suture track fistula (STF) is described with a tip of hypodermic needle under surface anesthesia. STF is a minor but annoying and frustrating complication following hypospadias surgery. Parents and patients are worried of soiling of dress from dribbling of urine through STF during urination. It is embarrassing particularly in the presence of peers. Nevertheless, no specific treatment is found in literature for its remedy other than the conventional procedures for repair of fistula. Here, we describe a simple day care procedure under surface anesthesia with prilocaine ointment. Thirty-five out of 42 STFs healed in single or repeat attempts with this 'needling' procedure.

Anephric Neonate and Evolution of our Study on Intestinal Dialysis.

PURPOSE: Intestinal dialysis for end-stage renal disease (ESRD) is a proposed renal replacement therapy, and studies are going on worldwide to make it practicable. We are also doing the same study in our institution and would like to share our experience in managing an anephric neonate with intestinal dialysis in the perspective of our ongoing study of intestinal dialysis since 2010. PATIENTS AND METHODS: We did double-ended jejunostomy in an isolated loop of the jejunum keeping the main tract intact with jejunojejunal anastomosis in this anephric neonate. Following that, we started irrigation with peritoneal dialysis fluid from the 3rd postoperative day (POD) in that jejunal loop through jejunostomy. RESULTS: This patient had no uremic features since re-admission and showed better laboratory and clinical outcomes with combined jejunal loop and colonic dialysis for 7 days. However, the patient died on the 9th POD following severe hypoglycemia. CONCLUSIONS: From this study, it seems intestinal dialysis, with necessary modifications done in our subsequent patients, which might be recommended for ESRD in children as well as in adults.

Factors Accountable for Unabated Obstruction Following Pyeloplasty.

PURPOSE: Split renal function (SFR) and frusemide washout (FWO) are assessed by the DTPA renogram to measure the renal parenchymal functions as well as the evidence of obstruction, both for diagnosis and to treat the pelviureteric junction obstruction. In good number of renal units, both these parameters remain unaltered even after surgery and cause anguish to parents and referring physicians and are usually attributed toward "defective pyeloplasty." In this study, we have tried to single out the bona fide responsible factor for the bad outcome; either the nonreversible kidney or the restenosis of pyeloplasty. PATIENTS AND METHODS: We studied file of 69 patients in whom a double "J" (DJ) stent was left in situ for internal drainage for a duration of 8 weeks in the postoperative period. DTPA scans were performed preoperative, at 8 weeks with a stent in place, and at 12 and 24 months postremoval of the stent to assess renal function. RESULTS: In our study, 45 patients (65.2%) showed improvement either in SRF or in FWO or in both after 8 weeks following pyeloplasty and 24 of 69 units (34.8%) did not show any change in renal function with DJ stent in place. Only in six units (8.7%), out of 69 units had deterioration of renal function after removal of DJ stent. CONCLUSIONS: In our opinion, no improvement of renal function found in 24 units (34.8%) even with internal drainage with DJ indicates irreversible renal damage. In 45 units (65.2%), renal function reversed after pyeloplasty and DJ stent. However, after the removal of the DJ, functions deteriorated in six units (8.7%) due to restenosis following pyeloplasties.

Insight into Posterior Urethral Valve from Our Experience: Paradigm Appended to Abate Renal Failure.

OBJECTIVE: The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF). PATIENTS AND METHODS: We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day-18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere. RESULTS: The mean duration of follow-up was 7.8 years (range 3-14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%). CONCLUSIONS: Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

Pubic osteotomy minimal for abdominal wall closure in exstrophy bladder.

We describe a novel 'pubic osteotomy minimal' (POM) done on body of pubis just lateral to the insertions of rectus abdominis and adductor longus muscles to bring rectus abdominis in midline without tension for abdominal wall closure without tension. In one patient, during pubic ramotomy, we missed middle of ramus and did osteotomy on the body on pubis found afterwards. Following good outcome, we did POM in another 17 patients. Abdominal wall closure was possible without tension and found satisfactory in all 18 patients in follow up. None had bladder wall dehiscence.

Regenerative urethroplasty in reoperative hypospadias: Buried strip principle revisited.

AIM: Reporting the feasibility of the Denis Browne (buried strip) principle along with tunica vaginalis (TV) pedicled wrapping of the strip in reoperative urethroplasty in hypospadias. MATERIALS AND METHODS: Over a period of 5 years, 32 patients presented with failure of previous urethroplasty and the range of failure was between 2 and 6 times; mean 2.5 times. Mean age was 12.9 (range 2 to 26 years) years. "Buried strip" urethroplasty (i.e., without tubularization of urethral plate) and wrapping with TV were done along with supra pubic cystostomy (SPC) for diversion of urine. Mean follow-up was 29.8 (range 12 to 56 months) months. RESULTS: One patient had fistula and vertical slit meatus was possible in 26 patients. The flow of urine was satisfactory in 31 patients and one patient developed pouch in penile urethra. CONCLUSIONS: The buried strip along with the additional coverage with TV was found to be simple and effective in salvaging the failed urethroplasty.

Novel bladder augmentation in a bilateral single system vaginal ectopia.

A 3-month-old girl presented with total urinary incontinence along with small bladder and bilateral single-system vaginal ectopic ureters [BSSVEU]. Bladder augmentation was done with dilated ureters (ureterocystoplasty) based on proximal blood supply of the ureters.