Surgical management of stricture urethra in patients with chronic renal failure: Ten years' experience at a tertiary center.

Introduction: Patients suffering from stricture urethra and deranged renal function have poor quality of life. The incidence of urethral stricture co-existing with renal failure is comparatively small and cause may be multifactorial. There is paucity of literature on management of urethral stricture associated with deranged renal function. We present our experience of managing stricture urethra associated with chronic renal failure. Materials and Methods: This was a retrospective study conducted from 2010 to 2019. Patients with stricture urethra and deranged renal function (serum creatinine >1.5 mg/dl) who underwent urethroplasty or perineal urethrostomy were included in our study. A total of 47 patients met the inclusion criteria and were included in this study. Patients were followed every 3 months in their 1st year of surgery and 6 monthly thereafter. Statistical analysis was done using SPSS version 16. Results: There was a significant increase in the mean postopérative maximum and average urinary flow rates when compared to the preoperative values. The overall success rate was 76.59%. Out of 47 patients, 10 had wound infection and delayed wound healing, 2 patients developed ventricular arrhythmias, 6 patients developed fluid and electrolyte imbalance, 2 patients developed seizures, and 1 patient developed septicemia in the postoperative period. Conclusion: Prevalence of patients with chronic renal failure associated with stricture urethra was 4.58% and features suggestive of deranged renal function at presentation were present in 1.81% patients. In the present study, complications related with chronic renal failure occurred in 17 (36.17%) patients. Multidisciplinary care of the patient along with appropriate surgical management is a viable option in this sub-group of patients.

Does endoscopic sclerotherapy in filarial chyluria affect renal function and morphology? A prospective study using dimercaptosuccinic acid renal scan.

OBJECTIVE: To look for change in relative renal function and document renal scarring following endoscopic renal pelvic instillation sclerotherapy (RPIS) in patients with chyluria by dimercaptosuccinic acid (DMSA) renal scan. METHODS: A prospective study was performed between November 2015 and September 2016. All patients with biochemically documented chyluria who underwent RPIS using either 1%-silver nitrate or 0.1%-povidine iodine were included. Patients received either 3-, 6- or 9-doses. DMSA renal scan was performed before and 2-3 months after sclerotherapy. RESULTS: Of the 34 patients, 22 were males. Mean age was 41.08 ± 16.64 years (range, 15-70 years). Thirty-two patients (94.1%) responded to therapy while two did not respond even after 9-doses. Average follow-up was 8.94 ± 3.70 months. The mean relative renal function (pre-instillation) of normal kidney was 50.76% ± 3.55% while that of affected renal unit (side of instillation) was 49.20% ± 3.44% (range, 43.0%-61.0%). After instillation therapy, the mean relative renal function of normal side was 52.26% ± 3.57% while that of affected renal unit was 47.50% ± 3.56% (range, 41.0%-54.0%). The relative renal function did not change >5% from the baseline value in any patient except one (in which the differential function increased paradoxically by 12%). Two patients developed renal scar in post-instillation renal scan. CONCLUSION: Endoscopic sclerotherapy in chyluria is safe and effective. The relative renal function does not deteriorate by more than 5%. There is a small risk of development of renal scar. More studies involving larger number of patients are needed to answer this dilemma.

Chyluria in pregnancy: Etiology, diagnosis, and management perspective.

Chyluria is clinically described as passage of milky urine. Chyle is absorbed by intestinal lacteals and is composed of emulsified fats, few proteins, and fibrin in varying proportions. Parasitic chyluria is caused mainly by Wuchereria bancrofti infection. The incidence of chyluria in pregnancy is not uncommon in endemic regions. The literature pertaining tomedical management of chyluria in pregnancy is scant. The antifilarial drugs have potential teratogenic risk and are not recommended in pregnant patients. Hence, there is a management dilemma for managing patients with chyluria during pregnancy. In this review, we have tried to highlight the evidence-based diagnosis and management of chyluria in pregnancy.

A Prospective Study to Evaluate Sexual Dysfunction and Enlargement of Seminal Vesicles in Sexually Active Men Treated for Benign Prostatic Hyperplasia by Alpha-blockers.

OBJECTIVE: To evaluate sexual dysfunction and enlargement of seminal vesicles in sexually active men who were treated by α1-blockers for benign prostatic hyperplasia and its possible clinical application. MATERIALS AND METHODS: This is a prospective cohort study from January 2015 to December 2016. We enrolled sexually active men above the age of 40 years having moderate to severe lower urinary tract symptoms (LUTS). We excluded patients with a history of prostate surgery, suspicious digital rectal examination findings, a serum prostate-specific antigen of >4 ng/dL, and a history of medication with anticholinergic, cholinergic, and diuretic agents. Patients were divided into groups A, B, and C based on the prescription of silodosin 8 mg, tamsulosin 0.4 mg, or alfuzosin 10 mg orally once for LUTS and at 4 and 12 weeks. RESULTS: The mean age was 54.8 years (41-68 years). Twelve weeks of treatment with silodosin, tamsulosin, and alfuzosin resulted in a significant improvement in the total International Prostate Symptom Score and the quality of life score (P <.001). The baseline erectile function scores were 26.4, 27.6, and 28.1, and the baseline overall satisfaction (OS) (International Index of Erectile Function [IIEF]-OS) scores were 7.1, 8.3, and 8.6 among groups A, B, and C, respectively. After 12 weeks of α1-blockers, the IIEF-erectile function scores were 24.0, 24.7, and 26.2, and the IIEF-OS scores were 6.4, 7.8, and 7.9. All 3 groups demonstrated a statistically significant enlargement of seminal vesicles after 12 weeks' treatment, most significant in group A patients (7.65-14.11 cc, P <.001). CONCLUSION: Alpha-blockers as silodosin, tamsulosin, and alfuzosin are a safe and effective tool in benign prostatic hyperplasia for improving LUTS and the quality of life. Loss of seminal emission with alpha-blockers appears as the cause of seminal vesicle enlargement. The exact mechanism of these findings needs further clinical and experimental research.

What is the fate of insignificant residual fragment following percutaneous nephrolithotomy in pediatric patients with anomalous kidney? A comparison with normal kidney.

Pediatric population has increasing incidence of renal calculus and it is estimated to be around 50/10,000 population. The treatment of choice for large and complex stone in anomalous kidney is percutaneous nephrolithotomy (PCNL). The fate of insignificant residual fragment after PCNL in pediatric patients is not well documented. Here, we are reporting our long-term experience and follow-up of insignificant residual fragment in pediatric patients with anomalous kidney in comparison to normal kidney. Intuitional ethical approval was taken. A retrospective analysis of PCNL in pediatric (<18 years) anomalous kidney was performed from 2001 to 2013. The data of 52 pediatric patients with anomalous kidney (group B) have been compared to 251 normal kidneys (group A). The mean age of the patients was 7.83 + 3.45 (range 3-18) in group A and 8.21 ± 3.25 (range 5-18) in group B. The mean size of the insignificant residual fragment was 2.2 + 0.5 mm (1-4) in group A and 2.1 + 0.6 mm (range 1-4) in group B. Most of these residual fragments were single in number (72.55 vs. 67.30%, respectively). 54.98% children in group A and 67.30% in group B were symptomatic in the follow-up. Stone size was increased, stable and spontaneously passed in 49.8 vs. 71.15, 22.7 vs. 19.23 and 27.49 vs. 9.61% (p < 0.03), respectively, over mean follow-up of 50.34 months. Insignificant residual fragments in children are notorious for regrowth (49.8% in normal and 71.15% in anomalous kidney) in future. Most of the children will require symptomatic treatment (55.37 vs. 82.69%) or reintervention (39 vs. 46%) for insignificant residual fragment.

Long-term outcome of laparoscopic vesicouterine fistula repair: Experience from a tertiary referral centre.

OBJECTIVE: Vesicouterine fistula (VUF) is an uncommon cause of female genito-urinary fistula. Most of these fistulas are due to lower segment uterine cesarean section (LSCS). Traditionally, open surgical repair has been the traditional treatment. However, laparoscopic repair of VUF is a minimally invasive technique and few case reports have been published with short term follow up. In the present study, we are presenting our long- term outcome of laparoscopic repair of VUF. MATERIAL AND METHODS: A retrospective analysis of 8 patients with VUF was performed from 2010 to 2015. Approval of Institutional Review Committee was obtained. All had history of LSCS of whom 3 had history of prolonged obstructed labor. Radiological imaging included ultrasound of kidney, ureter and bladder for all patients and hysterosalphingography in 4 patients and contrast enhanced computed tomography scan in 4 patients. RESULTS: Median age of the patient was 25.5 years (range, 22-32), and median follow up was 2.3 years (range, 1 -4). The most common presentation was cyclical menstrual bleeding through urine (menouria) in all, associated amenorrhea in 6 and vaginal leakage of urine in 2 cases. All patients underwent laparoscopic repair with successful outcomes. The mean operating time was 155±14.5 min (range, 135-186 min) with a median blood loss of 100 mL (range, 50-210 mL). Successful pregnancy was completed in 2 patients and other patients were taking contraceptives. CONCLUSION: Laparoscopic repair of VUF is a safe and effective minimally invasive technique with successful pregnancy in long- term follow up.

Outcome analysis of transrectal ultrasonography guided aspiration versus transurethral resection of prostatic abscess: 10 years' experience from a tertiary care hospital.

OBJECTIVE: To compare the effectiveness and safety of two minimally invasive methods (transrectal aspiration vs transurethral resection (TUR)/deroofing) of treating prostatic abscess. PATIENTS AND METHODS: A retrospective study was conducted, from 2007 to 2016, of patients with prostatic abscesses not responding to antibiotics and/or with large (>2 cm) or multiple abscesses. Patients were divided into two groups depending on treatment received: Group A, transrectal aspiration; and Group B, TUR/deroofing of abscess. RESULTS: The most common clinical presentation was dysuria (81.8%), followed by urinary frequency (68.2%), and fever (36.4%). Acute urinary retention occurred in seven patients. The most common infective organism in both groups was Escherichia coli (43.9%). The mean (SD, range) prostate volume was 36 (6.4, 17-68) mL and 37 (7.3, 21-72) mL in Groups A and B, respectively. The mean (SD, range) volume of the abscess was 51.24 (12.6, 21-215) mL and 48.34 (15.4, 15-240) mL in Groups A and B, respectively. Overall, 37 (84.1%) patients responded to treatment (68.4% in Group A and 96.0% in Group B, P < 0.23) after the first treatment session. Six patients in Group A and one patient in Group B had recurrence of abscess (P < 0.03). Of the six patients in Group A with recurrence, four patients had complete resolution after repeat aspiration (average 1-3 times). The mean (SD) follow-up duration was 17.25 (6.3) months. CONCLUSION: TUR of prostatic abscess is more effective (96%) than transrectal aspiration with a lesser hospital stay. However, transrectal aspiration was successful in 89% of cases, is less invasive and can be performed under local anaesthesia and or sedation.

Are there any factors affecting the outcome of endoscopic sclerotherapy in filarial chyluria? A prospective study.

INTRODUCTION: Filarial chyluria is a frequent problem in India. While endoscopic therapy is the mainstay of treatment, it is not always successful. We aimed to determine parameters that affect outcomes of endoscopic sclerotherapy for filarial chyluria (FC). METHODS: Prospectively maintained data of FC patients who received endoscopic sclerotherapy between June 2011 and March 2015 were analyzed. Sclerotherapy included either povidone-iodine (0.1%) or silver nitrate (1%). The parameters recorded included clinical evaluation, urinary triglyceride (TG)/cholesterol, sclerotherapy treatment, and follow-up. RESULTS: One hundred and fifty-seven patients (male: female, 104:53) with a mean age (± standard deviation [SD]) 41.12 ± 13.68 years underwent endoscopic sclerotherapy. Grade II (68.88%) chyluria was a most common presentation followed by Grade III (25.69%). One hundred and forty-four patients responded whereas six patients failed to respond; another seven were lost to follow up, and twenty patients had recurrence. Overall success rate was 86.11%. Baseline urinary TG (mean ± SD) between success and recurrence group was 195.51 ± 164.73 mg/dl and 652.65 ± 62.55 mg/dl and cholesterol (mean ± SD) was 16.99 ± 10.08 mg/dl and 89.07 ± 39.87 mg/dl, respectively. Patient with urinary TGs >300 mg/dl and urinary cholesterol >30 mg/dl had 3.2 and 1.3 times higher chance to have recurrence after endoscopic sclerotherapy, respectively. Choice of sclerosing agent (silver nitrate 1% versus povidone-iodine 0.1%) had no difference in success rate, but silver nitrate had slightly higher complications rate (25% vs. 20%). A higher number of instillations (>3) was associated with better success rate. Majority of the complications were either Clavien Grade 1 or 2. CONCLUSIONS: The factors predicting recurrence were higher clinical grade, higher number of pretreatment courses, and high urinary TG and cholesterol.

Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the literature.

OBJECTIVE: The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cosmetically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of performing laparoscopic ureteral reimplantation with Boari flap in 3 patients. MATERIAL AND METHODS: This prospective study was conducted between January 2011 December 2014. The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruction were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the manangement of long segment ureteral defect was evaluated. RESULTS: The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilateral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range 8.2-9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was 100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19 months (range 17-22 months). None of the patients experienced any complication related to the procedure in perioperative period. CONCLUSION: Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term results. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing.

Giant hydronephrosis: still a reality!

OBJECTIVE: Giant hydronephrosis (GH) is a rare entity in both developed and developing countries with less than 500 cases reported in the literature. Delayed diagnosis and management of GH, can result in long-term complications like hypertension, rupture of the kidney, renal failure and malignant change. We aim to highlight the importance of this often neglected entity and build a consensus for its early diagnosis and management. MATERIAL AND METHODS: Patients with GH were thoroughly worked up, managed and followed up between June 2013 and December 2015 and epidemiologic, radiological, perioperative and follow-up data was recorded. RESULTS: A total of 35 patients (adults and children) were reported. Flank pain in adults and abdominal lump in children were the most common clinical presentation. Percutaneous nephrostomy tube was placed in all patients and detailed work up was done to reach final diagnosis. Pelvi-ureteric junction obstruction (PUJO) was the final diagnosis in 32 patients (91.4%). Kidneys were non-functioning in 13 cases (37.1%) so nephrectomies were performed. Reduction pyeloplasty with nephropexy was done in 21 patients (60%) with 81% success and 23.1% complication rates. CONCLUSION: GH requires early diagnosis and management to prevent higher nephrectomy rate along with poor success rate of conservative surgery like pyeloplasty.

Nephrolithisis in a newborn: a rare case and review of literature.

Nephrolithiasis, although a common entity in adults, is less common in children and rare in newborns. The evaluation and management strategies of renal stones in neonates are unclear. We report a rare scenario of renal calculus in a newborn aged 3 days presenting with decreased urine output, fever and crying during micturition. Patient was thoroughly investigated and managed conservatively. Further follow-up showed increase in stone size with recurrent urinary tract infections, hence shock wave lithotripsy was performed to successfully break and clear the stone fragments. Patient recovered well and was doing fine until last follow-up.

Renal fistulae: different aetiologies, similar management.

Iatrogenic renocolic fistulae, although have been described in literature, is a rare clinical complication. Recently its incidence is on rise due to advent of minimally invasive surgery and percutaneous surgery of kidney. It has been reported after percutaneous nephrolithotomy but its incidence after percutaneous nephrostomy is quite uncommon and rarely reported. Though spontaneous renocutaneous fistula has been reported, acquired renocutaneous fistula is very uncommon and fistula after gun shot injury has not been reported to the best of our knowledge. Herein, we present two different varieties of renal fistula with completely different history and presentation. But the interesting point is that both were managed conservatively in a similar fashion and both of them responded well.

Outcome analysis of transurethral resection versus potassium titanyl phosphate-photo selective vaporization of the prostate for the treatment of benign prostatic hyperplasia; a randomized controlled trial with 4 years follow up.

OBJECTIVE: Photovaporization of prostate (PVP) is a newer surgical modality of benign prostatic hyperplasia (BPH) which is gaining importance recently. There are a few randomized controlled trials that showed safety and efficacy of PVP in comparison with transurethral resection of prostate (TURP) with limited follow-up period (<2 years). Here, we are presenting a comparative study performed on potassium titanyl phosphate (KTP) PVP laser versus TURP for the treatment of BPH with long-term follow-up period. MATERIAL AND METHODS: After institutional ethical clearance, 150 patients were prospectively included in the study from January 2010 to March, 2012. Improvement of International Prostate Symptoms Score (IPSS), Qmax, post-void residual (PVR) urine, International Index of Erectile Function (IIEF)-5 score and complications were assessed at 12, 24, 36 and 48 months. RESULTS: Mean age of the study group was 65.3±7.86 years in the TURP and 63.6±8.12 years in the PVP groups (p=0.45). IPSS symptom score improved significantly in both TURP and KTP groups (p<0.003). There was improvement in Q max during follow-up in both groups (p<0.001) which was maintained at 48 months. Most of the patients in both groups were satisfied with symptoms and bothersome at 48 months. All the sexual parameters are similar to both groups except retrograde ejaculation. Overall complication noted in 23 patients (15.33%). CONCLUSION: Both KTP Laser PVP and TURP afford durable relief from symptoms of BPH at 48 months follow-up. Both procedures are safe and associated with minimal complications. Both procedures do not have any detrimental effect on sexual function on long-term follow-up. Quality of life remains high even at 4 years in both groups.

Emphysematous pyelonephritis: Changing trend of clinical spectrum, pathogenesis, management and outcome.

OBJECTIVE: To highlight changing trend of clinical spectrum, comparing management options and predictors of outcome of emphysematous pyelonephritis. MATERIAL AND METHODS: This study included patients who were diagnosed as emphysematous pyelonephritis between August, 2001 to July, 2015. We excluded other possible causes of gas in renal system. Baseline patient characteristics, clinical spectrum, serum and urinary biochemical parameters, radiological findings, management and outcomes were recorded. Patients were classified as "responders" and "non-responders". RESULTS: We studied a total of 74 patients and categorised them as responders (62 patients) and non-responders (12 patients). Women outnumbered men constituting 62.16% of the study population (M: F; 1: 1.6). Fever was the most common presenting symptom followed by flank pain. Diabetes mellitus (85.14%) was the most common comorbidity followed by urolithiasis (32.43%). Escherichia coli was the commonest organism grown in urine culture (79.73%). Non-responders had distinct laboratory findings relative to responders as low hemoglobin (7.8±2.1/11.2±3.2 g/dL; p=0.0007), thrombocytopenia (91.67% vs. 11.29%; p=0.0001), proteinuria >3 g/L (50% vs. 6.45%; p=0.0008) and positive blood culture (100% vs. 67.74%; p=0.0288). CONCLUSION: Advanced age, higher body mass index, renal impairment, thrombocytopenia, altered sensorium, shock at presentation can be used as scores for poor prognosis. Emphysematous pyelonephritis management requires multidisciplinary collaboration including hydration and electrolyte management, broad spectrum antibiotics, strict glycaemic control, effective urinary drainage and lastly it may require emergency nephrectomy as a salvage procedure.

Large bladder calculus masking a stone in single-system ureterocele.

Ureterocele in an elderly is a rare entity. The presence of stone within ureterocele along with a large bladder calculus is an even rarer presentation. This phenomenon has not been reported so far to the best of our knowledge. We present an unusual case of a large bladder calculus with a concomitant stone in the associated ureterocele. The diagnosis was missed in the first instance due to the masking effect by the larger bladder calculus. Herein, we discuss this case and its management.

Transurethral resection of prostate in benign prostatic enlargement with underactive bladder: A retrospective outcome analysis.

PURPOSE: The purpose of this study was to evaluate the clinical outcome and efficacy of transurethral resection of the prostate in patients of benign prostatic enlargement (BPE) with underactive bladder. MATERIALS AND METHODS: Retrospective study of 174 patients, who underwent transurethral resection of prostate (TURP) between 2008 and 2015, for lower urinary tract symptoms with BPE with bladder underactivity. Clinical history, physical examination, renal function test, urinalysis, cystourethroscopy, transabdominal or transrectal ultrasonography, and urodynamic study were recorded. Patients having a history of neurologic conditions, spinal trauma or surgery, pelvic trauma or surgery, diabetes mellitus with end organ damage, urethral pathology or surgery, and prostatic cancer were excluded from the study. RESULTS: The mean follow-up period was 22.4 ± 6.2 months. Mean prostate volume was 42.8 ± 6.4 ml and mean serum prostate-specific antigen was 2.3 ± 1.8 ng/ml. The International Prostate Symptom Score changed from 24.6 ± 4.2 preoperatively to 10.8 ± 5.8 postoperatively which was found statistically significant. Quality of life (QOL) score changed from 4.8 ± 1.2 to 2.6 ± 0.4. Twenty-two patients out of 174 remained on a per-urethral catheter or clean intermittent catheterization due to voiding failure after TURP beyond 1 month. CONCLUSIONS: TURP should be considered a viable treatment option in men with enlarged prostate with underactive detrusor who had poor response to medical treatment. Preoperative counseling and postoperative follow-up are crucial in the management of such patients.

Percutaneous nephrolithotomy of bilateral staghorn renal calculi in pediatric patients: 12 years experience in a tertiary care centre.

To assess the outcomes of percutaneous nephrolithotomy (PCNL) in bilateral staghorn calculi in pediatric patients, we have performed a retrospective analysis. Staghorn calculus is defined as stone that fills a greater part of the pelvic-caliceal system. Still, in developing countries, patients may present with staghorn calculus. PCNL is the preferred treatment modality for staghorn calculus both in adult and children. Our study included fifty-one pediatric patients (<15 years) of bilateral staghorn calculi from 2004 to 2015. Staged PCNL was done after 2-3 days if needed and opposite side PCNL was performed after 10-14 days. Fifty-one patients with bilateral staghorn renal calculi underwent PCNL. The mean age of the study group was 10.25 ± 2.13 (range 3-15). Mean stone burden was 778.3 + 613.4 (range 231-3850 mm2). Forty-five patients underwent single puncture, twenty-two patients underwent double punctures whereas six patients underwent triple punctures during first session PCNL procedure. Most common puncture location was through the superior calyx (58.82 %). The mean operating time was 77.25 + 30.21 (range 58-145). After the first session PCNL, the success rate was 76.47 %. Thirteen patients (17 renal units) underwent relook PCNL and seven patients underwent ESWL. Overall complication noted in twenty-four (47.05 %) cases. Most of the complications were minor grade. Percutaneous nephrolithotomy for staghorn calculus in children needs expertise. PCNL in B/L staghorn renal calculus in children is safe and effective. B/L staghorn renal calculi with compromised renal function have higher chance of complications including bleeding.