Metabolic evaluation of first-time uncomplicated renal stone formers: A prospective study.

Background: Nephrolithiasis is a global health problem. The recurrence rate after the first stone clearance is approximately 50% at 5 years. Metabolic abnormalities are an important factor responsible for stone recurrence. Our prevalidated study aimed to evaluate metabolic abnormalities associated with first-time uncomplicated renal stone formers (FTURSF). Materials and methods: In this prospective, exploratory, time-bound, descriptive study, 30 first-time renal stone formers were evaluated for metabolic abnormalities. High-risk stone formers were excluded from the study. Data were collected in a predefined proforma, transferred to an Excel sheet, and analyzed using the Statistical Package for Social Sciences 20 and Epi Info 7. Fisher exact test, Mann-Whitney U test, paired t test, and Pearson correlation coefficient were used for statistical analyses. Results: The mean age of the participants was 35.57 ± 11.07 years, with a male-to-female ratio of 1.72. The most common abnormality was a 24-hour urine volume of <2.5 L in 73.33% of the participants. One or more metabolic abnormalities were detected in 76.67% of the participants. Other common metabolic abnormalities detected were hypocitraturia (60%), hypercalciuria (16.67%), hyperoxaluria (13.33%), and hyperuricosuria (3.33%). Parathyroid adenoma was detected in one participant (3.33%). Conclusions: Our study documented significant metabolic abnormalities in FTURSF. Therefore, a simplified metabolic evaluation protocol should be adopted while evaluating FTURSF. Detection of an underlying metabolic abnormality would enable the early institution of preventive measures to reduce stone recurrence and related complications.

Activated protein C modulates T-cell metabolism and epigenetic FOXP3 induction via α-ketoglutarate.

A direct regulation of adaptive immunity by the coagulation protease activated protein C (aPC) has recently been established. Preincubation of T cells with aPC for 1 hour before transplantation increases FOXP3+ regulatory T cells (Tregs) and reduces acute graft-versus-host disease (aGVHD) in mice, but the underlying mechanism remains unknown. Because cellular metabolism modulates epigenetic gene regulation and plasticity in T cells, we hypothesized that aPC promotes FOXP3+ expression by altering T-cell metabolism. To this end, T-cell differentiation was assessed in vitro using mixed lymphocyte reaction or plate-bound α-CD3/CD28 stimulation, and ex vivo using T cells isolated from mice with aGVHD without and with aPC preincubation, or analyses of mice with high plasma aPC levels. In stimulated CD4+CD25- cells, aPC induces FOXP3 expression while reducing expression of T helper type 1 cell markers. Increased FOXP3 expression is associated with altered epigenetic markers (reduced 5-methylcytosine and H3K27me3) and reduced Foxp3 promoter methylation and activity. These changes are linked to metabolic quiescence, decreased glucose and glutamine uptake, decreased mitochondrial metabolism (reduced tricarboxylic acid metabolites and mitochondrial membrane potential), and decreased intracellular glutamine and α-ketoglutarate levels. In mice with high aPC plasma levels, T-cell subpopulations in the thymus are not altered, reflecting normal T-cell development, whereas FOXP3 expression in splenic T cells is reduced. Glutamine and α-ketoglutarate substitution reverse aPC-mediated FOXP3+ induction and abolish aPC-mediated suppression of allogeneic T-cell stimulation. These findings show that aPC modulates cellular metabolism in T cells, reducing glutamine and α-ketoglutarate levels, which results in altered epigenetic markers, Foxp3 promoter demethylation and induction of FOXP3 expression, thus favoring a Treg-like phenotype.

Persistent Urogenital Sinus with Ambiguous Genitalia and Urethral Duplication in a Pubertal Female.

Urogenital sinus (UGS) and cloacal malformations are the spectra of disease affecting mainly females, resulting in an unusual confluence of the genital and urinary tract with or without the involvement of the gastrointestinal tract. Successful reconstruction of these anomalies depends on the accurate preoperative delineation of abnormal anatomy with the help of cross-sectional and other contrast studies like genitourogram along with cystourethroscopy wherever indicated. We hereby report a case of a 14-year-old female who presented with irregular cyclical hematuria and was diagnosed with persistent UGS with urethral duplication. After a thorough evaluation, the patient was successfully managed with surgical reconstruction, described in this study. Persistent UGS is a complex developmental anomaly. Complete characterization of anomaly requires a thorough evaluation such as hormonal assessment, endoscopy, cross-sectional, and radiological contrast study. Surgical reconstruction needs individualization and may need clitoroplasty, labioplasty, and urethral and vaginal mobilization. Morphological and functional outcome is satisfactory in a well-planned surgical reconstruction.

Penile Fracture with Urethral Rupture: The Feasibility of Repair through Penoscrotal Approach.

Penile fracture with an associated urethral injury is a rare urological emergency resulting from trauma to the erect penis during vigorous sexual intercourse. The patient often presents with swelling of the penis, discoloration of the penile skin, localized pain, and hematuria with a typical history of sudden detumescence during intercourse. Subcoronal penile degloving incision has been conventionally described and is frequently used by many clinicians for the management of penile fracture-urethral injury. Here, we describe a case of complex penile fracture managed through the vertical penoscrotal incision. The penoscrotal approach confers excellent exposure to both the ruptured corpus cavernosum and urethra. This approach ensures successful outcomes in such an emergency procedure without having disadvantages of the degloving incision.

When to Avoid a Restaging Procedure for Non-muscle Invasive Bladder Cancer? Inferences from a Tertiary Care Center.

The increasing incidence of urinary bladder carcinoma is alarming. Approximately seventy percent of these patients are non-muscle invasive bladder cancer (NMIBC). Restage transurethral resection of bladder tumor (TURBT) is the current recommendation for any T1 and or high-grade non muscle invasive bladder cancers (NMIBC) to accurately stage the malignancy. The question whether a second surgery is always required as a restage procedure is still unanswered. The patient's concern about completeness, morbidity, and financial considerations of a major surgery cannot be overlooked. Moreover, it also puts a strain on the already overburdened healthcare system. To answer this question, whether it is oncologically sound to omit a second resection, the current study evaluated the outcomes of patients undergoing restage TURBT, and analyzed the preoperative factors predicting a change in the staging of this malignancy. The study design was a prospective observational including NMIBC patients from September 2018 to February 2020. A total of 72 patients underwent restage TURBT. Their demographic data, imaging and cystoscopic findings, and histopathological data were recorded. The objective was to study the clinico-pathological correlations and factors predicting recurrence and upstaging of tumor in NMIBC patients undergoing restage TURBT. A total of 101 patients were found eligible for restage TURBT. Eventually, 72 underwent restage TURBT. Twelve (16.7%) patient had recurrence at restage while 3(4.16%) were upstaged to T2. Presence of lower urinary tract symptoms (LUTS) was independently associated with the risk of recurrence of same stage compared to no recurrence (p-0.025, OR-8.793, 95% CI-1.316-98.773). Chemical exposure (p-0.042) was also significantly associated with the same. Presence of lymphadenopathy on CT was independently associated with the risk of upstaging compared to no recurrence (p-0.032, OR-18.25, 95% CI-1.292-257.85). The study concluded that in the presence of a well-performed and adequate initial TURBT, restage TURBT could be skipped for further management. However, in small subgroup of patients with lymphadenopathy on preoperative imaging having a higher risk of tumor recurrence and upstaging, and patients with a history of chemical exposure and previous lower urinary tract symptoms having a high risk of recurrence alone, restage TURBT should still be performed to accurately stage the disease. Further studies with large patient cohort are needed to confirm and reinforce the facts proposed. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01516-8.

Papillary Renal Cell Carcinoma with Sarcomatoid Differentiation in a Native Kidney of Transplant Recipient: A Case Report and Review of Literature.

Renal cell carcinoma (RCC) developing in a transplant recipient is about 5-20 times higher than the general population. It is more common in native kidneys than graft kidney, and incidence varies between 0.3% and 4.8%. Clear cell and papillary types are more frequently reported. Most RCC of allograft recipient is usually low-grade with favorable prognosis. We present a case of papillary RCC with sarcomatoid differentiation (SD) in a native kidney of renal transplant (RT) recipient. The coexistence of sarcomatoid variant with papillary RCC, as in our case, makes it a high grade (WHO/ISUP grade 4) and portends a poor prognosis. Relative aggressiveness and rarity of this variant histology in transplant recipients prompted us to report this case and carry out an extensive search of the available literature.

Emphysematous cystitis: A case report and literature review of 113 cases.

Emphysematous cystitis (EC) is a rare complicated urinary tract infection characterized by gas formation within the wall of the urinary bladder. Although EC has multifactorial etiology, commonly seen in elderly, diabetic and female sex; most of the cases of EC present along with emphysematous pyelonephritis (EPN) and full-blown urosepsis. We present a case of EC with EPN presented with features of sepsis managed conservatively. Furthermore, we reviewed the literature of published cases reports of EC with or without EPN from 1999 to 2019 (20 Years). From eligible 113 case reports, data of clinical presentation, demographic profile, risk factors, diagnostic methods, treatment, and prognosis were analyzed.

Robot-Assisted Laparoscopic Approach in a Patient of Zinner Syndrome with Hematuria: A Rare Presentation.

Congenital malformations of the seminal vesicles (SVs) are rare and are often associated with abnormalities of the ipsilateral upper tracts as embryologically both the ureteral buds and SVs arise from the mesonephric ducts. The triad of SV cysts, ipsilateral renal agenesis, and ejaculatory duct obstruction is known as the Zinner syndrome. We herein present the case of Zinner syndrome with hematuria as the mode of presentation. A 52-year-old gentleman presented with complaints of gross and painless hematuria for 3 months. An initial ultrasound revealed absent right kidney with a cystic structure abutting the urinary bladder. Cystoscopic examination revealed a high bladder neck. Magnetic resonance imaging of the abdomen revealed an absent right kidney and a large tubular structure in the region of the right ureter extending up to right SV with blood content and stones within. It was distally seen communicating with one of the cysts of the right SV. The cystic structure was removed with a robot-assisted laparoscopic approach. The console time was 110 min with minimal blood loss. Postoperative course was uneventful. Histopathology of the cyst wall revealed chronic inflammation. The patient is doing well on 6 months follow-up. This case was unique in terms of it presenting with a large intra-abdominal cyst with sharp stones within, probably first of its kind to be ever reported. Surgery is mandated for such symptomatic cysts and the daVinci robot with its minimally invasive approach offers the perfect platform for treating such challenging cases.

Modified "parachute technique" of partial penectomy: A penile preservation surgery for carcinoma penis.

Carcinoma penis is a rare malignancy which mostly occurs after the sixth decade of life. It is managed surgically and partial penectomy is the most common procedure done in carcinoma involving the distal penis. Partial penectomy provides the opportunity of preservation of sexual function and enables the patient to micturate in standing position. The conventional technique of neourethra creation in partial penectomy is slitting the urethra dorsally. We propose an alternative approach to neourethra formation. Technique involves ventral slitting of the urethra followed by suturing which begins at the ventral aspect and continued in a parachute fashion toward the dorsal end. This new technique will help primary physicians and surgeons in providing better surgical results in caring for patients with carcinoma penis.

Ganglioneuroma presenting as an adrenal incidentaloma: Feasibility of adrenal-sparing surgery.

Adrenal ganglioneuromas (GNs) are very rare tumours that originate from neural crest cells. Most of the time, they are diagnosed incidentally as they are usually non-functional and remain asymptomatic. Nowadays, they are being detected more often due to better availability of imaging facilities such as computed tomography (CT)/magnetic resonance imaging (MRI). Minimally invasive adrenalectomy (laparoscopic or robotic) remains the standard of care for such lesions. Hereby, we report a case of a 15-year-old young girl with right adrenal incidentaloma which was diagnosed on CT with the features suggestive of GN. She underwent robot-assisted excision of the mass with adrenal-sparing surgery. Histopathology revealed benign GN and no adjuvant treatment was required. As GN is not known for recurrence or metastasis, minimal invasive adrenal-sparing surgery should be a preferred modality of choice.

Robot-assisted laparoscopic pyeloplasty: A retrospective case series review.

INTRODUCTION: Anderson-Hynes pyeloplasty has been gold standard in the management of pelviureteric junction obstruction (PUJO). It has evolved from open to laparoscopic and now robotic surgery. Open surgery has its drawback of long incision and scar mark, significant post-operative pain and long hospital stay. The main limitation of laparoscopic surgery had been the difficulty in endosuturing. Robotic surgery has incorporated the minimal access method of laparoscopy and endowrist movement of open surgery to overcome the challenge of intracorporeal suturing. Here, we present our initial experience of robotic pyeloplasty. PATIENTS AND METHODS: A total of 30 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) over 19 months. Diagnosis of PUJO was made by computed tomography urography, diuretic renogram and retrograde pyelogram in selected patients. All patients underwent RALP by colon reflecting approach. Post-operative evaluation was done by DTPA scan at 3- and 6-month follow-up. Data were analysed after a mean follow-up of 11 months. RESULTS: The mean operative time was 148 min and the mean hospital stay was 3.5 days. While 93% of the patients showed objective improvement in their drainage pattern on DTPA renogram, 90% of the patients were symptom-free at the end of 6 months. CONCLUSIONS: Robotic pyeloplasty is a safe and easily conquerable technique with comparable outcomes in the hands of surgeons who are beginners in this technique.

Technical modifications in dorsal onlay female urethroplasty: Time to make way for amendments.

OBJECTIVE: Surgical treatment for female urethral stricture is varied and lacks consensus. Dorsal and ventral approaches of urethroplasty have comparable success rate with debatable limitations. We describe modifications in dorsal onlay graft urethroplasty to mitigate the surgical limitations and improve functional outcomes. MATERIAL AND METHODS: We retrospectively analyzed 8 patients with strictures treated with dorsal onlay urethroplasty at our center. The inclusion criteria were American Urology Association (AUA) score >20, calibration <14 Fr, positive voiding cystourethrogram, urodynamics with maximum urine flow rate (Qmax) <12 mL/s, detrusor pressure at maximum flow >24 cmH2O, and urethroscopic visualization of the stricture. Surgical modifications included dorsal plane dissection away from the clitoris; limited lateral urethral dissection; omitting graft quilting onto the clitoris, and urethral slitting directly at the stricture site (for mid and proximal strictures), sparing the meatus and using canoe-shaped grafts for distal strictures. Success was defined as improvement in the AUA scores and Qmax >12 mL/s, without requiring any further intervention. RESULTS: The mean age was 50.5±10.6 years. Statistically significant improvements in mean AUA score [14.5±2.20 (p=0.012)], Qmax [23.63±2.44 (p=0.012)], post-void residual urine [107.88±40.37 (p=0.012)], and sexual function scores [6.833±2.23 (p=0.027)] were noted at a mean follow-up of 3 months. Distal strictures were more common. Mean urethral caliber was 9.62 Fr. No cases of de novo incontinence or sexual dissatisfaction were reported. CONCLUSION: In our experience, the dorsal onlay technique works well, but without a comparative evidence for ventral onlay, it is difficult to conclude that one is preferred over the other.

A study of morbidity profile among geriatric population in Uttarakhand: A community based cross-sectional study.

CONTEXT: Population of elderly in India is growing day by day. Elderly population of India is 8.6% and in Uttarakhand it is 8.9%. Health needs of geriatric people differs from others. This study was an attempt to study the morbidity profile of geriatric people that may serve as a baseline data and also help in planning the health services. AIMS: To study Morbidity profile of geriatric population in Uttarakhand. SETTINGS AND DESIGN: A community-based cross-sectional study was conducted among geriatric people in rural and urban areas of Uttarakhand. Study participants aged 60 years and above were included in the study and a sample size of 400 was calculated. METHODS AND MATERIALS: Predesigned, pretested and semistructured questionnaire was used to collect information on sociodemographic characteristics and morbidity status of study participants. STATISTICAL ANALYSIS USED: Data was entered into excel sheets and analyzed using SPSS version 23 utilizing appropriate statistical methods. RESULTS: Among 400 elderly people most common organ system affected was musculoskeletal (77.20%). Other commonly affected health systems were psychological (75.90%), digestive (73.60%), eye (56.67%), endocrine (35.90%), cardiovascular (33.08%), general and unspecified health problems (32.05%), ear (24.62%) and respiratory system (19.74%). Very few elderlies had neurological (6.67%) and urological (1.28%) problems. CONCLUSIONS: As shown in the present study very high percentage of morbidities were found in the study population. As a result, there is a need to further strengthen existing geriatric health care services at primary, secondary and tertiary level.

Epistaxis presenting as sentinel feature of metastatic renal cell carcinoma: A case report and review of literature.

About 30% of all newly diagnosed renal cell carcinoma (RCC) patients present with synchronous metastatic disease. Usual organs of involvement are lung (75%), soft tissues (36%), bone (20%), liver (18%), cutaneous sites (8%), and central nervous system (8%). Metastases to the paranasal sinuses (PNS) are relatively common and may be a part of synchronous multiorgan involvement or present in follow-up after radical nephrectomy (metachronous); but primary presentation as isolated paranasal mass before the diagnosis of RCC is extremely rare. Here, we report a case of 74-year-old female presented with epistaxis and nasal obstruction. On evaluation by magnetic resonance imaging (MRI), a heterogeneously enhancing mass was found involving left PNS. Biopsy from mass revealed clear cell RCC. Later on, contrast-enhanced computed tomography (CECT) of chest, abdomen, and pelvis showed enhancing mass from the upper pole of the left kidney with no evidence of metastasis elsewhere. The patient was started on pazopanib 800 mg once a day. At 6 months follow-up scan, there was a partial response at both primary as well as metastatic site.

Surgical Management of Genitourinary Tuberculosis: our Experience and review of literature.

<b>Background:</b> Genitourinary tuberculosis is one of the most common forms of extra-pulmonary tuberculosis. Owing to a myriad of clinical presentations and discrepancies in the diagnostic modalities, patients usually present late, which results in a high number of them requiring surgical intervention. The present study aims to retrospectively analyze the role of surgery in genitourinary tuberculosis. <br><b>Patients and method:</b> All patients diagnosed with genitourinary tuberculosis at our centre between October 2017 and September 2019 were included in the study. The mode of presentation, duration of symptoms, investigations performed, treatment received, and follow-up were studied. <br><b>Results:</b> Out of 25 patients diagnosed with genitourinary tuberculosis (GUTB), there were 15 (60%) males and 10 (40%) females. The mean age of presentation was 40.84 years. Nineteen (76%) patients underwent surgical intervention, and many patients required more than one surgical procedure. A reconstructive procedure was carried out in seven patients. At a median follow-up of 12 months, all patients did well, showing no relapse. <br><b>Conclusion:</b> Surgery, along with antitubercular treatment, is the key to the management of GUTB presenting with structural damage. However, surgery can be ablative or reconstructive, depending on various factors discussed in the present study. This preserves or restores the optimal function of the genitourinary system affected by the mycobacterium bacilli.

Robot-Assisted Nephron-Sparing Surgery of Renal Hydatid in Pregnancy: A Predicament in Management.

Background: Hydatid disease is a parasitic zoonosis caused by Echinococcus granulosus. Dog and other carnivores are the definitive hosts, which harbor adult worm. Humans are the accidental and dead-end hosts that acquire the infection by ingestion of eggs released from the intestinal tract of these carnivores, mainly dogs. The primary organ of echinococcosis in humans is the liver and lung, while the kidney is the third most commonly involved organ. Occurrence of hydatid disease of kidneys in isolation or with multiple organ involvement and their management has been reported and well described. The concurrent hydatidosis and pregnancy are an unusual clinical condition and poses a clinical challenge. Case Details: In this study, we present a case of 36-year-old woman with symptomatic hydatid disease of the right kidney during the first trimester of pregnancy. A multidisciplinary team discusses the pros and cons of hydatid during pregnancy with the patient. After taking informed consent from the patient, she was effectively managed by medical termination of pregnancy followed by robot-assisted laparoscopic pericystectomy. Conclusion: The co-occurrence of symptomatic renal hydatid and pregnancy is quite unusual. Medical or surgical management of hydatid during pregnancy can have some detrimental effect on the fetus. Hence these patients could be managed with medical termination of pregnancy followed by robot-assisted nephron-sparing surgery. Robot-assisted surgery for the renal hydatids is safe and effective, and has a shorter learning curve.