Paraurethral Leiomyoma: A Rare Entity Requiring Extensive Preoperative Counseling and Prompt Management.

Paraurethral leiomyoma is an exceptionally rare benign smooth muscle tumor adjacent to the female urethra, presenting diagnostic challenges due to nonspecific symptoms like urinary obstruction and dysuria. This case report details the clinical presentation, diagnostic workup, and surgical management of a 45-year-old woman with a paraurethral leiomyoma. Diagnosis involved clinical examination, imaging, and biopsy. The mass was excised via a perineal route without urethral injury, confirmed by histopathology. The patient recovered well, voiding without difficulty postoperatively. This case emphasizes the importance of thorough preoperative counseling, advanced imaging, and multidisciplinary collaboration in managing paraurethral leiomyomas.

Management of vaginoplasty canal complications.

PURPOSE OF REVIEW: Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques. RECENT FINDINGS: Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options. SUMMARY: Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.

Isolated Testicular Tuberculosis Disguised As a Testicular Tumor: A Report of a Rare Case.

Isolated testicular tuberculosis is rare, often diagnosed incidentally during histopathological examination due to its asymptomatic nature. We present a case of a 35-year-old male with a left testicular mass mimicking malignancy. Despite normal tumor markers and negative imaging for pulmonary tuberculosis, left inguinal orchiectomy revealed testicular tuberculosis. Diagnostic challenges are compounded by the disease's rarity and atypical presentation. Genitourinary tuberculosis's diagnostic complexity underscores the need for heightened clinical suspicion, particularly in tuberculosis-endemic regions. While orchiectomy may be necessary, this case underscores the importance of considering tuberculosis in testicular masses. Early recognition facilitates appropriate management and underscores the importance of diagnostic vigilance.

Zero Ischemia Open Partial Nephrectomy in Crossed Fused Ectopic Kidney - A Rare but Real Challenge.

Crossed fused renal ectopia (CFRE) is a rare congenital anomaly with both kidneys located on the same side of the retroperitoneal space. Due to complex anatomy, any renal tumours arising from this congenital anomaly will require careful pre-operative planning and intra-operating management to ensure oncological clearance while maximizing renal function. In this clinical case, a 57-year-old lady was referred to our center with a left to right CFRE and a 10cmx8cmx8cm mass arising from the interpolar region of left ectopic kidney on a background of multiple medical co-morbidities including stage 3a chronic kidney disease (CKD). Careful pre-operative planning and optimization was done, including 3D reconstruction of CT images, and the decision was made to perform a zero ischemia open partial nephrectomy to give her kidneys the best fighting chance. She recovered well postoperatively with only a mild increase in creatinine and histopathology revealing a renal cell carcinoma. The case emphasizes the need for adequate pre-operative planning with the use of upcoming imaging modalities like 3D reconstruction for optimum planning to ensure the best postoperative outcomes.

Double-face urethroplasty in patients with obliterative bulbar strictures post-transurethral resection of the prostate mid-term outcomes in high-volume referral center.

Objective: Incidences of post-transurethral resection of the prostate (post-TURP) strictures are between 2.2% and 9.8%. Stricture commonly occurs within the first 6 months. Our objective was to assess the outcomes of patients with obliterative strictures post-TURP that underwent a double-face urethroplasty. Methods: This is a single-center prospective study of 17 patients with obliterative proximal bulbar stricture post-TURP who underwent double-face graft urethroplasty by two surgeons between January 2014 and January 2020. We defined post-TURP obliterative strictures as those patients who presented with complete or almost complete obstruction of the urethral lumen and who have had a history of acute urine retention. We have excluded patients with bladder neck contracture. Primary outcome was treatment success, defined as the no need for further treatments. Secondary outcome was post-urethroplasty continent rate. Results: Seventeen patients were included in the study with median age of 66 (interquartile range 40-77) years; median time of follow-up was 24 (interquartile range 12-84) months; median stricture length was 4 (interquartile range 2-6) cm. Of the 17 patients, 15 (88.2%) were successful. All patients were continent after urethroplasty. Conclusion: With mid-term follow-up, treatment of obliterative proximal bulbar strictures with double-face buccal mucosa graft is a safe and effective procedure. Obliterative proximal bulbar strictures merit double-face urethroplasty with high-rate success and functional outcomes.

Influence of tumor size in the progression of venous tumor thrombus in renal cell carcinoma: A 7-year single-center experience.

Objective: The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus. Patients and Methods: We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed. Results: Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (P = 0.998) in level 1,2,3, and 4 tumors, respectively. Clear cell variant was seen in 32 patients (82%) with R0 resection in 17 patients. Twelve patients (30.7%) had systemic metastasis on presentation. The overall mean survival time was 66.4 months with 95% confidence interval (CI) (52.4-80.5 months). Mean recurrence-free survival is 76 months with (63-90) CI of 95%. Mean survival in patients who presented with metastasis is 47 months with 95% CI (52.4-80.5). Perioperative mortality rate was 5.12% in this study. Conclusion: The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

Which Are the Commonest Sites and Characteristics of Post-Transurethral Prostate Surgery Strictures in a High-Volume Reconstructive Center?

Background: Urethral stricture is a well-known complication after transurethral prostate surgery (TPS) and it is usually considered an easy-to-treat condition. We aimed to examine characteristics of post-TPS urethral stricture cases that were referred for urethroplasty at our tertiary center. Methods: We identified 201 patients with TPS-induced stricture treated with urethroplasty at our institution from 2017 to 2021. First, stricture length and location were evaluated during preoperative assessment. Second, multiple sets of multivariable logistic regression (MLR) analyses were run to assess whether clinical variables were associated with the location of the stricture. Results: Median stricture length was 5 cm (4-7). One hundred forty-one (70.1%) patients received previous no-invasive treatments (dilatation and/or direct visual internal urethrotomy). Proximal bulbar urethra was the commonest site for stricture, whereas panurethral stricture (≥10 cm) was diagnosed in 41 (20.4%) patients. Lichen sclerosus was more common in patients with penile stricture location, compared with patients with other involved segments (26% vs 19%, p = 0.03), and it was the only predictor of penile and midbulbar urethra location at MLR. Surgical approaches were augmented urethroplasty in 94% of patients, especially for patients with previous treatment including urethroplasty (95.8% vs 82.5% for naive, p = 0.004). Dorsal onlay was the preferred approach for bulbar (53.4%) and penile urethra (90.7%), whereas ventral onlay (38.2%) and double face augmentation (20.6%) were the preferred approaches in membranous strictures. Conclusions: Most patients who were referred for TPS-induced stricture attempted previous noninvasive managements. Referred TPS-induced urethral strictures were long and frequently involving multiple segments of urethra. Augmentation urethroplasty was our preferred surgical approach because of the characteristics and complexity of these strictures. The presence of lichen may increase the risk of post-TPS stricture in a specific segment of urethra, namely the penile and midbulbar urethra.

Dorsal approach for double-face bulbar urethroplasty: ventral inlay plus dorsal onlay using Kulkarni one-side dissection.

BACKGROUND: Non-traumatic obliterative bulbar urethral stricture with residual urethral lumen below 3 Fr is a challenging surgical scenario for reconstructive surgeons, because either anastomotic or single augmentation urethroplasty is not an option. OBJECTIVES: To describe our double-face buccal mucosa graft (BMG) urethroplasty with dorsal onlay and ventral inlay relying on the vessels and nerve-sparing technique of Kulkarni's one-side dissection. METHODS: We retrospectively reviewed a prospectively maintained database of patients with non-traumatic obliterative bulbar urethral strictures who underwent double-face bulbar urethroplasty with one-side dissection and dorsal onlay plus ventral inlay BMG. Patient demographics, clinical data, and follow-up were analyzed. RESULTS: A total of 59 patients underwent double-face urethroplasty with dorsal approach. The median age was 37 years (IQR 27-49) and the median stricture length was 5 cm (IQR 3.75-6). No patients had immediate post-operative complications. The overall success rate was 88% with a median follow-up of 30.9 months (IQR 16.9-44.2). Two patients were treated with DVIU, and two patients with open urethral surgery. One patient developed erectile dysfunction after surgery. Age, etiology, stenosis length and previous treatment were not factors related to surgical failure. CONCLUSION: Our preliminary albeit encouraging results showed that this approach was feasible in all patients and with negligible perioperative complications. Success rate was 88%. We did not find any factors related to surgical failure. Our dorsal double-face augmented urethroplasty may be a valid alternative to the Palminteri's ventral double-face urethroplasty, especially in those patients with mid-distal bulbar or peno-bulbar urethral strictures.

Graft Plus Fasciocutaneous Penile Flap for Nearly or Completely Obliterated Long Bulbar and Penobulbar Strictures.

BACKGROUND: Graft plus flap urethroplasty is gaining momentum in patients with nearly or completely obliterated urethral strictures, in whom staged procedures or perineal urethrostomy is the only possible alternative. However, graft plus flap urethroplasty is mainly adopted for strictures involving the penile urethra. OBJECTIVE: To report our experience on graft plus flap urethroplasty for bulbar and penobulbar reconstruction. DESIGN SETTING AND PARTICIPANTS: Between January 2014 and June 2020, patients with nearly or completely obliterated long (>4 cm) bulbar or penobulbar strictures, who required graft plus flap urethroplasty, were considered for this study. SURGICAL PROCEDURE: The bulbar and the penile urethra were accessed through a perineal incision and penile invagination when required. Grafts were harvested from cheek, lingual, or preputial skin and quilted over the corpora to reconstruct the dorsal plate of the neourethra. The fasciocutaneous penile flap recreated the ventral plate of the neourethra. The corpus spongiosum was flapped over the neourethra to prevent the formation of diverticula. MEASUREMENTS: Any need for instrumentation after surgery was defined as the primary failure. Obstructive symptoms or maximum flow rate (Qmax) below 10 ml/s, with or without a need for instrumentation, was defined as a secondary failure. RESULTS AND LIMITATIONS: We identified 15 patients who met the inclusion criteria. The median stricture length was 7 cm (interquartile range [IQR] 5-8 cm). The inner cheek was the preferred site for graft harvesting (53.3%). No perioperative complication of Clavien-Dindo grade ≥III were recorded in the first 30 postoperative days. The median Qmax at catheter removal was 23 ml/min (IQR 21.5-26 ml/min). The median follow-up was 25 mo (IQR 10-30 mo). The primary success rate was 86.7% (13/15) and the secondary success rate was 73.3% (11/15). Post-traumatic strictures represent a contraindication for this technique. CONCLUSIONS: In referral centers, graft plus flap urethroplasty represents a feasible option for patients with nearly or completely obliterated long (>4 cm) strictures. Our study demonstrated that this option is also feasible for strictures involving mainly the bulbar urethra. PATIENT SUMMARY: Perineal urethrostomy should be considered as the last option in patients with a nearly or completely obliterated bulbar urethral stricture. Nowadays, graft plus fasciocutaneous penile flap augmentation enriched our armamentarium of bulbar urethra reconstruction.

A Prospective Study on the Efficacy of Cognitive Targeted Transrectal Ultrasound Prostate Biopsy in Diagnosing Clinically Significant Prostate Cancer.

PURPOSE: We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men. MATERIALS AND METHODS: This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason's grades was analyzed. RESULTS: Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5-20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P<0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-<0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients. CONCLUSION: In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.

Day-case robot-assisted laparoscopic surgery: Feasibility and safety.

OBJECTIVE: The delivery of surgical services has undergone a shift in the past decade with increasing numbers of surgeries being performed in the daycare setting. Implementing a minimally invasive surgical approach with a robot with an enhanced recovery protocol permits robot-assisted laparoscopic surgeries (RALS) to be performed as a day-case (DC) procedure. This study aimed to assess the feasibility and safety of DC surgery according to our experience. MATERIAL AND METHODS: In this prospective observational study, 43 patients underwent DC RALS performed by a single surgeon over 18 months [simple nephrectomy (n=7), radical nephrectomy (n=15), radical nephrectomy with para-aortic lymphadenectomy (n=5), and adrenalectomy (n=5)]. In addition, reconstructive urological procedures that included pyeloplasty (n=9), ureteroureterostomy (n=1), and bladder diverticulectomy with ureteric re-implantation (n=1) were performed as DC surgeries during this study period. RALS was performed in the standard way with an enhanced recovery pathway of care for DC. We collected data regarding the demographic information, medical comorbidities, preoperative outcomes, intraoperative outcomes, complications, length of stay, and readmission rates. The data were analyzed and evaluated. RESULTS: All the patients (100%) were successfully discharged on the same day with no major complications (Clavien-Dindo grade>I). The readmission rates were 0%. CONCLUSION: DC RALS are safe and feasible with an enhanced recovery protocol. With adequate protocols in place, these surgeries might prove to be better than the available minimally invasive techniques and can become the standard of care in the future.

In situ Management of Large Upper Ureteric Calculus by Mini-Percutaneous Nephrolithotomy in the Era of Retrograde Intrarenal Surgery.

PURPOSE: The aim of the study is to demonstrate the ease and success of in situ management of large upper ureteric stones with mini percutaneous nephrolithotomy (PCNL). METHODS: This was a prospective observational study conducted in the Department of Urology between January 2018 and June 2019. All patients underwent standard prone mini PCNL with 15Fr amplatz with 80 cases of fluoroscopic and 12 cases of ultrasound guided access. In three cases of tortuous ureters, wire was passed via retrograde catheter and retrieved via amplatz to straighten the ureter. Calculi fragmented with laser. RESULTS: A total of 77 patients were included in this study, 62 unilateral and 15 bilateral cases (92 renal units). The mean age was 45.4±13.7 years (range 17-71), male to female ratio was 61:16, the disease laterality (left: right) was 28:34. The mean stone size was 17.6±1.4 mm. Mean operative time was 22.4±1.5 min. 88% patients were discharged as day care. Complication rate was 6.5%, three patients had transient fever and two patients had distal migration of small fragments and they were extracted at the time of DJ stent removal by rigid ureteroscopy (100%). CONCLUSION: We conclude that it is easy and effective to deal with large upper ureteric calculus when it is in a fixed position. In situ management of large upper ureteric calculus by mini-PCNL can be done safely and effectively as it is a fast procedure, prevents unnecessary manoeuvres, less complication rates and has good stone clearance rates.

Laparoscopic Management of a Misplaced Ureteral Stent in the Duodenum.

Background: Double-J stents (DJSs) are placed in the ureter to maintain urine flow from the kidney to the bladder. Extraurinary tract displacement of the stents is very rare, those observed in the literature are vascular displacement into inferior vena cava, into rectum after anticancer treatment of the cervix and a forgotten stent into third part of duodenum. We present a unique case of displaced DJS into the second part of the duodenum and its management laparoscopically. Case Presentation: A 59-year-old diabetic man on evaluation for right flank pain and intermittent episodes of fever with chills and rigors for 4 months was identified elsewhere on CT of kidney, ureter, and bladder (KUB) to have a retroperitoneal mass engulfing the right ureter with a small contracted kidney with mild hydronephrosis for which CT-guided retroperitoneal mass biopsy (reported as acute suppurative inflammation) and subsequent right Double-J stenting were done. He was lost to follow-up and presented to us 3 months later with similar complaints. On evaluation, CT of KUB with contrast revealed a shrunken, hydronephrotic, and poorly excreting right kidney but no mass. The right DJS was seen in the upper ureter and its proximal tip was seen to perforate the anterior wall of the right ureter, and it lay within the second part of the duodenum. The distal tip was seen in the bladder. Laparoscopic right nephrectomy was done with duodenal rent closure. During DJS retrieval, unfortunately, the smaller proximal end of the DJS slipped completely into the duodenum, but fortunately was expelled spontaneously by the patient (confirmed on postoperative day 10 with X-ray). Conclusion: It is ideal to place a DJS under fluoroscopic guidance or obtain a check X-ray to confirm its position postprocedure. Patients should always be counseled on the importance of follow-up and the complications of forgotten stents.

Robotic Management of Pelvic Lipomatosis-Experience with Difficulties Encountered and the Techniques to Successful Outcomes.

BACKGROUND: Pelvic lipomatosis (PL) is a rare condition characterized by diffuse pelvic overgrowth of nonmalignant but infiltrative adipose tissue in perivesical and perirectal space. OBJECTIVE: To share our robotic experience and difficulties encountered and suggested techniques to overcome them successfully. It is the first series from India. DESIGN SETTING AND PARTICIPANTS: A prospective observational study was conducted. All consecutive patients diagnosed with PL between 2016 and 2019 underwent robotic-assisted wide bladder fat extirpation and bilateral ureteral reimplantation (extravesical refluxing type) with double J stenting and were evaluated prospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographics, serum creatinine level, radiographic features, postoperative complications, and patient-reported outcomes were evaluated. Continuous variables are presented as median and range, as the sample size is very small. RESULTS AND LIMITATIONS: We encountered a total of five patients with PL. The median console time was 126 (range 120-130) min, with a median estimated blood loss of 120 (range 100-150) ml. Postoperative complications were Clavien-Dindo grade I in three cases, and the median hospital stay was 2 d. Distal ureteric margins showed subepithelial edema with submucosal fibrosis, and bladder fat biopsies were reported as adipose tissue with hemorrhage. At initial 3-mo and annual follow-ups, all patients had normal serum creatinine and there was no evidence of disease recurrence. Limitations of our study are the very small sample size (a low incidence of PL) and short follow-up time period (the question of how long the surgical effect will be sustained due to abnormal proliferation of fat cells remains unanswered). CONCLUSIONS: Robotic management of wide bladder fat extirpation and bilateral ureteral reimplantation with double J stenting has a good success rate and good outcome in PL. PATIENT SUMMARY: Pelvic lipomatosis is a very rare condition. Robotic management in treating the condition has good outcome for the patient. Here, we have discussed the difficulties encountered in treating the condition and the techniques used to overcome them.

Uterine Sarcomas: Experience from a Tertiary Cancer Care Center from India.

Uterine sarcomas are uncommon and aggressive tumors comprising 3-7% of all uterine malignancies. The aim is to evaluate clinical presentation, histopathologic pattern, recurrence pattern, and outcome of patients with uterine sarcomas presenting to a tertiary care cancer center over an 8-year period. A total of 11 cases of uterine sarcoma were diagnosed. The median age of patients at presentation was 51 years (range 30-67 years). Six patients had leiomyosarcoma (54.5%), 4 had endometrial stromal sarcoma (36%), and 1 had adenosarcoma (9%). The main presenting symptoms were abnormal vaginal bleeding, low abdominal pain, and white discharge. Median follow-up was 11 months ranging from 3 to 200 months. Median survivals for leiomyosarcoma, endometrial stromal sarcoma, and adenosarcoma were 6.5, 18, and 56 months. The 3- and 5-year survival by Kaplan-Meier survival analysis of the entire cohort was 30 and 20%. The mitotic index, age, adjuvant therapy (chemotherapy, radiotherapy), and performance of pelvic nodal dissection did not impact survival significantly in the patient with leiomyosarcoma. Stage and histology had the strongest bearing on survival and leiomyosarcoma has the worst survival, whereas adenosarcoma had the best prognosis. Adequately powered prospective studies are required to define the role of radiation therapy and chemotherapy in this rare disease.