Risk-based Management of Non-muscle Invasive Bladder Cancer: Experience from Tribhuvan University Teaching Hospital.

Background Most of the recent evidences suggest for risk-based management of non muscle invasive bladder cancer (NMIBC) to reduce the risk of recurrence and progression. Objective This study was conducted to assess the recurrence and progression of non muscle invasive bladder cancer in Nepalese patients using European Organization for Research and Treatment of Cancer (EORTC) risk tables and to assess the effectiveness of intravesical therapy to reduce the risk of recurrence. Method A prospective observational single centre study was conducted at Tribhuvan University Teaching Hospital from January 2010- December 2012. Forty six patients with non muscle invasive bladder cancer who underwent transurethral resection of bladder tumor and completed two years follow up were included. According to the European Organization for Research and Treatment of Cancer (EORTC) risk table, the patients were divided into low, intermediate and high risk groups. The patients received postoperative adjuvant therapy and surveillance as per the European Association of Urology guidelines. Result Among the 46 patients, the overall two year recurrence and progression rate was 8 (17%) and 1 (2%) respectively. Out of seven patients in low risk category, none of them developed recurrence or progression of disease. Out of 15 patients in intermediate risk category the one year and two year recurrence rate was 13% and 20% respectively. Out of 24 patients in high risk category the one and two year recurrence rate was 17% and 21% respectively. The risk reduction by use of intravesical Bacillus Calmette Guerin (BCG) for recurrence in high risk category was 58% and 60% in first and second year respectively. In our study, the overall and individual risk group, the one and two year recurrence rate was lower than that predicted by European Organization for Research and Treatment of Cancer risk table. Conclusion Risk-based management of non muscle invasive bladder cancer by using the European Organization for Research and Treatment of Cancer risk table is a useful method of management, though its prediction rates are lower in Nepalese population.

Cystoscopic bladder biopsies: a histopathological study.

Urothelial carcinoma is the most common tumor of the bladder and is a major cause of morbidity and mortality. Cystitis constitutes an important source of clinical signs and symptoms. In this study 31 cystoscopic biopsies subjected for histopathological examination were taken. The study was conducted in the department of Pathology of Nepal Medial College Teaching Hospital over a period of two years (October 2012 to September 2014). The mean age of the patient undergoing cystoscopic biopsy was 61.3 years, most of the patients being elderly male. 51.6% cases were clinically malignant. The most common histopathological diagnoses were cystitis (29%) and non invasive papillary urothelial carcinoma, low grade (29%). 58% are neoplastic lesions. 51.6% of the case was malignant lesions on histopathology. Among the malignant lesion of urinary bladder 93.7% were urothelial tumor and 6.3% were glandular neoplasm (adenocarcinoma, signet ring cell). There was no detrusor muscle in 33.3% cases of urothelial tumor to assess the muscle invasion. 26.7% cases of urothelial tumor shows muscle invasion. Histopathological study of cystoscopic biopsy helps in early detection of tumor and its management.

Phaeochromocytoma in Nepal--a single centre experience.

BACKGROUND: Phaeochromocytomas are rare tumors of chromaffin cells of neural crest that classically present with symptoms of catecholamine excess such as palpitations, headache and sweating. They are diagnosed by measuring plasma or urinary levels of catecholamines or their metabolites. Anatomic localization is done by computed tomographic scan or magnetic resonance imaging, or meta-iodobenzyl guanidine scan in certain cases. Adequate preoperative catecholamine blockade prevents perioperative hemodynamic instability. OBJECTIVES: To study the clinical spectrum and management of phaeochromocytomas in a tertiary care centre, Tribhuvan University Teaching Hospital, in Nepal. METHODS: Retrospective review of case records of histologically proven cases of phaeochromocytomas from 2008 -2011 was done, and data collected on clinical spectrum, diagnostic modalities, perioperative management and follow-up. RESULTS: Twelve cases of phaeochromocytomas were operated. The mean age was 36.41+/-14.07 years. There were 2 bilateral phaeochromocytomas and 1 extraadrenal paraganglioma. Apart from the common symptoms of catecholamine excess, patients had atypical presentations like psychiatric manifestations and blurred vision. A combination of urinary Vanillyl Mandelic Acid and computed tomographic scan was used for diagnosis, and open surgery was done in all cases. Pre-operative blood pressure control was achieved by prazocin or calcium channel blockers. Ten patients had intraoperative surge in blood pressure. There were no major morbidity or mortality. Three patients had high blood pressure postoperatively, but were effectively managed with antihypertensives. CONCLUSION: Phaeochromocytomas can have variable presentation. Good preoperative preparation and perioperative management can result in an excellent outcome.

Effect of feeding sericea lespedeza leaf meal in goats experimentally infected with Haemonchus contortus.

Effect of sericea lespedeza [SL; Lespedeza cuneata (Dum-Cours.) G. Don.] leaf meal feeding was evaluated in two experiments in indoor reared goats with experimental infection of Haemonchus contortus larvae. In the first experiment, ten 8-10 month old male Spanish and Alpine cross kids pair matched for body weight and age were fed SL or bermudagrass [BG; Cynodon dactylon (L.) Pers.] hay one week before infection and were infected with 5000 H. contortus L(3). The animals were maintained on the same diet for the remaining period and were slaughtered 28 days post-infection (DPI) to determine the establishment of incoming infective larvae. Goats fed SL had lower establishment (P<0.05) of H. contortus larvae than that of the control goats fed BG hay. In the second experiment, twenty-five 8-10 months old male Alpine cross, Saanen, Nubian×Saanen and Spanish kids reared in confinement on BG were experimentally infected with 5000 H. contortus L(3). On 35 DPI, the animals were allocated to two groups after blocking by fecal egg count (FEC), and one group was fed SL leaf meal (n=13), and another control group remained on BG (n=12). Four goats/group were slaughtered successively on days 7, 14, and 28 days post SL feeding, except on day 7, when five SL fed goats were slaughtered. Fecal egg counts and blood packed cell volume (PCV) were measured at weekly intervals and worm count, female worm fecundity, worm length and mucosal eosinophils, mast cells and globule leucocytes were measured after slaughter. Goats fed SL had a lower FEC (P<0.05) one week after feeding, as compared to those fed on BG, and the values remained at low level thereafter. Similarly, PCV was also significantly affected by feeding (P<0.01), and feeding and time interaction (P<0.05). However, worm burden, female worm fecundity, parasite length, and mucosal inflammatory cell count were similar between the groups. Feeding SL reduced the establishment of infective larvae and FEC of H. contortus in experimental studies and this plant could be used for biological control of parasite infection under field conditions to limit the harmful effects of the parasites in goats.

Pattern of renal cell carcinoma - a single center experience in Nepal.

BACKGROUND: Renal tumor is the 13th most common malignancy in the world and more than 90% of renal tumors are renal cell carcinomas. As there is no data available on renal cell carcinoma in Nepal, hence this study was undertaken to analyze the patterns of renal cell carcinoma in patients with renal mass at a tertiary level hospital in Nepal. OBJECTIVES: To analyze the patterns of renal cell carcinoma in patients with renal mass at a tertiary level hospital in Nepal. METHODS: The case records of 50 consecutive patients with renal cell carcinoma presenting at the Tribhuvan University Teaching Hospital, Kathmandu from July 2006 to June 2011 were retrospectively evaluated for presenting symptoms, physical finding, investigation and histopathology report. RESULTS: Out of 50 patients, 64% were male and 36% were female. The age ranged between 11 to 78 years (mean ± SD: 55 ± 15 years). Fifty four percent of patients were smokers. Incidentally tumor was detected in 40% cases by ultrasonography and the typical triad was present in only 4%. The tumor was occupying upper pole in 40% of cases. The tumor size ranged from 3 to 15 cm (mean ± SD: 7.3 ± 2.9 cm). Histopathologically, 76% of the patient had organ confined renal cell carcinoma (T1- 2 N0 M0). Clear cell was the most common type seen in 86%. Fuhrman nuclear grade 2 was found in 50%. CONCLUSION: Many of the renal cell carcinoma are detected incidentally, at an early stage and are of clear cell subtype.

Correlation of calcium, phosphorus, uric acid and magnesium level in serum and 24 hours urine of patients with urolithiasis.

UNLABELLED: BAKCGROUND: Urinary stones disease is common pathology encountered in urological practice in Nepal. Supersaturated urine and its stagnation are well known facts for the development of urolithiasis. Metabolic disorders like hypercalciuria, hyperuricaemia, hypocitraturia are also responsible for formation of urolithiasis. OBJECTIVE: The aim of this study was to identify the level of calcium, phosphorus, uric acid, and magnesium in the blood and urine of Nepalese patients with urinary stones. METHODS: This study was conducted over a period of six months (From May to November 2010). It is a descriptive cross sectional study and quantitative method was used for analysis. Primary data were collected and utilized from 79 cases. RESULTS: The prevalence of urolithiasis in male patients was 65.8% and 34.2% in female patients (p less than 0.05). Serum calcium in stone former and non-stone former was 8.3+/-1.2 and 7.5+/-1.5 (p less than 0.01) respectively. Serum phosphorus and uric acid in both groups were statistically not significant (p value 0.269 and 0.597 respectively) though in 24 hours urine of stone formers value of phosphorus was 447.9+/-182.4 but in non-stone formers it was 186.5+/-118.7 (p less than 0.001). Magnesium level in urine was 48.1+/-69.7 and 131.4+/-86.9 (p less than 0.001) respectively. CONCLUSION: Higher level of calcium in serum was found in patients with urolithiasis in our population. Though phosphate level in blood serum was not different in the both groups but in urine phosphate and magnesium levels were significantly different.

Primary mucinous adenocarcinoma of the renal pelvis and ureter.

Mucinous adenocarcinomas of the renal pelvis and ureter are among the rarest upper urinary tract neoplasm. We report a case of multifocal primary mucinous adenocarcinoma of the renal pelvis and ureter occurring in association with a staghorn calculus and pyonephrosis. A 68 year old man had suffered from right flank pain and upper abdominal swelling for one year. After a series of investigation, a right staghorn stone with pyonephrosis leading to non-functioning kidney was found. Right nephrectomy was performed. The pathological report showed mucinous adenocarcinoma with ureteric margin positive for tumour deposits. Patient was reoperated; right ureterectomy with removal of bladder cuff was done. Although uncommon, the possibility of a tumor should be kept in mind especially in patients with a long standing urolithiasis accompanied by hydronephrosis and/or infection.

Penile fracture at Tribhuvan University Teaching Hospital: a retrospective analysis.

Fracture of the penis is rupture of the tunica albuginea and the usual cause is abrupt bending of the erect penis by blunt trauma. Trauma during sexual relation is responsible for approximately one third of all cases. The incidence of urethral injuries associated with this condition ranged from 2.0% to 38.0%. Twelve patients who presented to emergency over a period of 4 years with diagnosis of penile fracture were reviewed retrospectively. Patient's profile and all relevant data were noted from charts. The etiology of fracture was related to coital activity in 6 (50.0%) cases while other denied such act. Surgery was performed on all the patients and discharged from hospital on removal of urethral catheter. Follow up continued until restoration of normal penile function without complaint. So fracture of the penis is an injury that can be diagnosed clinically and needs emergency surgical correction for better result.

Urological complication after kidney transplantation.

BACKGROUND: Renal transplantation is a regular service at Tribhuvan University Teaching Hospital and complications have been known to occur after it. This study was conducted to assess complications after transplantation. OBJECTIVES: To determine the incidence of urological complications after living related renal transplantation at Tribhuvan University Teaching Hospital. METHODS: A clinical study was performed (from August 2008 to July 2010) which included 50 living-related renal transplantations at Tribhuvan University Teaching Hospital. All the donors and recipients were evaluated preoperatively with necessary investigations and followed up postoperatively with standard hospital transplant protocol. The incidence of urological complications were documented and analyzed. RESULTS: Fifty living-related, renal transplantations were carried out during the study period. Seven doors had minor post operative complications; three had post operative fever, two had chest infections and each one had superficial surgical site infections and severe pain at incision site. Ureteroneocystostomy was performed with double J stent in all recipients. Urological complications were noted in 12 (24%) recipients. Clinical significant hematuria occurred in four cases. One patient had ureteric necrosis and urinary leak which required re-exploration post operatively. Two patients developed delayed ureteric stricture which were managed by antegrade Double J stenting and ureteric reimplantation. Peri-graft abscess occurred in two cases, which were drained percutaneously. surgical site infections was seen in one case. CONCLUSIONS: Urological complications are inevitable in renal transplantation and our complications rate appears similar to that reported in literature.

Renocolic fistula following percutaneous nephrostomy: a case report.

Renocolic fistula is a rare clinical entity. In the past, its incidence was high due to infection, especially tuberculosis, and renal stone complications; which gradually reduced with advancements in antimicrobial therapy and better stone management. The incidence of renocolic fistulae, specifically iatrogenic one, has re-emerged due to minimally invasive renal surgery and regular percutaneous nephrostomy placement for various reasons. We reported a case of fifty-five-years-old gentleman who presented to emergency room with left lithiasic pyonephrosis for which percutaneous nephrostomy was placed. Follow up antegrade pyelography diagnosed hydronephrotic left kidney with stone in renal pelvis with fistula communicating to descending colon. Contrast enhanced computer tomography revealed left non excreting kidney with retrorenal colon and percutaneous nephrostomy tube passing through the descending colon. The final diagnosis of post percutaneous nephrostomy renocolic fistula with non excreting left kidney was made and treated with ligation of fistulous tract and nephrectomy. Patient had uneventful recovery and histopathology showed chronic pyelonephritis.

Eradication of virulent footrot from sheep and goats in an endemic area of Nepal and an evaluation of specific vaccination.

Programmes based on the identification and treatment of cases and the culling of animals refractory to treatment had failed to eradicate virulent footrot from two districts in the western region of Nepal. From 1993 to 1996 vaccination against two endemic virulent strains of Dichelobacter nodosus was tested for its potential to contribute to the eradication of footrot from the region. Only sheep and goats which had been free of signs of footrot at three inspections at monthly intervals before their annual migration to alpine pastures were eligible for inclusion. From November 1992, the treatment of cases identified during inspections included the injection of specific vaccine. Successfully treated cases migrated with their flocks but were excluded from the vaccine trial. Non-responding cases were culled. Forty combined flocks of sheep and goats (approximately 9500 animals) were used initially to compare three vaccination regimens. Eleven flocks (sheep and goats) were treated with two doses of specific vaccine (group A), nine (sheep and goats) were treated with commercial vaccine followed by specific vaccine (group B) and 10 (sheep and goats) were treated with two doses of commercial vaccine (group C) in March to April 1993 before the annual migration; 10 flocks (sheep and goats) remained unvaccinated (group D). Only sheep and goats free of signs of footrot were allowed to migrate. Nevertheless, virulent footrot recurred in many flocks three months later. However, its prevalence was significantly lower in group A than in the other three groups combined. Groups A, B and C then received the specific vaccine before their migrations in 1994 to 1996; group D remained unvaccinated. The annual programme of inspection and identification and treatment of cases continued for seven years, but the vaccinations ceased after four years. There was no recurrence of virulent footrot after November 1993. After the first season the virulent strains of D nodosus used in the specific vaccine could no longer be isolated, although antigenically distinct, benign strains of the organism persisted in cases of benign footrot.

Ostertagia nianqingtanggulaensis Kúng & Li, 1965 (Nematoda: Trichostrongyloidea) from sheep and goats at high altitudes in Nepal.

The trichostrongyloid nematode Ostertagia nianqingtanggulaensis Kúng & Li, 1965, previously recorded only from sheep in Tibet, is redescribed and is shown to be a common parasite of both sheep and goats at higher altitudes in the Himalayan foothills of western Nepal. Herbage examination indicated that infective larvae can overwinter on snow covered slopes. Use of tracer animals confirmed that migratory flocks are exposed to infection when grazing on alpine pastures during the summer months. In contrast, nearby non-migratory flocks kept at lower altitudes did not harbour O. nianqingtanggulaensis and tracer animals grazed with these flocks did not become infected with this species.