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.

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.

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.

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.

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.

Schwannoma of the Submandibular Gland: A Rare Case Report.

Schwannoma is a slow growing, benign, encapsulated tumour of Schwann cells, which form myelin in peripheral nerves. It is the most common tumour of peripheral nerve, also known as neurilemoma or neurimoma. Schawannomas of head and neck area is common and may arise from peripheral, central or autonomic nerve but Salivary gland schwannomas are rare extracranial forms. We report a rare case of schawannoma of submandibular gland which presented with painless swelling in submandibular region, treated by total excision of submandibular gland. There was no postoperative nerve deficit or recurrence within 9 months of follow up.

Characteristics of Hollow Viscus Injury following Blunt Abdominal Trauma; a Single Centre Experience from Eastern India.

OBJECTIVE: To determine the presentation, anatomical distribution, diagnostic method, management and outcome of hollow viscus injury (HVI) from blunt abdominal trauma. METHODS: This  was  a  retrospective  cross-ecnal  study  including  patients  with  blunt  abdominal  trauma leading to HVI admitted at Rajendra Institute of Medical Sciences, Ranchi, over a period of 4.5 years (January 2009 to July 2014). Data were retrieved from patients' medical records. Total 173 patients with HVI due to blunt abdominal trauma, who underwent laparotomy at our institute, were reviewed. Data regarding clinical presentation, anatomical distribution, management and outcome were recorded and analysed. RESULTS: Out of 173 patients 87.1% were men and 12.9% were women. Mean age of patients was 29±14.02 years. The most common site of injury was ileum (46.2%) followed by jejunum (44.5%). There were 5 gastric perforations (2.9%), 2 (1.15%) duodenal, 2 (1.15%) colonic, 2 (1.15%) sigmoidal and 2 (1.15%) rectal injuries. One caecal injury was also recorded. Road traffic accident was the most common mechanism of injury (57.2%) followed by fall from height (36.4%) and assault (6.4%). Free gas under diaphragm on erect abdomen radiography was seen in 85.5% of cases while preoperative CT Abdomen was done in 11.6% of cases. Treatment consisted of simple closure of the perforation (66.5%), resection and anastomosis (11.0%) and stoma (22.5%). Major complication was anastamotic leak which was recorded in 6.4% cases and 15.6% patients developed burst abdomen. Average hospital stay was 13±6 days. Overall mortality rate was 12.7%. CONCLUSION: Although early recognition of intestinal injuries from blunt abdominal trauma may be difficult in all cases, it is very important due to its tremendous life threatening potential. Age of the patient, anatomical site and time of presentation are probably main prognostic factors.