Obstructive uropathy from a giant urinary bladder stone: a rare urological emergency.

A 53-year-old man presented with lower urinary tract symptoms and recurrent urinary tract infections since last 3 years without being investigated or treated properly. Examination revealed a hard mobile lump in the pelvis, and blood investigations showed raised serum creatinine of 2.9 mg/dL. Subsequent urgent ultrasound scan showed a large urinary bladder stone with bilateral hydroureteronephrosis, and X-ray kidney, ureter and bladder demonstrated a 9 cm×6 cm elliptical radio-opaque shadow in the pelvis. He underwent emergency admission followed by open cystolithotomy on the next day. He was discharged after 48 hours with a urethral catheter. After 2 weeks, his renal function recovered completely; repeat ultrasound scan revealed complete resolution of hydronephrosis. Urethral catheter was removed following a normal cystogram. Uroflowmetry after 6 weeks revealed underlying bladder outlet obstruction, and he was started on alpha blocker which improved his urinary flow.

Primary Urethral Tuberculosis With Urethrocutaneous Fistula in Association With Balanitis Xerotica Obliterans.

We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty.

Urethral Catheter Induced Huge Anterior Urethral Diverticulum.

We report a 22-year old gentleman who presented with postmicturition urinary dribbling for nearly 1 year along with urinary urgency and frequency. He had a history of brain tuberculosis 2 years back and was hospitalized for 4 months with a urethral catheter. Examination revealed a 3 cm cystic swelling in the penoscrotal junction. On pressing the sac, a gush of urine came out through the urethral meatus. A micturating cystourethrogram revealed a huge anterior urethral diverticulum. Cystoscopic assessment also confirmed the diagnosis and demonstrated transillumination. He subsequently underwent surgical excision of the diverticulum and is doing well on follow-up.

Spontaneous Ureterocutaneous Fistula Secondary to Obstructed Ureteric Stone.

We present a unique case of ureterocutaneous fistula secondary to an obstructed ureteric stone. A fistulagram confirmed a communication between right flank and the proximal ureter. Ureterocutanoues fistula in the absence of trauma, iatrogenic causes, granulomatous infection, or malignancy is highly unusual.

Short-term Alteration of Renal Function and Electrolytes after Percutaneous Nephrolithotomy.

PURPOSE: To analyse the changes in renal function and serum electrolytes in the early post-operative period ofpercutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A total of 110 patients with normal renal function, who underwent PCNL in our institutewere evaluated prospectively. Haemoglobin percentage, packed cell volume, blood urea nitrogen, serum creatinineand serum electrolytes, namely sodium, potassium, chloride and ionized calcium were measured on the day beforesurgery and after 72 hours of the procedure. Renal function was assessed by Cockcroft-Gault formula and estimatedglomerular filtration rate was calculated by modification of diet in renal disease formula. RESULTS: Serum creatinine increased significantly from a mean value of 0.89 ± 0.199 mg/dL to 0.96 ± 0.252 mg/dL(P = 0.0002) and both creatinine clearance and estimated glomerular filtration rate experienced a significant fall -from a median value (interquartile ranges) of 82.99 (72.37 to 96.88) mL/min to 75.38 (63.89 to 94.05) mL/min incase of creatinine clearance (P = 0.0004) and from a mean value of 95.18 ± 19.87 mL/min/1.73 m2 to 89.30 ± 23.14mL/min/1.73 m2 in case of estimated glomerular filtration rate (P = 0.003). Furthermore, there were significantdrops in both haemoglobin percentage and packed cell volume. There were no significant alterations in serum electrolytes- sodium and potassium (mmol/L) [Median (IQR)] changed from a pre-operative figure of 137.5 (134.0 to140.0) and 3.85 (3.60 to 4.10) to a post-operative value of 138 (135.0 to 140.0) and 3.85 (3.50 to 4.10) respectively. CONCLUSION: Even though there is no significant variation in serum electrolytes, PCNL causes significant reductionin renal function in the early post-operative period.

Chyluria: a scourge of our region.

Chyluria is endemic in the Gangetic belt of India with an average of 90 cases treated annually at our institute. It is almost exclusively caused by Wuchereria bancrofti in tropical areas. Chylomicrons and triglycerides are lost in the urine from an abnormal lymphourinary fistula due to obstructive lymphatic stasis, most commonly at the renal pelvis. It is a distressingly recurrent condition with multiple exacerbations and remissions over years. Severe weakness, weight loss and haematuria occur in some patients. Diagnosis can be made by visual examination of milky urine along with the ether test of urine for chylomicrons. Intravenous urography is used to locate the site of the fistula, although the detection rate is poor. Treatment starts with conservative measures such as a high-protein low-fat diet and diethylcarbamazine therapy. In cases where conservative measures fail, endoscopic sclerotherapy (renal pelvic instillation of silver nitrate, povidone iodine or others) and surgical therapy are used.

Urinary incontinence following transurethral prostatectomy presenting as self inflicted penile gangrene.

An elderly diabetic man with a 67 g prostate developed a moderate degree of stress urinary incontinence along with urge urinary incontinence after transurethral resection of the prostate. Initially, he did not perform the recommended pelvic floor exercise and wrapped a rubber band around his penis to control the problem. He presented with late development of penile gangrene requiring partial amputation of his penis. The stress urinary incontinence subsided on subsequent follow-up. The patient is now doing well.

A study of molecular signals deregulating mismatch repair genes in prostate cancer compared to benign prostatic hyperplasia.

Prostate cancer is one of the leading causes of mortality among aging males. There is an unmet requirement of clinically useful biomarkers for early detection of prostate cancer to reduce the liabilities of overtreatment and accompanying morbidity. The present population-based study investigates the factors disrupting expression of multiple functionally related genes of DNA mismatch repair pathway in prostate cancer patients to identify molecular attributes distinguishing adenocarcinoma from benign hyperplasia of prostate. Gene expression was compared between tissue samples from prostate cancer and benign prostatic hyperplasia using real-time-PCR, western blot and immunohistochemistry. Assessment of genotypes of seven single-nucleotide-polymorphisms of three MMR genes was conducted using PCR-coupled RFLP and sequencing. Promoter methylation was interrogated by methylation-specific-PCR and bisulfite-sequencing. Interaction between microRNAs and MMR genes was verified by 3'UTR-based dual luciferase assays. Concurrent reduction of three MMR genes namely hMLH1, hMSH6 and hMSH2 (34-85%, P<0.05) was observed in prostate cancer tissues. hMSH6 polymorphism rs1800932(Pro92Pro) conferred a borderline protection in cancer patients (OR = 0.33, 95% CI = 0.15-0.75). Relative transcript level of hMLH1 was inversely related (r = -0.59, P<0.05) with methylation quotient of its promoter which showed a significantly higher methylation density (P = 0.008, Z = -2.649) in cancer patients. hsa-miR-155, hsa-miR-141 and hsa-miR-21 gene expressions were significantly elevated (66-85%, P<0.05) in tumor specimens and negatively correlated (r = -0.602 to -0.527, P<0.05) with that of MMR genes. hsa-miR-155 & hsa-miR-141 and hsa-miR-155 & hsa-miR-21 were demonstrated to bind to their putative seed sequences in hMLH1 and hMSH6 3'UTRs respectively. Relatively higher expression of DNA methyl-transferases (DNMT1 and DNMT3b) and HIF-1α genes (34-50%, P<0.05) were also detected in tumor tissues. This study provides statistical evidence that MMR deficiency is correlated with hypermethylation of hMLH1 promoter and upregulation of hsa-miR-155, hsa-miR-141 and hsa-miR-21 in prostate cancer. This comparative study reflects that microRNA expression level, particularly hsa-miR-155, exhibits predictive signature of prostate adenocarcinoma.

Evaluation of stone-free rate using Guy's Stone Score and assessment of complications using modified Clavien grading system for percutaneous nephro-lithotomy.

To prospectively evaluate the ability of Guy's Stone Score (GSS) in predicting stone clearance rate and complication rate (by modified Clavien grade) for renal stones treated by percutaneous nephrolithotomy (PNL). From January 2013 to June 2014, a total of 142 patients undergoing PNL were evaluated prospectively. Patients with co-morbidities like hypertension, diabetes, renal failure were excluded from the study. All patients were classified according to GSS based on the findings of pre-operative intravenous urography (IVU) and per-operative retrograde pyelography (RGP). All PNL procedures were done by standard technique in prone position and success was defined as no residual stone visible on X-ray KUB done on the third postoperative day. Complications were classified according to modified Clavien grading system. The initial stone clearance rate was 71.1% and overall final stone clearance rate was 90.14%. The complication rate according to Clavien grading system was 40.1%. The final stone clearance rates were 93.9, 85.71, 90.47, and 77.77% in GSS I, II, III, and IV, respectively (p<0.001, <0.05, <0.05 and >0.05, respectively). The Clavien complication rates were 23, 61, 52, and 77.7% in GSS I, II, III, and IV, respectively (p<0.001). The GSS is a simple and easily reproducible system to preoperatively predict stone-free rate and perioperative complication rate. It helps in better patient counseling preoperatively.

Retained barium in the appendix or right ureteric colic? A case report of surgeons dilemma.

INTRODUCTION: Retention of barium in the vermiform appendix for more than 72h following barium meal study is uncommon. It may produce undue concern for increased risk for appendicitis and even prophylactic appendectomies have been performed for this. PRESENTATION OF CASE: We encountered one such patient who presented with X-ray plate suggestive of tubular radio-opacity in the right iliac fossa region. The patient had episodes of severe pain in the right lower abdomen for which he underwent barium meal study. Further evaluation and investigations established the diagnosis as, a case of recurrent right ureteric colic with retained barium in the appendix. DISCUSSION: Review of the literature suggests that, in absence of acute appendicitis there is no role of appendectomy, even in a case of retained barium in the appendix. CONCLUSION: If atypical presentation is there, they should be appropriately further investigated.

Parameatal Cyst : A report of Two Cases and Review of Literature.

Cyst formation in the parameatal area is a relatively rare entity and not many cases have been reported in the literature. Two such cases are reported here. First patient was a 46 year old sexually active male who developed a spherical, cystic swelling of 1 cm in size on right lip of external urethral meatus. The second case was a 4 year old boy who presented with asymptomatic recurrent left parameatal swelling. In both the cases, cysts were completely excised and defects were sutured. Histologically, the cyst walls were lined by tall squamous and columnar epithelium. Good cosmetic results were obtained in these two cases without any recurrence at 2 two months follow up.

Misinterpretation of the international prostate symptom score questionnaire by Indian patients.

INTRODUCTION: The international prostate symptom score (IPSS) is commonly used in the evaluation of the severity of symptoms of patients with prostatic enlargement. It is a self-administered questionnaire. It has not been validated in any Indian language and an English version is used which can be difficult to interpret by our patients who do not have English as their primary language. In this study, we evaluate the patient's ability to understand the IPSS by comparing the scores when the IPSS questionnaire was self-administered versus when it was administered using the assistance of a clinician. MATERIALS AND METHODS: Patients who presented with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, who had passed at least twelfth grade of school and had a reasonable command over English were included in the study. They were allowed to self-administer the IPSS questionnaire following which a clinician, blinded to these scores, assisted the patient in filling the questionnaire. For each question, the score in both the questionnaires was noted and kappa agreement statistical test was used to assess the agreement between the two scores. RESULTS: A total of 87 patients were included in the study. It was found that none of the questions had a perfect agreement of scores in the self-administered and the assisted administration. CONCLUSION: Our results show that our patients misinterpret the IPSS questionnaire. This problem can lead to significant errors in interpretation of the symptom severity.

Calvarial and cutaneous metastasis as the primary presentation of a renal cell carcinoma.

Renal cell carcinoma is an aggressive urological malignancy. Metastases from the lesion are encountered late in the course of the disease and most often involve the lung and the liver. It is rare that metastatic lesions are the primary presentation of an otherwise clinically silent renal cell carcinoma. We report a case who presented with calvarial and cutaneous lesions which were later found to be metastases from an asymptomatic renal cell carcinoma.

Prolapsed ureterocele, with calculi within, causing urinary retention in adult female.

A case of a simple ureterocele, containing multiple calculi within, prolapsing through the urethra and presenting as a vulval mass in a woman aged 35 years with urinary retention. Following confirmation of diagnosis by plain X-ray and sonography, the calculi were extracted by incising the ureterocele, which was reduced in the bladder and later resected transurethrally.

Idiopathic bilateral male breast abscess.

A 38-year-old man presented with bilateral breast swelling, along with pain and redness for 7 days. Bilateral axillary nodes were also palpable; which were multiple and discrete. A provisional diagnosis of bilateral breast abscess was made with suspicion of underlying malignancy. Incision and drainage through subareolar incision was performed and the adjoining tissue was excised and sent for histopathological examination.

Familial bulbar urethral strictures.

Strictures are commonly encountered in the urological practice. The most common aetiologies are infection, trauma and iatrogenic events. Familial occurrence of urethral stricture is exceptionally rare. We present a case in which bulbar urethral strictures developed in a father and his two sons.

Tuberculosis of the glans penis healing with meatal stenosis.

A 45-year-old man presented with ulceroproliferative lesion of the glans penis. Clinical diagnosis was penile carcinoma and incisional biopsy was performed. Histopathology report came as penile tuberculosis. The lesion healed with antitubercular treatment. Meatal stenosis occurred at 2 months follow-up and was managed with meatotomy.