Is sterile pyuria another minor diagnostic criterion in urinary tuberculosis?

INTRODUCTION: Composite reference standard (CRS) is used for diagnosis of urinary tract tuberculosis (UTB). We examined if addition of a new 'component test' as minor criterion in the form of SP could improve the yield. METHODS: We identified patients admitted with a diagnosis of UTB from January 2009 to February 2016 from our patient database. We performed the validation of addition of a new 'component' "sterile pyuria" to the existing basic CRS. RESULTS: SP was seen in 50 patients (65.7%). Forty (52.6%) of these patients had one major criterion positive and 10 (13.1%) were diagnosed based on minor criteria. If SP was added as a minor criterion, an additional 8 (9.2%) patients would have been diagnosed based on minor criteria alone without the need for a histopathology. CONCLUSIONS: SP could improve the diagnostic yield of existing CRS by 8% with a 70% decrease in reliance on histopathology for diagnosis.

Outcomes of second-look percutaneous nephrolithotomy in renal calculi-a single centre experience.

OBJECTIVE: Percutaneous nephrolithotomy (PCNL) carries significant potential for morbidity. Scant data exists on indications and outcomes of second-look PCNL after a failure to completely clear renal stones at the first attempt. We present our experience with second-look PCNL. MATERIAL AND METHODS: This was a retrospective record review of 922 patients who underwent unilateral PCNL at a tertiary care center in South India. Baseline patient, stone characteristics and outcomes were compared between 844 patients undergoing primary PCNL and 78 patients requiring second-look PCNL. RESULTS: Increased stone complexity in terms of Guy stone score (GSS), stone size, staghorn calculi and stones in multiple locations were significantly associated with primary treatment failure (p<0.001). Operative time >75 min had a significant association with need for second-look PCNL and complications. Initial PCNL was discontinued due to bleeding (28; 35.9%), pelvicalyceal system perforation (3; 3.9%) and purulent urine leading to urosepsis and hemodynamic instability (2; 2.6%). Staged PCNL was done in 44 (56.3%) patients. During second-look PCNL, new access tracts were necessary in majority (42; 53.9%) of the patients and multiple tracts in 20 (25.6%) patients. In second-look PCNL, complications were comparable to primary PCNL (p=0.289). CONCLUSION: Second-look PCNL should be advocated in patients where the initial PCNL was discontinued due to bleeding, perforation of collecting system, prolonged operative time (>75 min) and in patients with large stone burden.

Urodynamic profile in posterior urethral valve patients following fulguration: Does age at fulguration matter?

INTRODUCTION: Children with posterior urethral valve (PUV) may develop urinary bladder (UB) dysfunction even after valve fulguration (VF). Using Urodynamics (UDS), we sought to identify whether age at VF and time elapsed since VF contributed to UB dysfunction. MATERIALS AND METHODS: Between January 2009 and July 2016, 39 PUV patients referred to a tertiary care center for UDS were classified into Groups A and B (based on age if <2 or ≥2 years at VF) and subclassified into Group A1/A2 and B1/B2 depending on time duration after VF (TVU). A1 and B1 constituted TVU ≤4 years and A2 and B2 constituted TVU >4 years, respectively. RESULTS: Median (range) ages at VF and UDS were 18 (1-108) months and 9 (1-19) years. Median (range) time between VF and UDS was 60 (6-164) months. Reduced compliance was seen in 67%, detrusor overactivity in 38.5%, and leak in 15.4% boys, respectively. Median (range) Qmax was 8 (0-28) ml/s and 25% boys had hypocontractile detrusor at voiding. Statistically significant reduction was found in compliance when comparing Group B versus Group A (P = 0.037) and in bladder capacity (P = 0.002) and compliance (P = 0.043) in Group A2 versus A1. CONCLUSIONS: Boys with VF at <2 years had better urodynamic profiles than those with fulguration over 2 years of age. As the time period since fulguration increased, there was a higher incidence of bladder dysfunction in both the groups.

Clinical profile and successful outcomes of conservative and minimally invasive treatment of emphysematous pyelonephritis.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a rare clinical entity, characterized by gas in the renal system, due to an acute, fulminant and potentially fatal necrotizing process with varying clinical presentations. It is much more aggressive than uncomplicated pyelonephritis, with the mortality of 20-40% in the contemporary meta-analysis. MATERIAL AND METHODS: A retrospective record review of inpatients at the Institute of Nephro Urology, Bangalore, India (2007-2014), who were treated after EPN was diagnosed with the aid of a CT (computed tomography) scan. RESULTS: Sixty-six patients (M:F 27:39) treated for EPN over the past seven years with the mean (±SD) age of 52.32 (±12.48) years were analyzed. Median (interquartile range) duration of hospital stay was 8 (11.25) days with 4 (6%) patients requiring intensive care unit admission (median, IQR = 5.5, 1.5 days) of whom two passed away due to septicemia. Fifty-six (84.85%) patients were diabetics, forty (60.6%) patients had estimated glomerular filtration rate (eGFR) <60 ml/min/1.7 3 m2, 6 (9.1%) patients had eGFR <30 ml/min/1.73 m2 including 3 (4.5%) with eGFR <15 ml/min/1.73 m2 requiring hemodialysis and twenty-two (33%) had thrombocytopenia. Fifty (75.76%) patients were classified as Huang and Tseng Class 2, 7 (10%) as Class 3 with perinephric abscess requiring open drainage and 9 (13.64%) had bilateral EPN (Class 4). Majority (43; 65%) responded to piperacillin-tazobactam treatment. Double J stenting was done in 17 (25.76%) patients, percutaneous drainage in 5 (7.58%) patients and nephrectomy in 2 (3%) patients. CONCLUSIONS: Although EPN historically carries high morbidity and mortality, modern day medical management with timely intervention in the form of urinary drainage is effective and curative in most patients resulting in a low mortality rate.

Clear cell adenocarcinoma of the urethra with inguinal lymph node metastases: A rare case report and review of literature.

Urethral cancer is a rare malignancy with urothelial subtype being the most common followed by adenocarcinoma. In women, the usual presentation is urinary retention and hematuria. Clear cell variety of adenocarcinoma is a rarer entity which usually has a better prognosis than other variants. Lymph node metastasis is seen in about 30% of urethral cancers. Histopathological differential diagnosis includes Skene gland carcinoma and nephrogenic adenoma. Herein, we present a 58-year-old female patient who presented for evaluation of lymph node mass in the inguinal region. The detailed evaluation revealed clear cell adenocarcinoma of the urethra as the primary with lymph node metastasis.

Tubeless Pediatric Percutaneous Nephrolithotomy: Assessment of Feasibility and Safety.

INTRODUCTION: Tubeless pediatric percutaneous nephrolithotomy (TL-PCNL) is evolving and adult criteria are being safely applied to children. We examine the feasibility, safety, and outcomes of pediatric TL. MATERIALS AND METHODS: A retrospective review of pediatric (≤18 years) PCNL patients at our institute was done. Patients eligible for TL but underwent tube (T) PCNL due to surgeon choice or protocol were compared with TL. Only children with 100% stone clearance were included, and those receiving nephrostomy for intraoperative complications were excluded from the study. Demographic, baseline, and stone characteristics were matched. Safety, outcome, and complications were assessed. Group T was classified into large bore (22F-LB) and small bore (16F-SB) based on nephrostomy size. Statistical analysis was done. RESULTS: A total of 46 children were eligible - TL in 17 (37%) and T in 29 (63%). Among T, SB was performed in 6/29 (20.7%) and LB in 23/29 (79.3%). TL had fewer complications. Urinary leak developed in 2 (6.9%) patients in T. Eight (27.6%) patients in T and 3 (17.7%) patients in TL had supracostal access with complications similar to infracostal access. SB had significantly lesser and analgesic requirement than LB. SB and TL had similar LOH and analgesic requirement. Adult expanded criteria such as supracostal access, 2 punctures, prior renal surgery, and larger tract size were feasible. CONCLUSIONS: TL is safe, feasible, and less morbid alternative to T in uncomplicated pediatric nephrolithiasis. TL is feasible with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is reasonable when tube is indicated.

UWIN (Urgency, Weak stream, Incomplete Void, Nocturia) Score for Assessment of Lower Urinary Tract Symptoms: Could it Replace the American Urology Association Symptom Index Score? An Open Label Randomized Cross over Trial.

OBJECTIVE: The American Urology Association symptom index (AUASI) is the most accepted tool to assess lower urinary tract symptoms (LUTS). UWIN (urgency, weak stream, incomplete void, nocturia) score is a simplified questionnaire with fewer and more distinctive options omitting three questions from AUASI. We sought to identify if UWIN is equally efficient in capturing LUTS and could replace the gold-standard AUASI. METHODS: Consecutive consenting male patients with benign prostatic hyperplasia (BPH)-LUTS were randomized to receive either UWIN/AUASI questionnaire first followed by the other. Education levels, time taken to complete, need for assistance, ease of comprehension and satisfaction to symptom assessment were assessed for each questionnaire. Correlation analysis was done for corresponding items, total and QoL scores on both questionnaires. RESULTS: Total of 294 completely filled questionnaire pairs were analyzed. Between corresponding UWIN and AUASI items, there was 93-97% correlation. When obstructive and irritative scores were added, correlation was 85% and for QOL scores 89%. Overall, AUASI required more assistance (58 vs 34%, P < 0.001), took longer to complete (11.2 vs 4.8 min, P < 0.001) and required higher educational level for comprehension (P = 0.02). Significantly higher percentage of patients preferred the UWIN and more comprehensible. CONCLUSION: UWIN is as effective in capturing LUTS as the gold-standard AUASI in spite of three questions of AUASI being omitted in UWIN. Severity of obstructive and irritative nature of LUTS and quality of life are interpreted similar to AUASI. UWIN is easier to comprehend and rapid, needing lesser assistance even with lower educational status.

Nasogastric tube as abdominal pressure sensor in urodynamics-Proof of concept of a novel approach.

AIMS: The standard sensor for abdominal pressure (Pabd) measurement in urodynamics (UD) is a rectal sensor. In patients where the rectum is not available due to prior surgery or when external anal sphincter (EAS) tone is poor, rectal sensor may slip, making Pabd recording unreliable. Vaginal Pabd measurement and wireless vaginal sensors have been tried. We present our preliminary series of a novel nasogastric tube (NG) sensor for Pabd measurement. METHODS: We identified patients undergoing UD with a NG Pabd sensor from a prospectively maintained UD database of a tertiary care urological center between July 2013 and December 2016. RESULTS: Out of 1325 urodynamic procedures done, 46 (3.5%) were performed using NG Pabd sensor. The median (IQR) age was 44 (12) years. Indications for UD in these patients were neurogenic bladder in 22 (47.8%), urinary retention in 17 (37%), post-meningomyelocele repair in four (8.7%), traumatic paraplegia in two (4.3%), and cervical myelopathy in one (2.2%). The indications for NG Pabd sensor were lax EAS tone (40; 86.9%), post-abdominoperineal resection (2; 4.3%), and painful thrombosed hemorrhoids (4; 8.7%). It was possible to make definitive urodynamic diagnosis in all patients using NG Pabd sensor. Initial calibration and NG Pabd excursions throughout the study were similar to that of rectal Pabd sensor. There were no problems with NG tube tolerance. CONCLUSION: Use of nasogastric sensor is feasible, accurate, cost-effective, and viable alternative for Pabd measurement in patients with poor anal tone or absent rectum due to postoperative status.

Validation of APACHE II scoring system at 24 hours after admission as a prognostic tool in urosepsis: A prospective observational study.

Purpose: Urosepsis implies clinically evident severe infection of urinary tract with features of systemic inflammatory response syndrome (SIRS). We validate the role of a single Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 hours after admission in predicting mortality in urosepsis. Materials and Methods: A prospective observational study was done in 178 patients admitted with urosepsis in the Department of Urology, in a tertiary care institute from January 2015 to August 2016. Patients >18 years diagnosed as urosepsis using SIRS criteria with positive urine or blood culture for bacteria were included. At 24 hours after admission to intensive care unit, APACHE II score was calculated using 12 physiological variables, age and chronic health. Results: Mean±standard deviation (SD) APACHE II score was 26.03±7.03. It was 24.31±6.48 in survivors and 32.39±5.09 in those expired (p<0.001). Among patients undergoing surgery, mean±SD score was higher (30.74±4.85) than among survivors (24.30±6.54) (p<0.001). Receiver operating characteristic (ROC) analysis revealed area under curve (AUC) of 0.825 with cutoff 25.5 being 94.7% sensitive and 56.4% specific to predict mortality. Mean±SD score in those undergoing surgery was 25.22±6.70 and was lesser than those who did not undergo surgery (28.44±7.49) (p=0.007). ROC analysis revealed AUC of 0.760 with cutoff 25.5 being 94.7% sensitive and 45.6% specific to predict mortality even after surgery. Conclusions: A single APACHE II score assessed at 24 hours after admission was able to predict morbidity, mortality, need for surgical intervention, length of hospitalization, treatment success and outcome in urosepsis patients.

Page Kidney in Wunderlich Syndrome Causing Acute Renal Failure and Urosepsis: Successful Timely Minimally Invasive Management of a Devastating Clinical Entity.

Wunderlich Syndrome (WS) is an uncommon condition where acute onset of spontaneous bleeding occurs into the subcapsular and perirenal spaces. It can prove fatal if not recognized and treated aggressively at the appropriate time. A 32-year-old male diagnosed elsewhere as acute renal failure presented with tender left loin mass, fever and hypovolemic shock with serum creatinine 8.4 mg/dl. He was started on higher antibiotics and initiated on haemodialysis. Ultrasonogram (USG), Non-Contrast Computed Tomography (NCCT) and Magnetic Resonance Imaging (MRI) showed bilateral perirenal subcapsular haematomas - right 3.6 x 3.1 cm and left 10.3 x 10.3 cm compressing and displacing left kidney, fed by capsular branch of left renal artery on CT angiogram. Initial aspirate was bloody but he persisted to have febrile spikes, renal failure and urosepsis and he was managed conservatively. Repeat NCCT 10 days later revealed left perinephric abscess and Percutaneous Drainage (PCD) was done. Patient improved, serum creatinine stabilized at 2 mg/dl without haemodialysis and PCD was removed after two weeks. To conclude, bilateral idiopathic spontaneous retroperitoneal haemorrhage with renal failure is a rare presentation. This case highlights the need for high index of suspicion, the role of repeated imaging and successful minimally invasive management with timely PCD and supportive care.

Complications after prone PCNL in pediatric, adult and geriatric patients - a single center experience over 7 years.

INTRODUCTION: CROES-Clavien system (CCS) for grading complications in percutaneous nephrolithotomy (PCNL) is a step towards standardization of outcomes. We categorized complications based on CCS and predicted risk factors across the entire cohort and individually for pediatric (P: ≤18 years), adult (A: 19-65 years) and geriatric (G: ≥65 years) subgroups to assess the risk factors in each subset. We assessed association of complications with length of hospitalization (LOH) and operation time (OT). MATERIALS AND METHODS: Retrospective record review of unilateral PCNL performed between January 2009-September 2015 at a tertiary care center in India, performing around 150 PCNL per year. RESULTS: Out of 922 (P=61; A=794; G=67) PCNL, 259 (28.09%) complications occurred with CCS I, II, III and IV constituting 152 (16.49%), 72 (7.81%), 31 (3.36%) and 4 (0.43%) respectively and its distribution was similar across the subsets and majority (224; 24.3%) were minor (CCS-1, 2). Placement of a nephrostomy (47.4%; 18/38) in Group P, supracostal access, ≥2 punctures, higher GSS, nephrostomy, staghorn stones, ≥2 stones, stone size in Group A and hydronephrosis and prolonged OT in Group G were significantly associated with complications. On logistic regression, need of nephrostomy (adj. OR - 4.549), OT (adj. OR - 1.364) and supracostal access (adj. OR - 1.471) significantly contributed to complications in the study population. LOH was found to be significantly associated with complications (p<0.001). CONCLUSIONS: Contrary to the belief that extremes of ages are associated with complications of prone PCNL, we found age does not alter the incidence or grade of complications and LOH.

Complications after prone PCNL in pediatric, adult and geriatric patients - a single center experience over 7 years

ABSTRACT Introduction CROES-Clavien system (CCS) for grading complications in percutaneous nephrolithotomy (PCNL) is a step towards standardization of outcomes. We categorized complications based on CCS and predicted risk factors across the entire cohort and individually for pediatric (P: ≤18 years), adult (A: 19-65 years) and geriatric (G: ≥65 years) subgroups to assess the risk factors in each subset. We assessed association of complications with length of hospitalization (LOH) and operation time (OT). Materials and Methods Retrospective record review of unilateral PCNL performed between January 2009-September 2015 at a tertiary care center in India, performing around 150 PCNL per year. Results Out of 922 (P=61; A=794; G=67) PCNL, 259 (28.09%) complications occurred with CCS I, II, III and IV constituting 152 (16.49%), 72 (7.81%), 31 (3.36%) and 4 (0.43%) respectively and its distribution was similar across the subsets and majority (224; 24.3%) were minor (CCS-1, 2). Placement of a nephrostomy (47.4%; 18/38) in Group P, supracostal access, ≥2 punctures, higher GSS, nephrostomy, staghorn stones, ≥2 stones, stone size in Group A and hydronephrosis and prolonged OT in Group G were significantly associated with complications. On logistic regression, need of nephrostomy (adj. OR - 4.549), OT (adj. OR - 1.364) and supracostal access (adj. OR - 1.471) significantly contributed to complications in the study population. LOH was found to be significantly associated with complications (p<0.001). Conclusions Contrary to the belief that extremes of ages are associated with complications of prone PCNL, we found age does not alter the incidence or grade of complications and LOH.

Anatrophic Nephrolithotomy in the Management of Large Staghorn Calculi - A Single Centre Experience.

INTRODUCTION: With advances in endourology, open stone surgery for staghorn calculi has markedly diminished. Anatrophic Nephrolithotomy (AN) is performed for complex staghorn stones which cannot be cleared by a reasonable number of Percutaneous Nephrolithotomy (PNL) attempts. AIM: To assess the indications and outcomes of AN in the modern era. MATERIALS AND METHODS: Between April 2008 and July 2015, AN was done in 14 renal units in 13 patients. In this retrospective study, demography, stone characteristics, operative details, clearance and long term outcomes were assessed. RESULTS: AN was performed for complex staghorn calculi involving pelvis and all calyces in 10 patients, infundibular stenosis in two patients and failed PNL in one patient. Mean (SD) in situ cold ischemia time was 47.64 (5.27) minutes. Retroperitoneal drain and double J stent were placed in all 13 patients. Median (IQR) estimated blood loss was 130 (75) ml. There was no perioperative mortality. Surgical site infection was seen in 2 patients and urosepsis in 2 patients. Drain was removed at a mean (SD) of 9.11 (6.15) days. Mean (SD) postoperative length of hospitalization was 15.44 (7.14) days. Stent removal was done in all patients between 2-8 weeks. Median (IQR) clearance was 95 (7.5%). There was no renal failure or new calculi during the follow up period {median (IQR): 1(3) years}. CONCLUSION: AN is effective in management of large staghorn calculi failed minimally invasive approaches and achieves 80%-100% clearance without much need for secondary interventions. Renal function is preserved and with emergence of laparoscopy and robotics, postoperative stay is minimized with expedited recovery and comparable results with open surgery.

Efficacy of preprocedural diclofenac in men undergoing double J stent removal under local anesthesia: A double-blind, randomized control trial.

INTRODUCTION: Double J (DJ) stents are often removed under local anesthesia using a rigid cystoscope. Patients experience significant pain during this procedure and also continue to have discomfort during voiding for a few days. We assessed the efficacy and safety of preemptive oral diclofenac in pain relief in patients undergoing DJ stent removal (DJSR) by rigid cystoscopy compared to placebo. METHODS: Consecutive consenting male patients undergoing DJSR under local anesthesia between March 2014 and July 2015 were enrolled. Patients were randomized to receive 75 mg oral diclofenac (Group A) or placebo (Group B) 1 h before procedure by double-blind randomization. Intraurethral 2% lignocaine gel (25 ml) was used in both groups. Pain during rigid cystoscopy, pain at the first void, and at 24 h after cystoscopy was assessed using visual analog scale (VAS) (0-100). Adverse reactions to diclofenac and episodes of acute urinary retention, if any, were assessed (Trial registered at clinicaltrials.gov: NCT02598102). RESULTS: A total of 121 males (Group A [n = 62]; Group B [n = 59]) underwent stent removal. The median (Interquartile range) VAS during the procedure in Group A was 30 (30) and Group B was 60 (30) (P < 0.001), at first void was 30 (30) and 70 (30) (P < 0.001) and at 24 h postoperatively was 20 (20) and 40 (20) (P < 0.001). The incidence of epigastric pain, nausea, vomiting, and acute urinary retention was comparable in the two groups (P > 0.05). CONCLUSIONS: A single oral dose of diclofenac administered 1 h before DJSR using rigid cystoscope under intraurethral lignocaine anesthesia decreases pain significantly during and up to 24 h postprocedure with minimal side effects.

Penile Circular Fasciocutaneous (McAninch) Flap as an Option for Complex Anterior Urethral Stricture in Case of Non-Viable Buccal Mucosal Graft.

The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially when buccal mucosa is unavailable due to various reasons. A 65-year-old gentleman, chronic smoker and tobacco chewer, hypertensive on treatment, presented with obstructive lower urinary tract symptoms for 8 months. He had no prior urethral catheterization. On examination, he had circumcised penis, with stenosis of the external urethral meatus. Glans had no changes suggesting balanitis xerotica obliterans. Suprapubic cystostomy was done as he developed acute urinary retention during evaluation. Retrograde urethrogram (RGU) showed pan-anterior urethral stricture. He was planned for substitution urethroplasty. On oral cavity examination, he had moderate trismus with oral submucous fibrosis. As buccal mucosal graft was unavailable, he was planned for FCF. A ventral onlay tubularization FCF urethroplasty from meatus to bulbar urethra based on dartos dorsal pedicle was done. His postoperative recovery was uneventful. Pericatheter RGU did not show extravastion and he voided well with Qmax 14 ml/second. He is doing well at follow-up.

Evaluation of CROES Nephrolithometry Nomogram as a Preoperative Predictive System for Percutaneous Nephrolithotomy Outcomes.

PURPOSE: Scoring systems have been devised to predict outcomes of percutaneous nephrolithotomy (PCNL). CROES nephrolithometry nomogram (CNN) is the latest tool devised to predict stone-free rate (SFR). We aim to compare predictive accuracy of CNN against Guy stone score (GSS) for SFR and postoperative outcomes. MATERIALS AND METHODS: Between January 2013 and December 2015, 313 patients undergoing PCNL were analyzed for predictive accuracy of GSS, CNN, and stone burden (SB) for SFR, complications, operation time (OT), and length of hospitalization (LOH). We further stratified patients into risk groups based on CNN and GSS. RESULTS: Mean ± standard deviation (SD) SB was 298.8 ± 235.75 mm2. SB, GSS, and CNN (area under curve [AUC]: 0.662, 0.660, 0.673) were found to be predictors of SFR. However, predictability for complications was not as good (AUC: SB 0.583, GSS 0.554, CNN 0.580). Single implicated calix (Adj. OR 3.644; p = 0.027), absence of staghorn calculus (Adj. OR 3.091; p = 0.044), single stone (Adj. OR 3.855; p = 0.002), and single puncture (Adj. OR 2.309; p = 0.048) significantly predicted SFR on multivariate analysis. Charlson comorbidity index (CCI; p = 0.020) and staghorn calculus (p = 0.002) were independent predictors for complications on linear regression. SB and GSS independently predicted OT on multivariate analysis. SB and complications significantly predicted LOH, while GSS and CNN did not predict LOH. CNN offered better risk stratification for residual stones than GSS. CONCLUSION: CNN and GSS have good preoperative predictive accuracy for SFR. Number of implicated calices may affect SFR, and CCI affects complications. Studies should incorporate these factors in scoring systems and assess if predictability of PCNL outcomes improves.

Laparoendoscopic single site surgery for extravesical repair of vesicovaginal fistula using conventional instruments: Our initial experience.

OBJECTIVE: Vesicovaginal fistula (VVF) is a major complication with psychosocial ramifications. In literature, few VVF cases have been managed by laparoendoscopic single site surgery (LESS) and for the 1(st) time we report VVF repair by LESS using conventional laparoscopic instruments. We present our initial experience and to assess its feasibility, safety and outcome. PATIENTS AND METHODS: From March 2012 to September 2015, LESS VVF repair was done for ten patients aged between 30 and 65 (45.6 ± 10.15) years, who presented with supratrigonal VVF. LESS was performed by modified O'Conor technique using regular trocars with conventional instruments. Data were collected regarding feasibility, intra- or post-operative pain, analgesic requirement, complication, and recovery. RESULTS: All 10 cases were completed successfully, without conversion to a standard laparoscopic or open approach. The mean operative time was 182.5 ± 32.25 (150-250) min. The mean blood loss was 100 mL. The respective mean visual analog score for pain on day 1, 2, and 3 was 9.2 ± 1, 5 ± 1, and 1.4 ± 2.3. The analgesic requirement in the form of intravenous tramadol on days 1, 2, and 3 was 160 ± 51.6, 80 ± 63.2, and 30 ± 48.3, mgs respectively. No major intra- or post-operative complications were observed. The mean hospital stay was 2.6 ± 0.7 (2-4) days. CONCLUSION: In select patients, LESS extravesical repair of VVF using conventional laparoscopic instruments is safe, feasible with all the advantages of single port surgery at no added cost. Additional experience and comparative studies with conventional laparoscopy are warranted.

Ureteric lymphoma as a rare cause of right lower ureteric obstruction.

Primary lymphoid neoplasms of the urinary tract are exceedingly rare, with only 21 cases being reported and comprising less than 5% of all primary extranodal lymphomas. We report a case of a 45-year-old man who presented with right flank pain and weight loss, and who was found to have a stricture in the right lower ureter causing ureteral obstruction. Histopathology revealed lower ureteric non-Hodgkin lymphoma, which, on further evaluation, was found to be isolated ureteric lymphoma. The patient was doing well after six cycles of R-CHOP chemotherapy. This case is being reported as a rare cause of distal ureteric obstruction.

Living donor intestinal transplant using a standardized technique: first report from India.

AIM: We describe the first living donor intestinal transplant (LDIT) in India and discuss the indications and problems of this complex procedure. METHODS: A 43-year-old male patient required massive bowel resection for gangrene due to thrombosis of the superior mesenteric artery. He was maintained on parenteral nutrition but developed cholestasis and well as repeated catheter related infections with progressive loss of venous access due to thrombosis of central veins. A LDIT was performed using 200 cm of small intestine from the patient's son. The graft was based on the continuation of the superior mesenteric vessels beyond the ileocolic branch. The artery was anastomosed directly to the aorta and the vein to the venacava. RESULTS: The graft functioned well and he was weaned off parenteral nutrition. However, he later developed complications (wound dehiscence and enterocutaneous fistula) and developed sepsis. He succumbed to sepsis with a functioning graft 6 weeks after the transplant. The donor recovered uneventfully and was discharged on the 4th postoperative day. CONCLUSIONS: LDIT can be life saving in patients with intestinal failure and failure of parenteral nutrition. There is a need to introduce this modality in India. In a setting of scarcity of deceased donor organs the living donor option has advantages.