Forgotten double-J stent: Experience of a tertiary care center.

INTRODUCTION: We share our experience of managing 15 cases of forgotten double-J (DJ) stent in our tertiary care center. METHODS: This is a retrospective analysis of cases with forgotten DJ stent for a period of 2 years spanning from January 2017 to January 2019. The details included sex, age, literacy, socioeconomic status, stenting indication, duration of indwelling stent, presenting complaints, type of encrustations, various treatments given, intraoperative complications, and their management and eventual outcome. RESULTS: The male-to-female ratio was 2:1, and the mean age was 39.5 years (17-65). The mean indwelling time was 31.7 months. The majority of patients had an education score of 1 out of 7 and belonged to lower socioeconomic class according to the modified Kuppuswamy scale. The most common presentation was irritative voiding symptom. The complicated and heavily encrusted stents were managed by combination of endourological procedures, and procedures were staged whenever deemed necessary. Majority of the stents were removed with simple retrograde cystoscopic removal. There was no mortality in our study. CONCLUSIONS: A forgotten DJ stent affects population having low education score and belonging to the lower end of the socioeconomic class. Endourological procedures are quite successful in managing a forgotten DJ stent, provided the treatment options are selected judiciously and meticulously. We also suggest some protocols to be followed in our study in order to prevent a forgotten DJ stent.

Effects of fluid absorption following percutaneous nephrolithotomy: Changes in blood cell indices and electrolytes.

BACKGROUND AND AIMS: Effects of fluid absorption on hematological profile in the immediate postoperative period in patients undergoing percutaneous nephrolithotomy (PCNL) have not been given due importance. Considering the limited number of studies available, we conducted this study to evaluate the changes in hemodynamics, complete blood count (CBC), and electrolytes in patients undergoing PCNL using normal saline for irrigation in the prone position. Furthermore, we evaluated the common factors known to affect the absorption. MATERIALS AND METHODS: Forty American Society of Anesthesiologist Class I or II patients aged 18-65 years were recruited who underwent PCNL under general anesthesia. Heart rate, blood pressure (BP), CBC, and serum electrolytes were recorded preoperatively and just before extubation and compared using the Student's t-test. Correlation of these changes with height and total volume of irrigating fluid, total time of irrigation, duration of operation, and total intravenous fluids administered intraoperatively were performed using the Pearson's correlation coefficient. RESULTS: There was a statistically significant fall in mean hemoglobin (12.5 g/dL to 11.5 g/dL), packed cell volume (38.6%-35.6%), platelet count (2.9 × 105 cells/µL to 2.5 × 105 cells/µL), and sodium ion concentration (Na+) (138.9 meq/L to 137.7 meq/L) in the immediate postoperative period as compared to that of the preoperative values. Rest of the blood indices and electrolytes did not show any significant change. There was a significant rise in postoperative heart rate and BP. Postoperative systolic BP showed a significant positive correlation with the total volume of irrigating fluid. No significant correlation was observed with height and total time of irrigation. CONCLUSION: This study reveals that there is a significant fall in hemoglobin and Na+ during PCNL in the immediate postoperative period. Only, total volume of irrigating fluid and total duration of surgery had a significant correlation with blood cell indices.

Laparoscopic heminephrectomy in horseshoe kidneys: A single center experience.

INTRODUCTION: Laparoscopic approach in horseshoe kidney (HSK) is a challenge because of the aberrant vessels, the renal isthmus and the renal ectopia are all unique features of this anomaly encountered during the surgery. We report our single center experience with this technique in managing three patients with HSK. METHODS: A total of 15 cases (9 males and 6 females) were operated between June 2011 and December 2016 for various indications. Of these four patients were managed laparoscopically, two patients with HSK had non-functioning renal moiety underwent transperitoneal heminephrectomy. The third patient with a mass in right moiety with thin fibrous isthmus was successfully managed with laparoscopic heminephrectomy. Fourth patient with pelvi-ureteric junction obstruction with multiple renal calculi was managed with pyeloplasty and complete clearance of all calyceal the stones. RESULT: Mean operating time was 140 ± 1.8 (100-180) min, and estimated blood loss was 131 ± 12.6 (30-320) ml. The mean hospital stay was 2.3 ± 1.4 (1-5) days. There were no major intra- and post-operative complications except minimal postoperative discomfort. CONCLUSION: Laparoscopic nephrectomy is technically feasible, safe, and reliable for benign and malignant diseases in a HK with mainly three factors posing challenges during the surgery are the abnormal vasculature, division of the isthmus, and lower location of the kidney.

Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience.

Primary use of the autogenous arteriovenous access is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. In spite of troublesome comorbidities associated with basilic vein transposition (BVT), it is still the most preferred technique when autologous veins are not suitable to construct radio-cephalic fistula (RCF) and brachiocephalic fistula (BCF), arteriovenous fistula (AVF). The present study highlights our experience with BVT, with small incision technique, over a period of two years with excellent outcome. This retrospective study included all the patients who underwent BVT at our tertiary care center between March 2013 and March 2015. It was performed in patients with failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. The patients with minimum 3 mm basilic vein diameter on Doppler were only included in the study. A 3-cm horizontal incision was made in antecubital fossa to expose brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2-3 cm) were made to explore proximal part of basilic vein. Side branches of the vein were isolated and ligated. The divided basilic vein in antecubital fossa was brought over fascia through newly created subcutaneous tunnel followed by end-to-side anastomosis. A total of 18 (12 males and 6 females) underwent BVT in the two years period. The mean fistula maturation time was 42 ± 10 days. Maturation rate was 100%, and the postoperative flow rate was 290 ± 22 (mL/min). No bleeding, thrombosis, failure, pseudo aneurysm, or rupture occurred in our patients. Arm edema occurred in ix (33%) patients, infection in three (17%), and lymphorrhea in five (28%). The mean follow-up was six months. BVT is an alternative method with excellent initial maturation and functional patency rates requiring less extensive skin incision and surgical dissection. It is the most durable hemodialysis access procedure for those patients having multiple forearm AVF surgeries.

Renal stone in crossed fused renal ectopia and its laparoscopic management: Case report and review of literature.

Management of renal stone in crossed fused renal ectopia (CFRE) is difficult because of abnormal location, malrotation, and its relations with vertebral column and small bowel. Management is not standardized because of the paucity of literature and variable anatomy. We managed an 8-year-old boy with multiple renal stones in right side crossed kidney by laparoscopic pyelolithotomy and nephro pyeloscopy with the help of ureteroscope. Until now, there is only one prior report of laparoscopic pyelolithotomy in CFRE. We share our experience in this case and review the literature regarding the management of kidney stones in this rare anomaly.

Middle calyx ureterocalicostomy in ectopic pelvic kidney with ureteropelvic junction obstruction: Only alternative for renal salvage.

Anomalous kidneys are mostly asymptomatic and are often found incidentally during physical or radiological investigations for urological or other medical complaints. The associated genital anomalies ranges from 15% to 45%. Females are associated with bicornuate or unicornuate uterus, rudimentary or absent uterus while males have undescended testes, duplication of the urethra, and hypospadias. A 21 year old married female presented with on and off lower abdomen pain for the past one year with history of primary amenorrhea. On examination an ill defined tender lump palpated in the lower abdomen. USG showed left ectopic pelvic kidney with gross hydronephrosis. The computed tomography confirmed hydronephrotic left ectopic pelvic kidney in front of the sacrum with anteriorly directed renal pelvis with ureter located posteriorly. There was delayed excretion from the ectopic kidney but right kidney was in normal position and function. The diethylene triamine pentaacetic acid (DTPA) scan showed 33% function of the ectopic kidney. On diagnostic laparoscopy, the uterus was small hypoplastic with bilateral ovaries appearing normal. The patient was taken for open pyeloplasty where the ureter was transected below PUJ but for a dependent drainage, the middle calyx as was the most dependent calyx as seen on the CT-scan. So a middle calyx ureterocalicostomy was performed calyx with excellent outcome. The ectopic kidney always remains a challenge because of complex neurovascular anatomy, presence of viscera and associated UPJO, but for a dependent drainage, middle calyx ureterocalicostomy is a feasible option with excellent outcome as was in our case.

Homocysteinemia: A rare cause of priapism.

Priaprism is a persistent painful erection that continuous beyond or is unrelated to sexual stimulation. Majority of cases are idiopathic (46%), alcohol and drug related (21%), perineal trauma (12%), sickle cell anemia and hypercoagualable state related (11%). We report case of priapism caused by hyperhomocysteinemia with favorable outcome with only few cases so far reported in the literature to the best of our knowledge. A 31 year-old male referred to our institution with non resolving priaprism for the last 6 days. Immediate distal shunt (Al-ghorab) was created but it could not achieve the detumescence. The penile Doppler showed no flow into the corpora, so a proximal shunt (Quackels) was made which achieved satisfactory detumescence. On thorough evaluation for the cause of priaprism, only homocysteine level was found to be significantly raised (40.46 µmol/L), being the unusual and rare cause for priaprism. The patient was discharged on homocheck. In the follow-up the patient is on vacuum assisted device for the erectile dysfunction and has been advised for the penile implant. Priaprism being a urological emergency should be thoroughly evaluated even for the rare causes and should be timely intervened to avoid the unavoidable consequences of permanent erectile dysfunction.

Nephron-sparing surgery in case of emphysematous pyelonephritis.

Emphysematous pyelonephritis is fatal necrotizing infection where life saving emergency nephrectomy is recommended for severe cases, but we performed nephron sparing surgery. Elderly diabetic female presented with left flank pain and fever for 15 days. On examination tender lump was palpable in left lumbar region. Investigations showed hyperglycemia, leucocytosis and creatinine 3.0 mg/dl. NCCT-KUB suggested class 3B-EPN. Following emergency pigtail, a repeat CT-scan suggested upper and lower pole destruction. In open drainage both poles debrided with sparing of middle pole. Follow-up CECT-KUB showed spared kidney with normal function. No literature for nephron sparing surgery in similar cases of EPN was found.

Total endoscopic management of a large bladder leiomyoma.

Leiomyoma of the urinary bladder is a very rare entity and represents < 0.5% of all bladder tumours, with only 250 cases reported worldwide to date. We report a case of leiomyoma of the bladder 55 -year-old female presented with chief complaints lower abdomen pain since 1 year associated with intermittency, burning, frequency and hesitancy in micturation. Bimanual examination of the patient revealed a mass on the right side near the bladder neck. USG suggested a well circumscribed polypoidal soft tissue lesion seen projecting in urinary bladder lumen and attached to the posterior wall and base of bladder with no internal vascularity. On cystoscopic examination, large smooth sessile growth arising from the right postero-lateral wall was noted with right ureteric orifice not visualized. Magnetic resonance imaging showed Large well defined rounded soft tisssue lesion close to anterior surface of the cervix and vagina which was Isointense to the skeletal muscles on T1 and T2 images with small focal irregular cystic areas of necrosis seen. It could be urinary bladder neoplasm or sub serosal cervical fibroid. Transurethral resection of tumor was performed. The pathologic diagnosis was leiomyoma of the bladder. We discuss the diagnosis and management of leiomyoma of the bladder and briefly review the literature.

Urinothorax: A path, less travelled: Case report and review of literature.

Urinothorax is a very rare occurrence of urine in the pleural space. Urinothorax can occur as a consequence to percutaneous nephrolithotomy (PCNL), ureterorenoscopic lithotripsy (URSL) or shock wave lithotripsy (SWL). We herewith report a rare case of Urinothorax in a 35 years old male patient and discuss its current knowhow and clinical management.

Reno-invasive fungal infection presenting as acute renal failure: importance of renal biopsy for early diagnosis.

Renal zygomycosis, caused by invasive fungi, is a rare and potentially fatal infection. The patient usually presents with non-specific symptoms and renal failure. A 34-year-old male non-diabetic and without any predisposing factors for systemic fungal infection presented to the emergency department with diffuse abdominal pain, high-grade fever and acute renal failure with a serum creatinine of 6.5. A computed tomography showed bilateral diffuse globular nephromegaly. A urine smear for fungal examination showed right angle branching hyphae and kidney biopsy showed fungal hyphae within the glomeruli, tubules and interstitium. Although radiological investigations can give us a clue, the definitive diagnosis can only be made by kidney biopsy. A high index of suspicion and timely diagnosis is important for a proper management.

Laparoscopic heminephrectomy in nonfunctioning right moiety of a horseshoe kidney: Technical challenges and method to deal with.

Laparoscopic heminephrectomy in patients with horseshoe kidney is technically challenging procedure and only few cases have been reported in the literature. Various approaches have been described for handling the isthmus. We report the management of a case of symptomatic nonfunctioning right moiety of a horseshoe kidney secondary to ureteropelvic junction (UPJ) obstruction using Ligasure™ for vessel sealing and division of isthmus. We discuss here the various challenges during laparoscopic heminephrectomy and ways and tricks to deal with.

Retroperitoneoscopic pyelolithotomy: a minimally invasive alternative for the management of large renal pelvic stone.

INTRODUCTION: Large stones in renal pelvis can be treated with percutaneous nephrolithotomy (PCNL) or pyelolithotomy (either by open or laparoscopic techniques). PCNL is difficult in undilated system. For pyelolithotomy, laparoscopy is more preferable over the open surgery. Surgeons are more familiar with the tansperitoneoscopic anatomy than retroperitoneoscopic one, but retroperitoneoscopic approach can be attempted if we anticipate the problems in the transperitoneal route. CASE: A fifty years old gentleman presented to us with the complaint of dull aching right flank pain. On ultrasonographic examination, he was found to have a large stone in renal pelvis with minimal hydronephrosis and thickened omentum on right side. Xray KUB showed a large radio-opaque shadow in renal area. We did the CECT-Urogram of the patient to know the detailed anatomy, which showed a stone of 5.3 x 3.7 cm in right extra-rena pelvis without hydronephrosis and a large focal area of marked fat stranding in omentum on the right side in mid and lower abdomen with swirling of fat stranding on the superior aspect suggestive of omental infarction and torsion. Due to undilated caliceal system, we preferred laparoscopic surgery over the PCNL in this patient. As whole of the omental tissue was stuck on right side we decided to proceed with transperitoneoscopic route instead of retroperitoneoscopic one. The DJ stent was inserted preoperatively.The surgery was performed in the flank position with three ports, one 10mm port just antero-inferior to tip of 12th rib for camera and two 5mm working ports, one at anterior axillary line and other at renal angle. We created the retroperitoneal space with the customized balloon, made with the glove-fingure. RESULTS: The operative time was 1 hour 40 minutes, and there were no intra or post-operative complications. The stone was removed in toto. Patient was orally allowed on first postoperative day and foleys was removed on second day. patient was discharged on day 2. DJ stent was removed after 15 days. At two months follow-up the patient was asymptomatic. CONCLUSION: The retroperitoneoscopic pyelolithotomy is a good alternative for removal of large stone in renal pelvis, with the added advantages of no peritoneal contamination and a quick recovery of bowel function.

Delivery after augmentation cystoplasty: Implications and precautions.

A young female with history of genitourinary tuberculosis with solitary functioning kidney became pregnant 1 year after augmentation cystoplasty (AC) with ureteric reimplantation. Throughout pregnancy she had two episode of febrile urinary tract infection. Her renal function remained normal. She was planned for cesarian section due to obstetric indications. Despite altered pelvic anatomy, we successfully did the lower segment cesarian section. We reviewed the literature regarding pregnancy in patients with AC to find that what the treating Urologist and Gynecologist should know about these rare cases. Various complications which should be anticipated and measures to prevent them are also discussed.

Percutaneous management of renal caliceal diverticular stones: Ten-year experience of a tertiary care center with different techniques to deal with diverticula after stone extraction.

INTRODUCTION: Caliceal diverticulae are a frequent surgical problem. We present our experience with caliceal diverticular stones (CDS) managed with percutaneous nephrolithotomy (PCNL) and describe the two different techniques to deal with diverticula after stone retrieval. MATERIALS AND METHODS: We retrospectively analyzed 10-year data of 44 consecutive patients who underwent PCNL for CDS. During PCNL, if the guide wire could be negoted through the neck of the diverticula, we dilated and stented it. If we couldnot find the neck, we fulgurated the diverticular walls. Follow-up included intravenous urogram at 3 months and annual plain films thereafter. We analyzed the outcome, complications, and recurrence rate. RESULTS: Total stone clearance was obtained in 40 (90.90%) patients. We dilated and stented the diverticula in 35 (79.5%) patients and fulgurated the walls in nine (20.5%) patients. Complications occurred in three patients. The postoperative intravenous urogram showed obliteration of diverticula in seven patients and the improved drainage in 37 patients. At the average follow-up of 2 years, 41 (93.18%) patients were asymptomatic and two (4.5%) patients showed the recurrence of stone. CONCLUSIONS: PCNL can clear calculi from caliceal diverticula in most cases with minimal morbidity. After stone retrieval, the diverticula may be drained into the pyelocaliceal system, if the neck is negotiable and fulgurated if the neck cannot be dilated.

Inflammatory myofibroblastic tumor of the urinary bladder managed by laparoscopic partial cystectomy.

Inflammatory myofibroblastic tumor of the urinary bladder is a rare mesenchymal tumor with uncertain malignant potential. It often mimics soft tissue sarcomas both clinically and radiologically. Surgical resection in the form of partial cystectomy or transurethral resection remains the mainstay of treatment. Herein we report the case of an inflammatory myofibroblastic tumor in a young girl, which was managed by laparoscopic partial cystectomy. To the best of our knowledge, this is the first reported case of laparoscopic management of an inflammatory myofibroblastic tumor of the urinary bladder.

Management of 1-2 cm renal stones.

INTRODUCTION: The preferred treatment of >1cm stone is shockwave lithotripsy (SWL), while that of stone <2 cm is percutaneous nephrolithotomy (PCNL), but treatment of 1-2 cm renal stones is a controversial issue. We searched the literature to present a comprehensive review on this group. MATERIAL AND METHODS: Pubmed search of literature was done using the appropriate key words. We separately discussed the literature in lower polar and non lower polar stone groups. RESULTS: For non lower polar renal stones of 1-2 cm, SWL is preferred approach, while for the lower polar stones; literature favors the use of PCNL. Retrograde intrarenal surgery (RIRS) is emerging as a promising technique for these calculi. CONCLUSIONS: Treatment of renal stone disease depends on stone and patient related, as well as on renal anatomical factors. Treatment should be individualized according to site of stone and available expertise.

Dorsal onlay vaginal graft urethroplasty for female urethral stricture.

INTRODUCTION: Female urethral stricture is an underdiagnosed and overlooked cause of female bladder outlet obstruction. The possible etiologies may be infection, prior dilation, difficult catheterization with subsequent fibrosis, urethral surgery, trauma, or idiopathic. We present our technique and results of dorsal onlay full thickness vaginal graft urethroplasty for female urethral stricture. MATERIALS AND METHODS: A retrospective review was performed on 16 female patients with mid-urethral stricture who underwent dorsal onlay vaginal graft urethroplasty from January 2007 to June 2011. Of these, 13 patients had previously undergone multiple Hegar dilatations, three had previous internal urethrotomies. The preoperative work up included detailed voiding history, local examination, uroflowmetry, calibration, and micturating cystourethrogram. RESULTS: All patients had mid-urethral stricture. Mean age was 47.5 years. Mean Qmax improved from 6.2 to 27.6 ml/s. Mean residual volume decreased from 160 to 20 ml. Mean duration of follow-up was 24.5 months (6 months to 3 years). Only one patient required self-calibration for 6 months after which her stricture stabilized. None of the patient was incontinent. CONCLUSION: Dorsal vaginal onlay graft urethroplasty could be considered as an effective way to treat female urethral stricture.

Endoscopic management of emphysematous periurethral and corporal abscess.

We came across an interesting case which was presented with fever, dysuria and perineal pain, not responding to antibiotics. The computed tomography scan showed periurethral abscess containing multiple air specs with involvement of bilateral corpora cavernosa. We successfully treated this patient with endoscopic drainage. Spontaneous periurethral and corporal abscess in male is a rare entity and emphysematous form in corpora has not been described before.