A retrospective analysis of the factors associated with increased risk of readmission within 30 days after primary transurethral resection of bladder tumor.

Background: Transurethral resection of bladder tumor (TURBT) is associated with perioperative morbidity of 5% to 10%, which can lead to unplanned readmissions. In this study, we aimed to identify the factors that lead to an increased risk of unplanned readmissions within 30 days of primary TURBT. Materials and methods: A retrospective study was conducted to identify patients who underwent primary TURBT at our institute from 2011 to 2019. Clinical and demographic factors, history of smoking, antiplatelet drugs intake, comorbidities, tumor size (<3 or >3 cm), multifocality, and histopathological type were abstracted. Patients who were readmitted were identified, and reasons for admission were recorded. Results: A total of 435 patients were identified. The median age of the patients was 66 years. From 378 male patients (86.9%), 110 (25.3%) and 37 (8.5%) had a history of smoking and antiplatelet agents intake, respectively. In the cohort, 166 patients (38.2%) were diabetic, 239 (54.9%) were hypertensive, 72 (16.6%) had chronic obstructive pulmonary disease, and 78 (7.9%) had hypothyroidism. A total of 206 patients (47.4%) had a tumor >3 cm; multifocality was seen in 140 (32.2%) patients, whereas muscle invasive tumors were present in 161 patients (37%). A total of 22 patients (5.06%) had readmissions within 30 days, with hematuria being the most common etiology. On univariate and multivariate analyses, a history of smoking (p = 0.006 and p = 0.008, respectively) or antiplatelet agents intake (p < 0.001 and p < 0.001, respectively) was significantly associated with increased unplanned readmission. Conclusions: Our study revealed smoking and antiplatelet agents intake as factors leading to an increased risk of unplanned readmissions.

Para-aortic nodal metastasis of mesenteric perivascular epithelioid cell tumor (PEComa).

Perivascular epithelioid cell tumors (PEComas) are a group of tumours of mesenchymal origin having a characteristic pathological presence of the epitheloid cell around blood vessels. They are uncommon tumours and hence their exact etiology and pathogenesis remain unclear. They can occur at any part of the body but the common sites of involvement are the gastrointestinal system and the genitourinary system. The isolated involvement of the intestinal mesentery is very rare, with only a few cases reported in the literature till date. The involvement of lymph nodes by these tumours is exceptionally rare. We report a hitherto undescribed case of mesenteric PEComa in a young female who developed para-aortic nodal metastasis.

The clinical conundrum of a catecholamine secreting giant adrenal myelolipoma.

Adrenal myelolipomas are uncommon tumours of unknown aetiology. They arise from the adrenal cortex and comprise lipomatous and myeloid elements. They are considered to be functionally inert, and metabolic evaluation is not mandatory for them. Adrenal myelolipomas can rarely be functionally active, and patients may present with hypertension, electrolyte imbalance or features of Cushing's syndrome. The association of these tumours with catecholamine secretion is exceptionally rare. We describe a case of a functional adrenal myelolipoma associated with catecholamine secretion in a 55-year-old female patient with a history of hypertension. The surgical excision of the mass resulted in normalisation of the urinary catecholamine levels and resolution of the hypertension.

Clinicopathological characteristics, prognostic factors and treatment outcomes of seminomatous germ cell tumours from a tertiary cancer centre in eastern India.

Background: . Seminomatous germ cell tumour (SGCT) is a rare but curable malignancy of young adults. The literature on management and outcome of SGCT is scarce from India. We report the demography and treatment outcome of SGCT at our centre. Methods: . We did a retrospective analysis of patients with SGCT treated from March 2011 to December 2018. Patients were staged appropriately with imaging, and pre- and postoperative tumour markers. High inguinal orchiectomy was performed in all with a testicular primary and received subsequent stage-adjusted adjuvant treatment. Patients were monitored for metabolic syndrome during follow-up after completion of treatment. Results: . We treated 85 patients with a median age of 37 (range 20-68) years. The primary site of the tumour was the testis in 80 (94%) and mediastinum in 5 (6%) patients. Cryptorchidism was present in 20 (25%) patients and testicular violation was present in 11 (14%) patients. Stage of the disease was I in 61, II in 13 and III in 6 patients. Adjuvant treatment in stage I disease was single-agent carbo-platin (area under the curve ×7) in 38 (62%), surveillance in 20 (33%) and radiotherapy in 3 (5%) patients. Five patients in the surveillance group relapsed. The 7-year mean (SD) relapse-free survival and overall survival were 83.1% (8%) and 98.7% (1.3%), respectively. Thirty-one patients (n = 52, 60%) had features of metabolic syndrome. Conclusions: . SGCTs have a high cure rate. Long-term follow-up is essential for monitoring toxic effects. Early diagnosis, avoidance of testicular violation and multidisciplinary management are the key features for better long-term outcome in SGCT.

Simplifying Laparoscopic Nephrectomy for Beginners: Double Window Technique With En Bloc Hilar Stapling.

Laparoscopic nephrectomy is a commonly performed procedure. As with any surgical procedure, this too has a significant learning curve. The management of renal hilum is the most critical part of this surgery. It requires a meticulous intra-hilar dissection to identify the renal artery and vein. The kidneys are extremely vascular structures and any injury to these vessels during dissection can result in life-threatening bleeding. Hence, it is obvious that beginners most often face difficulty and apprehension at this step of the laparoscopic nephrectomy. We describe a simple technique of laparoscopic nephrectomy which includes the creation of two windows, one at the lower pole and the second at the upper pole, isolation of the hilum, and en bloc stapling of the renal hilar vessels. This method safeguards against collateral damage to the surrounding structures. It also avoids the need for intra-hilar dissection, hence decreasing the chances of vascular injuries.

Outcome of testicular non-seminomatous germ cell tumours: report from a tertiary cancer centre in eastern India.

Non-seminomatous germ cell tumour (NSGCT) is a rare but highly curable malignancy. The literature on the management and outcomes of NSGCT is scarce from India. Here, we report the demography and treatment outcomes of NSGCT treated at our centre. This is a retrospective analysis of testicular and retroperitoneal NSGCT patients treated from March 2011 to December 2019. Patients were staged appropriately with imaging, pre- and post-operative tumour marker. Patients received stage adjusted adjuvant treatment after high inguinal orchiectomy. Patients with advanced disease were risk stratified as per International Germ Cell Cancer Collaborative Group (IGCCCG) classification. A total of 100 patients were treated with a median age of 28 years (Range: 18-51). Primary site was testis in 92 and retroperitoneum in 8 patients. Testicular violation was present in 17 (18%) patients. The stage of the disease was I in 32, II in 19 and III in 49 patients, respectively. IGCCCG risk groups were good in 29 (46%), intermediate in 13 (21%) and poor in 21 (33%) patients. Eleven patients (24%) underwent retroperitoneal lymph node dissection amongst 45 with post-chemotherapy residual disease. After a median follow-up of 26.6 months (range: 2.2-100.7), 3-year event-free survival and overall survival (OS) were 70.7% ± 5.6% and 78.2% ± 5.4%, respectively. S3 tumour marker (p = 0.01) and non-pulmonary visceral metastasis (p < 0.001) emerged as independent poor prognostic factors for OS in multivariate analysis. To conclude, testicular NSGCT has very high cure rate. Two-third patients present with advanced disease and one-third of them had poor risk disease. S3 tumour marker and non-pulmonary visceral metastasis are poor risk factors for OS.

Clear cell renal cell carcinoma with hemangioblastoma-like features: A recently described pattern with unusual immunohistochemical profile.

The diagnosis of clear cell renal cell carcinoma may sometimes pose challenges because of the presence of uncharacteristic morphology, varied immunophenotypic patterns and due to lack of molecular or genetic determinants. More often, the morphological variations can be easily overlooked in routine practice and a more common diagnosis is usually put forward. Solid, acinar and alveolar are the common patterns described in the literature. We report a recently described pattern of clear cell renal cell carcinoma which has hemangioblastoma-like morphology and an unusual immunoprofile. In our case, the tumor showed a diffuse hemangioblastoma-like pattern and diffuse positivity for Alpha-inhibin on immunohistochemistry. A thorough literature search, extensive sampling and an expanded immunohistochemistry panel revealed a clear cell renal cell carcinoma component. Presence of renal vein thrombosis and focal necrosis were other helpful features in discerning the malignant nature of tumor.

Management of an iatrogenic injury in a crossed ectopic kidney without fusion.

Crossed renal ectopia is a condition in which a kidney is located on the side opposite of its ureteral insertion. Ninety percent of crossed ectopic kidneys are fused to their ipsilateral uncrossed renal unit. Crossed renal ectopia without fusion is rare, with only 62 patients reported in the literature to date. These kidneys may suffer iatrogenic injury during an unrelated surgical intervention. The injury, unless self-limiting, may necessitate the removal of the ectopic kidney. We present a unique case of a dual injury, renal as well as ureteric, in a crossed ectopic kidney without fusion that was successfully managed without surgical excision.

Bilateral single ectopic ureters draining into a grossly dilated vagina in an adolescent female.

A 16-year-old female presented with dribbling of urine along with voluntary voiding since birth. Renal imaging revealed hydroureteronephrosis on the right side; the uterus and ovary were normal. A radionuclide scan showed a left nonfunctional kidney. On cystovaginoscopy, the urethra was shown to be normal and the urinary bladder was tubular with small capacity and an absent trigone. Although the vagina was capacious, no ureteric orifices were found. Computed tomography corroborated the diagnosis of bilateral, single ectopic ureters draining into a grossly dilated vagina. This case is unique because it is a bilateral single-system ureteral ectopia in a completely differentiated female genital tract that presented late in adolescence. To the best of our knowledge, this is the second such ureteral abnormality reported in the literature so far. The patient underwent ileocystoplasty with right ureteric reimplantation and nephroureterectomy for the left nonfunctional kidney, which histopathology showed to be tuberculosis. The patient is continent with cystometric capacity of more than 300 mL.

Transobturator taping for the treatment of incontinence after neobladder reconstruction.

Incontinence in the patients with neobladder is a distressing condition. Although conservative management may be helpful in some, a significant number of patients require some form of surgical intervention. Any surgical intervention, especially from the abdominal route can be significantly morbid in these patients because of extensive surgery done previously. There is a need for a technique that can take care of the postoperative incontinence without subjecting the patient to significant surgical risk. Artificial sphincters have been used in male patients but their use in female patients can be technically difficult. There are limited options available for women like transurethral bulking agents and pubovaginal slings. These procedures do not have very good results and female patients often end up with a cutaneous stoma. We, in this report, describe a female patient with incontinence after orthotopic neobladder reconstruction that could be successfully treated with transobturator taping.

Comparison of the efficacy and safety of topical diltiazem and nitroglycerine for pain relief during transrectal ultrasound guided biopsy of the prostate.

INTRODUCTION AND OBJECTIVE: Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease this pain. This study was done to compare the efficacy and safety of two topical medications that relax the anal sphincter, diltiazem and nitroglycerine, in decreasing the pain associated with transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: 66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 mL of 2 % topical diltiazem or 2 mL of 0.2 % topical nitroglycerine or placebo 20 minutes before prostate biopsy. All patients also received 15 mL of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure. RESULTS: The pain scores due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine were significantly lower compared to the placebo group (p < 0.001). There were no significant differences in the pain scores between the patients receiving diltiazem compared to those receiving nitroglycerine. Higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine compared to those receiving diltiazem. CONCLUSION: Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal prostatic biopsy. Diltiazem is safer compared to nitroglycerine.

Comparison of the efficacy and safety of topical diltiazem and nitroglycerine for pain relief during transrectal ultrasound guided biopsy of the prostate

INTRODUCTION AND OBJECTIVE: Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease this pain. This study was done to compare the efficacy and safety of two topical medications that relax the anal sphincter, diltiazem and nitroglycerine, in decreasing the pain associated with transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: 66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 mL of 2% topical diltiazem or 2 mL of 0.2% topical nitroglycerine or placebo 20 minutes before prostate biopsy. All patients also received 15 mL of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure. RESULTS: The pain scores due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine were significantly lower compared to the placebo group (p < 0.001). There were no significant differences in the pain scores between the patients receiving diltiazem compared to those receiving nitroglycerine. Higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine compared to those receiving diltiazem. CONCLUSION:Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal prostatic biopsy. Diltiazem is safer compared to nitroglycerine.

Successful management of urethro-ileal pouch fistula by cynoacrylate glue instillation.

Uro-enteric fistulae are difficult clinical conditions that have a significant bearing on the patient's quality of life. Surgical correction, though challenging, is the usual mode of treatment offered to these patients. We describe a case of urethro-ileal pouch fistula which could be managed successfully without surgery with the help of cynoacrylate glue instillation.

"4 × 4 vasovasostomy": A simplified technique for vasectomy reversal.

OBJECTIVES: An ideal vasovasostomy procedure requires precise mucosal approximation with a watertight anastomosis. The standard two-layer microdot technique requires multiple sutures within each layer and is a technically difficult operation to perform. We describe a two-layered technique which adheres to the principles of tubular anastomosis, but is simpler and provides excellent results. MATERIALS AND METHODS: Patients with secondary infertility following a previous vasectomy underwent the modified two-layered vasovasostomy. Two 8-0 polyamide sutures were placed at 5 and 7 o'clock positions in the sero-muscular layer to approximate the two ends of the vas. Next, four double-armed, 10-0 polyamide sutures were sequentially placed, inside out in the mucosa of the vasal ends, at 3, 6, 9, and 12 o'clock positions and tied. Two additional sero-muscular sutures were placed at 1 and 11 o'clock positions to complete the anastomosis. Patients with a suspected proximal block in the epididymis underwent a vasoepididymostomy. Semen analysis was performed at 6 weeks after surgery. RESULTS: Between the period February 2008 and August 2009, eight men underwent vasectomy reversal using the 4 × 4 technique. The procedure was performed bilaterally in six men whereas two patients underwent a two-suture, longitudinal intussusception vasoepididymostomy on the second side. Mean operative time was 90 min per patient. All men had sperm in the ejaculate at the first semen analysis. There were no complications. CONCLUSIONS: The "4 × 4" modified two-layer vasovasostomy is a simple technique that can be performed in quick time with excellent results. It may allow a common ground between the complex microdot two-layer technique and the over-simplified single-layer procedure.

Intussusception vasoepididymostomy with longitudinal suture placement for idiopathic obstructive azoospermia.

PURPOSE: Surgical reconstruction is an important treatment option for obstructive azoospermia. Vasoepididymostomy results have primarily been described in men with previous vasectomy. We evaluated vaso-epididymal anastomosis outcomes using a 2-suture microsurgical intussusception technique with longitudinal suture placement in men with idiopathic obstructive azoospermia. MATERIALS AND METHODS: Between April 2007 and May 2009, 24 men with idiopathic obstructive azoospermia underwent 2-layer vaso-epididymal anastomosis using a 2-suture intussusception technique. Two double armed 10-zero polyamide sutures were placed parallel to each other longitudinally along the epididymal tubule to intussuscept the tubule into the lumen of the vas deferens for the inner layer of the anastomosis. Patency was assessed by return of sperm in the semen. RESULTS: A total of 23 men with a mean age of 31 years provided at least 1 postoperative semen sample. All had a mean 67-month history of primary infertility. In 11 men (48%) patency was noted a mean of 6.6 months (range 3 to 15) after surgery. One patient reported pregnancy by natural conception. Men with motile sperm in the epididymal fluid and those with bilateral surgery were more likely to have a patent anastomosis. CONCLUSIONS: Within 1 year after surgery approximately half of the men who underwent longitudinal vaso-epididymal anastomosis for idiopathic azoospermia had return of sperm in the ejaculate.

Laparoscopic pyeloplasty versus robotic pyeloplasty for ureteropelvic junction obstruction: a series of 60 cases performed by a single surgeon.

PURPOSE: To compare operative parameters and outcomes in 30 cases of robotic pyeloplasty (RP) versus 30 cases of laparoscopic pyeloplasty (LP), performed by a single surgeon, for ureteropelvic junction (UPJ) obstruction. METHODS: Patients with primary UPJ obstruction were included in the study. The same surgeon (AKH) performed RP (usually using a transperitoneal Anderson-Hynes technique) on 30 patients in Group I and employed LP on 30 patients in Group II, in a nonrandomized fashion. The patients were followed for 18 months postoperatively. Three robotic and one assistant port were required in Group I, and 3 or 4 ports were utilized in Group II. In Group I, 26 patients had antegrade double-J stenting, 1 patient had retrograde double-J stenting, and 3 patients had stentless RP. In Group II, 22 patients had antegrade double-J stenting and 8 patients had retrograde double-J stenting. RESULTS: The mean total operating times were 98 minutes and 145 minutes, the mean estimated blood losses were 40 mL and 101 mL, and the mean hospital stays of the patients were 2 days and 3.5 days, for patients in Group I and Group II, respectively. These patients were followed up postoperatively for 18 months. They received a clinical examination, an ultrasound, and a diuretic renal dynamic scan. At 18 months, imaging studies found no obstructions in the patients in Group I and found an obstruction in only one patient in Group II. One patient in Group II required a repeat open pyeloplasty following failed endoscopic management. CONCLUSION: In this patient series, UPJ obstruction was managed effectively with either RP or LP, and outcomes were durable. Compared to pure LP, pure RP enabled the surgeon to achieve quicker dissection, reconstruction, and intracorporeal suturing with fine sutures and with antegrade double-J stenting. With RP, the operating time was decreased, and the procedure offered greater ergonomic convenience to the surgeon. Long term postoperative success, however, was equivalent on follow up in both patient groups.

Robotic repair of complex vesicouterine fistula with and without hysterectomy.

OBJECTIVE: To present robotic repair of vesicouterine fistulae (VUF) with and without hysterectomy in 3 cases and to discuss the technique with its outcome. METHODS: Three patients were diagnosed with VUF, of whom 2 had a prior history of multiple cesarean sections and 1 had obstructed labor. Preoperative diagnosis of VUF was based on classic history, cystoscopy and imaging studies. All patients underwent pure robotic repair of VUF with hysterectomy in 1 case. The steps of the technique are cystoscopy, bilateral ureteral catheterization, port placement, adhesiolysis, separation of bladder and uterus and excision of the VUF with freshening of margins, closure of the uterus and bladder, hysterectomy in 1 case, and omental interposition. RESULTS: Robotic repair of VUF was successful in all cases with mean operative time of 127.5 min and average blood loss of 120 ml. One patient underwent simultaneous robotic hysterectomy. All patients were ambulatory on day 1 and were discharged on day 3 with indwelling Foley's catheter, which was removed on day 10. conclusion: Robotic repair of VUF is safe and effective with successful outcome in all cases and has all the advantages of open and laparoscopic surgery. If required, concomitant robotic hysterectomy can also be performed. This is the first case series in the world.

Transmesocolic robot-assisted pyeloplasty: single center experience.

PURPOSE: To demonstrate the technical feasibility of the transmesocolic approach of robotic pyeloplasty for left ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS: Between July 2006 and December 2007, 60 patients underwent robot-assisted pyeloplasty that included 33 cases on the right side and 27 cases on the left side. Of the 27 left-side cases, 24 were performed using a transmesocolic approach. Three left-side surgeries were performed by mobilizing the colon because of associated accessory vessel and renal calculi. A pure robot-assisted dismembered reduction pyeloplasty with excision of the ureteropelvic junction was performed in all cases. RESULTS: The mean operative time was 125.33 minutes. The time to perform the anastomosis was 43.58 minutes, and mean blood loss 38.7 mL. Average hospital stay was 2.5 days, and the drain was removed within 48 hours. One patient had prolonged drainage with fever because of a misplaced ureteral stent. Of the 24 patients, 23 were followed for 1 year and 1 was lost to follow-up. No patient demonstrated clinical or radiographic evidence of repeated obstruction. CONCLUSION: In the transmesocolic approach, mobilization of the colon is not necessary, and the UPJO can be approached directly after incising the mesocolon. This approach is safe and feasible in patients with a thin mesentry and when extensive mobilization of the kidney is not needed for any associated problems. The technique is highly effective with durable success rates similar to those of open surgery.