Predictors for severe hemorrhage requiring angioembolization post percutaneous nephrolithotomy: A single-center experience over 3 years.

CONTEXT AND AIM: About 1% of the patients undergoing percutaneous nephrolithotomy (PCNL) have bleeding severe enough to require angioembolization. We identified factors which could predict severe bleeding post-PCNL and reviewed patients who underwent angioembolization for the same. SETTINGS AND DESIGN: This is a single-institutional, retrospective study over a period of 3 years. SUBJECTS AND METHODS: We retrospectively studied 583 patients undergoing PCNL at our institute from 2013 to 2016. We analyzed nine patients (three from our institute and six referred patients) who underwent angioembolization for severe bleeding post-PCNL. We analyzed the preoperative characteristics, intraoperative findings, and postoperative course of these patients and compared this with those patients who did not have a severe post-PCNL bleeding. STATISTICAL ANALYSIS USED: Fischer's exact test and Chi-square test were used in univariate analysis. Logistic regression analysis was used in multivariate analysis with a value of P < 0.05 considered statistically significant. RESULTS: Three of the 583 patients (0.51%) who underwent PCNL at our institute required embolization to control bleeding. Preoperative characteristics that were significant risk factors for severe bleeding were a history of ipsilateral renal surgery (P = 0.0025) and increased stone complexity (P = 0.006), while significant intraoperative factors were injury to the pelvicalyceal system (P = 0.0005) and multiple access tracts (P = 0.022). Angiography revealed arteriovenous fistula in two patients and a pseudoaneurysm in seven patients. All patients underwent successful superselective angioembolization with preserved renal perfusion in six patients on control angiography postembolization. CONCLUSIONS: History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system are risk factors predicting severe renal hemorrhage post-PCNL. Early angiography followed by angioembolization should be performed in patients with severe post-PCNL bleeding who fail to respond to conservative measures.

Fractured Penis: Not So Rare!

INTRODUCTION: Penile fracture is a relatively common phenomenon. The main problem associated with this condition is the lack of patients' awareness on the urgency of the situation. This study reports the different modes of presentations and treatment results. MATERIALS AND METHODS: We reviewed 21 cases of penile fracture over 5 years. Parameters were mode of injury, age group, time interval before presentation, management, site of injury, urethral involvement, results, complications and erectile function at follow-up. RESULTS: The mean age of patients was 34 years, the mean time interval until presentation was 26 h. Cases involving the right corpus cavernosum comprised 57.14% and 42.85% were cases involving the left corpus cavernosum. Two patients had full circumferential urethral tear. Two patients developed wound infections and 2 patients developed mild penile curvature (<30°). These 4 patients had all presented late for treatment (>40 h). CONCLUSION: Urologists need to consider penile fracture a urological emergency and atypical presentations need to be considered when deciding on management.

TRUS Biopsy Yield in Indian Population: A Retrospective Analysis.

INTRODUCTION: The reported cancer detection rate of Trans-Rectal Ultrasonography (TRUS) biopsies (TRUS biopsy yield) has been around 30 percent in western countries. However it is much lower in Asian countries, including India. Hence a larger proportion of patients in India undergo unnecessary biopsies. AIMS: To find out the cancer detection rate of TRUS biopsy (TRUS biopsy yield) in contemporary Indian population. Also, to study the positive predictive values at different serum Prostate-Specific Antigen (PSA)/PSA Density (PSAD) cut off levels and suspicious Digital Rectal Examination (DRE) findings. MATERIALS AND METHODS: This retrospective study was carried out in a tertiary care institute. All symptomatic patients who underwent TRUS guided biopsy for indication of raised serum PSA level (>4 ng/ml) or suspicious DRE findings (nodule, irregularity, hard consistency, immobile rectal mucosa) from January 2012 to December 2014 were included. For serum PSA range (4-10) ng/ml, TRUS guided biopsy was done in patients with percent free/total PSA < 25. Statistical analysis used were Chi-square test, Mann-Whitney U-test, Spearman's rank correlation analysis and Receiver-Operating Characteristic (ROC) curve. RESULTS: Out of the 235 patients included, 60 patients had malignancy (overall cancer detection rate= 25.53%). The cancer detection rate for PSA ranges of (4-10) and (10-20) ng/ml was as low as 5.95% and 13.16% respectively. Patients with malignant disease had significantly smaller prostate gland size than patients with benign disease (53.89 vs 63.06; p-value <0.05). On the other hand, cancer detection rate was 100% for PSA greater than 50ng/ml. The cancer detection rates were only upto 10% for PSA density ranges upto 0.25 ng/ml/cm3. The Area Under the Curve (AUC) for PSA and PSAD was 0.876 and 0.884 respectively. Only one patient (0.43%) had post-biopsy complication (acute bacterial prostatitis) requiring hospital admission. CONCLUSION: The current serum PSA and PSAD cut offs of 4 ng/ml and 0.15 ng/ml/cm3 need to be raised for Indian population to increase its positive predictive value. Prospective study validation of this finding is lacking.

Role of calculated glomerular filtration rate using percutaneous nephrostomy creatinine clearance in the era of radionuclide scintigraphy.

CONTEXT: Gates method tends to over-estimate glomerular filtration rate (GFR) in borderline functioning kidneys. We study the role of calculated GFR in these cases in decision-making regarding performing kidney-sparing surgery or nephrectomy. AIMS: The aim of this study is to find the correlation between GFR calculated by percutaneous nephrostomy (PCN) urine creatinine clearance in obstructed kidneys and GFR by radionuclide scintigraphy. It also studies the role of this calculated GFR in borderline functioning kidneys. SETTINGS AND DESIGN: Single tertiary care center; retrospective. MATERIALS AND METHODS: A total of 46 patients in whom PCN was inserted as an emergency measure in an obstructed kidney and for whom diethylene-triamine-penta-acetic acid/ethylene-di-cysteine (DTPA/EC) scan was also done (Gates method) were analyzed retrospectively. PCN creatinine clearance was calculated for 3 consecutive days, and the mean value was used. STATISTICAL ANALYSIS USED: Pearson's correlational analysis; Chi-square test. RESULTS: Overall strong correlation was found between the two GFR values (Pearson's r = 0.540692, P < 0.001). Totally 26 patients (56.52%) had comparable GFR values (P > 0.05). Among the 36 patients with borderline functioning kidneys, DTPA/EC scan significantly over-estimated GFR in one-third of the patients. The management plan was changed in 7 out of those patients (46.67%), with nephrectomy performed in all instead of kidney-sparing procedure. When the highest value of calculated GFR was compared, 28 patients had comparable GFRs (60.87%). CONCLUSIONS: GFR based on radionuclide scintigraphy may be insufficient for evaluation of residual renal function to determine the management of obstructed kidney with borderline function. For adequate decision-making, other factors including creatinine clearance via PCN should also be considered. Gates method tends to overestimate GFR as compared to calculated creatinine clearance at low GFR levels.

High grade leiomyosarcoma of the testes.

Testicular leiomyosarcoma is a rare tumor. It may arise secondarily following exposure to radiotherapy, chronic inflammation, or usage of high dose anabolic steroids. However, in absence of risk factors, it is rarely seen. Only 15 cases of Primary Intra testicular leiomyosarcoma have been reported in world literature. We present a case of testicular tumor in an elderly male. Preoperative work up showed raised Lactate Dehydrogenase (LDH) levels. He underwent high orchidectomy. Histopathology and immunohistochemistry confirmed it to be a primary intra testicular leiomyosarcoma. A brief case report with review of literature is presented.