Overactive bladder: A multicenter study in Pakistan.

OBJECTIVE: To determine the overall prevalence of overactive bladder in Pakistan, and to determine the difference in prevalence in relation to gender. METHODS: The multicenter study was conducted from February 2017 to October 2018 at 11 institutions across the country, and comprised randomly selected healthy subjects of either gender who were assessed on the basis of symptoms defined by the International Continence Society for overactive bladder. Data was collected using a questionnaire based on the symptoms which was filled for the respondent by designated health workers. Data was analysed using SPSS 23. RESULTS: Of the 1291 respondents, 632(49%) were males with a mean age of 37.8±14.4 years, and 659(51%) were females with a mean age of 38.3±13.7 years. The overall prevalence of overactive bladder was 82(6.4%). Among the males, it was 15(2.4%) and among the females 67(10.2%) (p=0.001). Urgency, frequency and nocturia were reported by 82(6.4%) respondents; 15(1.2%) males and 67(5.2%) females (p=0.001). CONCLUSIONS: The prevalence of overactive bladder was found to be low when assessed with strict application.

Vesicouterine fistula.

A 41 years lady presented with 13 years history of urinary incontinence alongwith menouria, which had developed after the first vaginal delivery. However, she had four normal vaginal deliveries later. Intravenous urography showed normal flow on both sides but there was spillage of contrast from the urinary bladder into the uterus, in the cystographic phase. Cystoscopy showed a fistulous opening in the posterior wall of bladder above the trigone. She was subjected to total abdominal hysterectomy with repair of the fistulous bladder opening. Postoperative recovery was smooth and the patient became asymptomatic.

Transitional cell carcinoma of ureter in a solitary functioning kidney.

We present a 60 years old male with transitional cell carcinoma of the left ureter. The right kidney was non excretory while the left one was the solitary functioning kidney with multiple renal cysts. He had presented with significantly deranged renal profile and left obstructed ureter. The ureterorenoscope could not be negotiated so exploration of the left ureter was done. This showed a growth in left ureter, confirmed as transitional cell carcinoma (TCC) on histopathology. Subsequently excision of the distal left ureter along with the tumour and the cuff of bladder (segmental ureterectomy) was contemplated. Proximally transureteroureterostomy was performed. Postoperative recovery was smooth and the renal profile became normal within 3 months.

Inverted papilloma of ureter: a rare cause of hydronephrosis.

A case of hydronephrosis with a rare underlying cause in a 35 years old male is described. He reported with pain in the left lumbar region with a past history of left ureterolithotomy. The ultrasound and IVU studies were suggestive of left hydronephroureter. CT Scan showed left hydronephroureter with narrowing at the lower end of left ureter. Ureterorenoscopy (URS) confirmed polypoidal lesions in the left lower ureter, completely obliterating the lumen and involving the whole circumferential wall of the lower ureter. The biopsy of the lesion revealed an inflammatory polyp. Accordingly open surgical intervention was planned. Excision of the lower third of left ureter with ureteric reimplantation was done with a Boari flap. The histopathology report of the lower third of ureter confirmed inverted papilloma of ureter. The patient made a smooth postoperative recovery.

Ureterovaginal fistula--etiological factors and outcome.

OBJECTIVE: To assess the etiological factors and the outcome of ureterovaginal fistula in an urban setting. METHODS: The observational study was conducted at the Armed Forces Institute of Urology, Military Hospital, Rawalpindi, from January 2009 to January 2011. All the patients of uretero-vaginal fistula at the centre were included on the basis of non-probability purposive sampling. The etiology, clinical presentation and the investigative procedures were recorded. The operative modality contemplated was noted and post-operative results were evaluated. The data was entered in a structured proforma and analysed for descriptive statistics using SPSS version 14.0. RESULTS: Seventeen cases of ureterovaginal fistula were recorded. Amongst these 10 (58.8%) were post-hysterectomy, while 7 (41.1%) cases post-caesarean section. The emergency procedures performed by the residents/junior registrars contributed 12 (70.2%) of the cases. All these patients were treated surgically; 14 (82.3%) were managed with ureteroneocystostomy, 2 (11.7%) required Boari Flap reconstruction, and in psoas hitch was performed in 1 (5.8%) case. The time of intervention was 4 - 12 weeks (9.76 +/- 2.223). Post-operatively, only 1 (5.8%) case had superficial wound infection and 1 (5.8%) urinary tract infection. All the patients remained dry with a follow-up period of 3 - 24 months (mean 12.24 +/- 6.879). CONCLUSION: Ureterovaginal fistula is one of the complications of emergency procedures, especially in the hands of inexperienced surgeons. Prompt diagnosis and surgical intervention produce excellent results. Intervention can be done safely as early as 4 weeks after the initiation of the condition.

Bulbar uretheral stricture repair with buccal mucosa graft urethroplasty.

OBJECTIVE: To evaluate the use of buccal mucosa graft in single stage urethral reconstruction of bulbar urethral stricture. METHODS: In Armed Forces Institute of Urology Rawalpindi, from Jan 2008 to Oct 2009, 56 patients underwent single stage dorsal onlay urethroplasty using buccal mucosa graft for long bulbar urethral strictures (> 2cm). Urethra was incised along the strictured segment in the 12 o'clock (dorsal) position starting from the distal end. A buccal mucosa graft of required length was harvested. The graft was anchored in a spread fixed fashion to the corporal bodies opposing the dorsally incised strictured urethra. The urethra was rotated back to the normal anatomic position. The margins of urethral incision were sutured to the fixed graft edge and corporal body using interrupted 4-0 vicryl. After completion of right margin's stitches, a 16 Fr silicon catheter was placed and then left margin stitches were completed. RESULTS: Only 54 out of 56 patients could be evaluated because 2 patients were lost to follow up. Mean age of the patients was 48 +/- 11.32 years (range 19-67 yrs). Mean length of the buccal mucosa graft was 3.4 +/- 0.6 cm (range 2.6 - 5.5 cm). Duration of follow up was 4-20 months, mean 16.3 +/- 3.65 months. In 47 (87%) patients, the procedure was successful, 7 (13%) patients developed recurrence, out of these 7 patients, 2 (3.7%) required optical urethrotomy and 5 (9.25%) patients responded to urethral dilatation. Mean operative time was 92 +/- 13.22 minutes. CONCLUSION: Buccal mucosa graft urethroplasty produces encouraging results in long bulbar urethral strictures. Longer follow up is required.

Bladder outlet obstruction in a 5 years boy.

We report a 5 years old boy with bladder outlet obstruction secondary to a fibroepithelial polyp of prostatic urethra. The micturating cystourethrogram showed a filling defect in the posterior urethra. Cystourethroscopy revealed a polyp in the prostatic urethra proximal to the verumontanum. Transurethral resection was done and histopathology confirmed fibroepithelial polyp of the urethra.

A rare complication of forgotten ureteral stent.

A 35 years old lady presented with history of something coming out of the genitalia for the last 5 days. She also had history of pain in the left lumbar region which was initially investigated but the patient did not follow-up. About 15 years ago she also underwent left ureteric reimplantation. On examination, a stick like tube was protruding out of the urethral meatus which was fixed to the underlying vesical calculus. The calculus was evident radiologically and on ultrasound. The projecting portion of the stick like tube was cut and the vesical calculus with the inner portion of the tube was removed by open procedure. On evaluation of the specimen, it was found that the vesical calculus was fixed to the plastic tube which had concretions around it. This plastic tube had been placed after the ureteric reimplantation done 15 years ago and the patient was not aware of it.

Pattern of malignant renal tumours using 2004 WHO classification of renal tumours on radical nephrectomy.

OBJECTIVE: To determine the type of malignant renal tumours subjected to radical nephrectomy at a tertiary care urology unit using the 2004 WHO classification for renal tumours. METHODS: It was an observational study conducted at Department of Urology, AFIU Rawalpindi, from October 2008 to September 2010. The study included 92 patients with malignant renal tumours of both genders aged above 15 years. The histopathological types and grades were recorded along with the gross tumour presentation. The data was entered in structured proforma and analysed for descriptive statistics using SPSS-14. RESULTS: Over the span of 24 months study, 92 cases of malignant renal tumours were subjected to radical nephrectomy. The age was 16-82 (57.23 +/- 14.61) Years and male to female ratio was 2.1:1. The lesions were mostly unifocal (96.7%) and 58.6% affecting the right side. The commonest malignant renal tumour encountered was the conventional clear cell renal carcinoma (78.2%). The other tumours in descending order were the transitional cell carcinoma (7.6%), papillary (chromphilic) renal cell carcinoma (6.5%), renal cell carcinoma unclassified (3.2%), chromophobe renal cell carcinoma (2.1%), Wilm's tumour and oncocytoma (1.7%). T1 lesions were found in 42 cases (45.6%), T2 lesions in 25 cases (27.1%), T3a lesions in 17 cases (18.4%) each, while 8 cases (8.6%) had T3b lesions. Four cases had high and 3 had low grade lesions in transitional cell carcinoma. Wilm's tumour had favourable prognosis, 1 case had oncocytoma limited to kidney. Among the rest, 26 (28.2%) were G1, 35 (38%) were G2, 16 (17.3%) were G3, and 6 (6.5) were G4. CONCLUSION: The commonest type of the malignant renal neoplasm remains the clear cell (conventional) renal cell carcinoma. The lesions from T1 to T3 are amenable to radical nephrectomy and may not include the ipsilateral adrenalectomy as well. The grade may range from G1 to G4.

Fracture penis with complete urethral disruption during intercourse.

We present a rare case of fracture penis with complete urethral disruption in a 38 years old male. This resulted in an erect penis during sexual intercourse. He presented with diffuse and tense swelling of the penis along with acute urinary retention and distended urinary bladder. Emergency exploration revealed complete urethral disruption with tears in both corpus cavernosa. Evacuation of haematoma, repair of corpora and primary urethral repair was performed. Post-operative recovery was smooth and the patient developed satisfactory erectile and voiding function.

Metastatic malignant pheochromocytoma of adrenal gland.

Malignant pheochromocytoma is a rare disease with a high mortality. Surgical removal is usually curative while chemotherapy and radiotherapy are palliative treatments. A case of metastatic malignant pheochromocytoma of the right adrenal gland is presented who had fluctuating blood pressure with episodic headache and raised urinary VMA levels. Thoraco-abdominal resection of the tumour resulted in control of blood pressure and patient was asymptomatic at 4 months follow-up.

Polypropylene mesh repair of incisional hernia.

OBJECTIVE: The purpose of this study is to report the results of tension-free repair of primary and recurrent incisional hernias using polypropylene (Prolene) mesh. DESIGN: Descriptive Study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Kharian and Pano Aqil from January 1998 to September 2002. SUBJECTS AND METHODS: Twenty-seven patients underwent tension-free repair of primary and recurrent incisional hernias with polypropylene mesh in extrafascial position. Nine of them had recurrent incisional hernias, 02 hernias were irreducible and 01 presented with acute intestinal obstruction. Ten patients had hernias in the midline incision, 04 at paramedian incision and rest of them had hernias on transverse abdominal incisions. RESULTS: The mean age was 43.7 years. The only death occurred in a known cirrhotic presenting with obstructed hernia. Another patient was seen developing seroma and wound infection in one case. No recurrence was seen during the mean follow-up period of 2.2 years. CONCLUSION: The tension-free repair of incisional hernia, with polypropylene mesh in extrafascial position, is safe and easy procedure with acceptable morbidity and no recurrence.