Impact of COVID-19 pandemic on non-COVID patient's management in urology: a public hospital experience in Mumbai.

BACKGROUND: To evaluate the impact of COVID-19 lockdown on non-COVID urological patient's management in tertiary care urology centres. METHODS: This is an observational study in which data of patients visiting the urology department of all the MCGM run tertiary care hospitals were recorded for the duration of 1 April 2020 to 31 July 2020 and were compared to data of pre-COVID-19 period of similar duration. RESULTS: There was a decrease of 93.86% in indoor admissions of urology patients during the COVID-19 lockdown. Indoor admissions for stone disease, haematuria, malignancy accounted for 53.65%, 15.85%, 9.75%, respectively. Elective surgeries had the highest percentage decrease followed by emergency and semi-emergency procedures. There was a reduction of more than 80% in patients attending outpatient clinics. Stone disease and its consequences were the main reasons for visiting outdoor clinics (39%). A substantial number of patients presented with flank and abdominal pain (14.8%) and benign enlargement of the prostate (10.23%). Malignancy accounted for a very small number of patients visiting outdoor clinics (1.58%). CONCLUSIONS: COVID-19 pandemic has a profound impact on patient care and education in Urology. There was more than ninety percent reduction in indoor admissions, operative procedures, and outpatient clinics attendance. Once the pandemic is controlled, there will be a large number of patients seeking consultation and management for urological conditions and we should be prepared for it. Surgical training of urology residents needs to be compensated in near future. Long-term impact on urological patient outcome remains to be defined.

Does site of buccal mucosa graft for bulbar urethra stricture affect outcome? A comparative analysis of ventral, dorso-lateral and dorsal buccal mucosa graft augmentation urethroplasty.

OBJECTIVE: To compare long- term outcomes of buccal mucosa graft (BMG) augmentation urethroplasty for long segment bulbar urethral strictures done by placing the graft ventrally, dorso-laterally and dorsally. MATERIAL AND METHODS: We conducted a single institution retrospective study on 112 who underwent BMG augmentation urethroplasty for non-traumatic bulbar urethral strictures between January 2005 to December 2014. The cases were divided into three groups based on the site of placement of BMG graft i.e. (a) Ventral (n=44), (b) Dorso-lateral (n=48) and (c) Dorsal (n=20). Follow-up period was from one year to five years. Patients with failed outcomes underwent urethroscopy or retrograde urethrogram to note the site of recurrence of stricture. RESULTS: Out of 112 cases 91 (81%) were successful and 21 (19%) failed. The success rates for ventral, dorso-lateral and dorsal BMG augmentation procedures were 89%, 79% and 70%, respectively (p=0.18). Among 21 failed cases, 12 cases (57%) had stricture at proximal anastomotic site, 4 cases (19%) at graft and 5 cases (24%) at distal anastomotic site (p=0.01). CONCLUSION: The overall success rate for BMG augmentation urethroplasty is equal for all techniques. Ventral onlay urethroplasty provides better exposure of proximal anastomotic site thus it is associated with minimum proximal anastomotic site recurrence rates. Patients with extensive spongiofibrosis and long segment strictures had higher rates of failure.

Bilateral single-system ectopic ureters opening into vaginalized urogenital sinus.

A 5-year-old female presented with continuous dribbling of urine without any voiding stream since birth. Upon investigations, the bladder neck and both ureters were opening into the vaginalized urogenital sinus and the urethra was absent. Coarctation of the aorta was an associated anomaly. To our knowledge, this is the first report in literature of bilateral single-system ectopic ureters opening into vaginalized urogenital sinus. The report highlights the necessity for consideration of continent diversion in such cases because of the absence of the urethra in addition to an incontinent bladder neck and tiny dysfunctional bladder.

Factors predicting success in hypospadias repair using preputial flap with limited pedicle mobilization (Asopa procedure).

OBJECTIVES: To analyze the objective factors determining success in hypospadias repair by the Asopa technique of limited preputial pedicle mobilization. METHODS: This was a prospective study involving a cohort of 48 patients (age range 1-19 years) who underwent hypospadias repair in a tertiary care teaching institution, with a follow-up of 20-58 months. Patient inclusion criteria were absence of past history of any local surgery with urethral plate less than 6 mm and hooded prepuce. RESULTS: At a median follow-up of 33.5 months, the overall complication and fistula rates were 22.9% and 16.7%. Complication and fistula rates were 40% and 30% with tube repairs vs. 18.4% and 13.2% with onlay repairs. CONCLUSIONS: In patients unsuitable for Snodgrass repair, the Asopa technique of transverse preputial flap repair provides reasonably good results. Patients with proximal hypospadias, conical glans configuration, tube repairs, and more advanced age had higher complication rates with transverse preputial flap repair.

Urodynamic evaluation of urinary disturbances following traumatic brain injury.

OBJECTIVES: To identify the incidence and the type of voiding dysfunction by doing urodynamic studies (UDS) in head injury patients. The purpose of this paper is to present our findings and promote research in this field. PATIENTS AND METHODS: A prospective study was conducted recruiting patients sustaining head injuries with positive CT scan findings. Clinical and radiological evaluation was done. Patients then underwent standardized UDS. The urodynamic findings were correlated with outcome and analyzed. RESULTS: Three out of 11 patients (27.3%) had unstable bladder with multiple involuntary contractions in the filling phase. All of them had significant contusions in the right frontal region and 2 of them had subarachnoid hemorrhage. All of these patients had normal proprioception, voluntary detrusor contractions and nil post-void residue. Two out of the 3 patients had catheter in situ and 1 patient had complaints of frequency and urgency. At 1 year of follow-up, all 3 patients had a normal voiding pattern and the upper tracts were normal on ultrasound in all patients. CONCLUSIONS: Voiding dysfunction is a significant problem in patients with head injury. Bladder hyperreflexia is seen in patients with injuries above the pontine micturition center. The voiding abnormality has good prognosis and resolves spontaneously. Treatment in the acute phase may require anticholinergics for a few months.

Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture.

OBJECTIVE: To determine the impact of earlier urethral interventions on the outcomes of anastomotic urethroplasty in post-traumatic stricture urethra. METHODS: From October 1995 to March 2008, a total of 58 patients with post-traumatic posterior urethral stricture underwent anastomotic urethroplasty. Eighteen patients had earlier undergone urethral intervention in the form of urethrotomy (3), endoscopic realignment (7), or open urethroplasty (8). Success was defined as no obstructive urinary symptoms, maximum urine flow rate > or = 15 mL/s, normal urethral imaging and/or urethroscopy, and no need of any intervention in the follow-up period. Patients who met the above objective criteria after needing 1 urethrotomy following urethroplasty were defined to have satisfactory outcome and were included in satisfactory result rate along with patients who had a successful outcome. Results were analyzed using unpaired t test, chi-square test, binary logistic regression, Kaplan-Meier curves, and log rank test. RESULTS: Previous interventions in the form of endoscopic realignment or urethroplasty have significant adverse effect on the success rate of subsequent anastomotic urethroplasty for post-traumatic posterior urethral strictures (P <.05). Previous intervention in the form of visual internal urethrotomies (up to 2 times) did not affect the outcome of subsequent anastomotic urethroplasty. Length of stricture and age of patient did not predict the outcome in traumatic posterior urethral strictures in logistic regression analysis. CONCLUSIONS: Previous failed railroading or urethroplasty significantly decrease the success of subsequent anastomotic urethroplasty. Hence, a primary realignment or urethroplasty should be avoided in suboptimal conditions and the cases of post-traumatic urethral stricture should be referred to centers with such expertise.

Idiopathic renal replacement lipomatosis: a case report and review of literature.

Idiopathic renal replacement lipomatosis is a rare condition in which the renal parenchyma, especially the renal sinus is replaced with adipose tissue with increase in perirenal fat. We report a case of renal replacement lipomatosis presenting as a renal mass clinically. The computed tomography scan revealed low density and nodular masses of adipose tissue within the renal parenchyma. The differential diagnosis before surgery was angiomyolipoma, lipoma, and xanthogranulomatous pyelonephritis. After the histological examination and extensive literature search, the diagnosis of renal replacement lipomatosis was made. It is a rare entity and may be missed if not considered due to lack of experience, so we hope that more urologists, radiologists, and pathologists become aware of this entity and recognize it.

Dorsolateral onlay urethroplasty for anterior urethral strictures by a unilateral urethral mobilization approach.

CONTEXT: For management of long segment anterior urethral stricture, dorsal onlay urethroplasty is currently the most favored single-stage procedure. Conventional dorsal onlay urethroplasty requires circumferential mobilization of the urethra, which might cause ischemia of the urethra in addition to chordee. AIMS: To determine the feasibility and short-term outcomes of applying a dorsolateral free graft to treat anterior urethral stricture by unilateral urethral mobilization through a perineal approach. SETTINGS AND DESIGN: A prospective study from September 2005 to March 2008 in a tertiary care teaching hospital. MATERIALS AND METHODS: Seventeen patients with long or multiple strictures of the anterior urethra were treated by a dorsolateral free buccal mucosa graft. The pendulous urethra was accessed by penile eversion through the perineal wound. The urethra was not separated from the corporal bodies on one side and was only mobilized from the midline on the ventral aspect to beyond the midline on the dorsal aspect. The urethra was opened in the dorsal midline over the stricture. The buccal mucosa graft was secured on the ventral tunica of the corporal bodies. STATISTICAL ANALYSIS USED: Mean and median. RESULTS: After a follow-up of 12-30 months, one recurrence developed and 1 patient needed an internal urethrotomy. CONCLUSIONS: A unilateral urethral mobilization approach for dorsolateral free graft urethroplasty is feasible for panurethral strictures of any length with good short-term success.

Safety and efficacy of percutaneous nephrolithotomy in the pediatric population.

PURPOSE: We reviewed our experience with percutaneous nephrolithotomy (PCNL) in patients in the pediatric age group and compared its efficacy and safety over a 5-year period. PATIENTS AND METHODS: We studied retrospectively and prospectively 31 patients who were treated with PCNL for renal stones larger than 1.5 cm. Variables assessed were stone bulk, size, location, and type. Metabolic and anatomic factors were also assessed. PCNL punctures and number of tracts were recorded. Clearance with PCNL and ancillary procedures was recorded. RESULTS: There were 31 renal units. Mean age of the patients was 9.6 years (range 1.5-15 years). Fifteen (48.4%) patients had single calculi; eight (25.8%) patients had staghorn calculi. Lower-pole access was the preferred route of entry, and upper-pole access was used only when necessary. We used a 22F nephroscope for the procedure. We dilated the tract to 30F in the majority of patients, but limited dilation to 24F when appropriate. If needed, we used a ureteroscope. Complete clearance was achieved in 83.9% of patients after PCNL and in 90.32% of patients after dual therapy (PCNL + shockwave lithotripsy). Average hemoglobin drop was less than 1 g/dl. Factors responsible were the size of the tract (larger than 24F) and the number of tracts. Six patients were treated for an anatomic abnormality. A metabolic abnormality was diagnosed in three patients. CONCLUSION: PCNL is effective in children, with a clearance rate of 83% and, with dual therapy, more than 90%. We recommend that tract dilation be restricted to 24F or smaller whenever possible. Approximately 40% of patients had either an anatomic or metabolic abnormality.