Analysis of anastomotic urethroplasty for pelvic fracture urethral distraction defect: Decadal experience from a high-volume tertiary care center.

CONTEXT: Pelvic fracture urethral distraction defect (PFUDD) may be challenging for the treating urologist. Anastomotic urethroplasty is the established surgical procedure for the treatment of PFUDD. Few studies in literature focus purely on PFUDD, and majority of the studies include anterior urethral stricture as well. The period of these studies is relatively short. We conducted a retrospective analysis of patients who underwent primary or redo anastomotic urethroplasty for PFUDD over a period of 12 years at a tertiary care center in northern India. AIMS: The aim is to study anastomotic urethroplasty for pelvic fracture urethral distraction defect with regard to long-term success rate and complications. SETTINGS AND DESIGN: This was a retrospective study. Subjects and. METHODS: This retrospective study was conducted in the Department of Urology, King George's Medical University, Lucknow, India, from August 2004 to July 2016. All patients who underwent progressive perineal anastomotic repair of PFUDD were included in this study. Demographic findings, type of pelvic fracture, length of distraction defect as per retrograde urethrography (RUG) and micturating cystourethrography, any history of erectile dysfunction in the preoperative or postoperative phase, and urinary incontinence in postoperative phase were analyzed. Decision regarding catheter removal was taken after pericatheter RUG at 4 weeks. Follow-up was done at 3 and 6 months in postoperative period. RESULTS: A total of 226 anastomotic repairs were done in 221 patients. Of the 221 patients, 51 (23%) were redo urethroplasty. The mean age of patients was 27.6 years. The mean length of distraction defect was 2.7 cm. The mean duration of hospital stay was 6 days. Primary urethroplasty was successful in 163 (93.14%) of 175 patients and redo urethroplasty in 44 (86.27%) of 51 patients. Out of 165 patients, 18 (10.9%) patients reported occasional incontinence while 6 (3.63%) patients reported mild incontinence. CONCLUSIONS: Anastomotic urethroplasty is the definitive procedure for PFUDD. Our success rate for primary deferred anastomotic urethroplasty is 93.14% and for redo anastomotic urethroplasty is 86.27%.

Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy.

CONTEXT: Clean intermittent catheterization (CIC) after direct vision internal urethrotomy (DVIU). AIMS: The aim is to assess the quality of life (QOL) in patients with urethral strictures on CIC following DVIU. SETTINGS AND DESIGN: Prospective study. MATERIALS AND METHODS: This prospective study was conducted between August 2013 and July 2015 in the Department of Urology at KGMU, Lucknow. We included patients above the age of 18 years with stricture urethra, who were on CIC following direct visual internal urethrotomy. Patients below the age of 18 years, noncompliance, concomitant neurogenic voiding dysfunction, multiple strictures, pan anterior strictures, and posterior stenosis were excluded from the study. A 16 French Foley catheter was used for CIC following DVIU. Patients were evaluated at follow-up visit at 3, 6, and 12 months. At each follow-up visits, patients were assessed using CIC-QOL questionnaire, maximum urine flow rate and complications related to CIC if any. STATISTICAL ANALYSIS USED: Unpaired t-test was used to compare continuous data, and Fisher's exact test was used to analyze categorical data. RESULTS: Among total 144 male patients evaluated, we included 97 patients, who underwent DVIU. Mean age of the study population was 37.7 ± 14.03 years. Most urethral strictures were idiopathic (64.02%) followed by postinflammatory (24.25%). A significant number of patients reported difficulty in performing CIC, which hampered daily activities. No major procedure related complications were reported. Patients who were compliant to CIC reported no stricture recurrence till 6 months follow-up. CONCLUSIONS: CIC following DVIU remains a reasonable adjunctive option. All the parameters of CIC-QOL questionnaire had improved on continuing CIC. Young men on CIC had greater impairment of QOL when compared to aged patients.

Identification of essential surgical competencies to be imparted in urological residency: A survey-based study.

INTRODUCTION: There are variations in surgical procedures included in urology residency curricula across various programs. We conducted a survey of practicing urologists to determine which procedures are considered essential to a core urology residency curriculum. MATERIALS AND METHODS: A web-based survey was conducted between October 2016 and February 2017 using SurveyMonkey. The questionnaire, comprising a set of 5-questions, was sent to the members of the Urological Society of India. Respondents were requested to grade 37 of the most common urological procedures (competencies) into three groups. Group A, were those that the respondent believed were vital for the trainee to learn (must know). Group B, were those that the respondent thought were essential to acquire (good to know). Group C procedures were labeled as desirable to know by respondents. RESULTS: A total of 485 (15.75%) responses were received out of 3018 members contacted. 67% respondents were working in the private-sector. Out of the 37 listed procedures, 20 procedures received a median weightage of 1 indicating vital clinical competency for urology curriculum, 15 were identified as "essential to know" while two procedures were identified as "desirable to know." CONCLUSIONS: Twenty surgical procedures were identified as'must-know' for a urology trainee. The choice of procedures was not affected by the region of the responder or his practice type, suggesting a wide consensus.

Prospective study to evaluate the clinical outcome of intralesional interferon-α2b in the management of Peyronie's disease.

CONTEXT: Interferon (IFN)-α2b in Peyronie's disease (PD). AIMS: This study aims to evaluate clinical efficacy of the IFN-α2b in both subjective and objective manner for the treatment of PD and compared with previously used intralesional verapamil in terms of cost-benefit analysis. SETTINGS AND DESIGN: Prospective study. MATERIALS AND METHODS: A prospective study conducted from January 2013 to July 2016 in the Department of Urology, Government Medical College, Kota, Rajasthan, India. We included patients with identifiable Peyronie's plaque with or without pain, curvature ranging between 30 and 90 degrees. We excluded patients with a calcified plaque and the ventral location of the plaque, any infective foci over the penis, erectile dysfunction due to other etiologies and patients who had received previous intralesional therapy. Patients were evaluated by clinical history, physical examination including plaque location, size, consistency, and penile curvature. Patients received intralesional IFN-α2b in a dose of 3 × 106 IU. Patients completed the visual analogue pain (VAS) score for pain, and International Index of Erectile Function-5 (IIEF-5) questionnaire at first visit as well as at follow-up of 1 month and 3 months. STATISTICAL ANALYSIS USED: Comparisons were performed using the paired Student's t-test and Chi-square tests as appropriate. Patient's objective and subjective clinical characteristics were described as a means (standard deviation). RESULTS: We included 86 patients in this study. Patients had a mean age of 48.6 years, mean plaque volume 256 mm3, and disease duration of 15.2 years. After 1 month of treatment, there was a significant change in plaque volume 256-60.8 mm3; P < 0.01) and penile curvature 34.8-24.6°; P < 0.01). The patients reported significant improvement in pain score VAS and IIEF-5. CONCLUSIONS: IFN-α2b, as minimal invasive (intralesional) options for the treatment of PD, demonstrated significant improvement in plaque volume, penile curvature with minimal complications. Patients subjectively reported significant improvement in pain on erection and sexual activities. IFN-α2b and verapamil had an almost similar clinical outcome, but verapamil at much lower cost.

Page kidney: A rare but surgically treatable cause of hypertension.

The Page kidney is a rare phenomenon. External renal parenchymal compression is the culprit. We report two cases of young males with flank pain, renal mass, and hypertension with history of blunt abdominal trauma. Initially, hypertension was controlled by angiotensin-converting enzyme (ACE) inhibitors but gradually became refractory to medical treatment. Laparoscopic nephrectomy was performed in both patients. We emphasize the Page kidney as a cause of hypertension in young patients, presenting with flank pain and renal mass with or without complications of hypertension. Management is aimed to control blood pressure by ACE inhibitors, aspiration of the hematoma, open hematoma evacuation, or nephrectomy.

A Prospective Study to Evaluate Sexual Dysfunction and Enlargement of Seminal Vesicles in Sexually Active Men Treated for Benign Prostatic Hyperplasia by Alpha-blockers.

OBJECTIVE: To evaluate sexual dysfunction and enlargement of seminal vesicles in sexually active men who were treated by α1-blockers for benign prostatic hyperplasia and its possible clinical application. MATERIALS AND METHODS: This is a prospective cohort study from January 2015 to December 2016. We enrolled sexually active men above the age of 40 years having moderate to severe lower urinary tract symptoms (LUTS). We excluded patients with a history of prostate surgery, suspicious digital rectal examination findings, a serum prostate-specific antigen of >4 ng/dL, and a history of medication with anticholinergic, cholinergic, and diuretic agents. Patients were divided into groups A, B, and C based on the prescription of silodosin 8 mg, tamsulosin 0.4 mg, or alfuzosin 10 mg orally once for LUTS and at 4 and 12 weeks. RESULTS: The mean age was 54.8 years (41-68 years). Twelve weeks of treatment with silodosin, tamsulosin, and alfuzosin resulted in a significant improvement in the total International Prostate Symptom Score and the quality of life score (P <.001). The baseline erectile function scores were 26.4, 27.6, and 28.1, and the baseline overall satisfaction (OS) (International Index of Erectile Function [IIEF]-OS) scores were 7.1, 8.3, and 8.6 among groups A, B, and C, respectively. After 12 weeks of α1-blockers, the IIEF-erectile function scores were 24.0, 24.7, and 26.2, and the IIEF-OS scores were 6.4, 7.8, and 7.9. All 3 groups demonstrated a statistically significant enlargement of seminal vesicles after 12 weeks' treatment, most significant in group A patients (7.65-14.11 cc, P <.001). CONCLUSION: Alpha-blockers as silodosin, tamsulosin, and alfuzosin are a safe and effective tool in benign prostatic hyperplasia for improving LUTS and the quality of life. Loss of seminal emission with alpha-blockers appears as the cause of seminal vesicle enlargement. The exact mechanism of these findings needs further clinical and experimental research.

What is the fate of insignificant residual fragment following percutaneous nephrolithotomy in pediatric patients with anomalous kidney? A comparison with normal kidney.

Pediatric population has increasing incidence of renal calculus and it is estimated to be around 50/10,000 population. The treatment of choice for large and complex stone in anomalous kidney is percutaneous nephrolithotomy (PCNL). The fate of insignificant residual fragment after PCNL in pediatric patients is not well documented. Here, we are reporting our long-term experience and follow-up of insignificant residual fragment in pediatric patients with anomalous kidney in comparison to normal kidney. Intuitional ethical approval was taken. A retrospective analysis of PCNL in pediatric (<18 years) anomalous kidney was performed from 2001 to 2013. The data of 52 pediatric patients with anomalous kidney (group B) have been compared to 251 normal kidneys (group A). The mean age of the patients was 7.83 + 3.45 (range 3-18) in group A and 8.21 ± 3.25 (range 5-18) in group B. The mean size of the insignificant residual fragment was 2.2 + 0.5 mm (1-4) in group A and 2.1 + 0.6 mm (range 1-4) in group B. Most of these residual fragments were single in number (72.55 vs. 67.30%, respectively). 54.98% children in group A and 67.30% in group B were symptomatic in the follow-up. Stone size was increased, stable and spontaneously passed in 49.8 vs. 71.15, 22.7 vs. 19.23 and 27.49 vs. 9.61% (p < 0.03), respectively, over mean follow-up of 50.34 months. Insignificant residual fragments in children are notorious for regrowth (49.8% in normal and 71.15% in anomalous kidney) in future. Most of the children will require symptomatic treatment (55.37 vs. 82.69%) or reintervention (39 vs. 46%) for insignificant residual fragment.

Outcome analysis of transrectal ultrasonography guided aspiration versus transurethral resection of prostatic abscess: 10 years' experience from a tertiary care hospital.

OBJECTIVE: To compare the effectiveness and safety of two minimally invasive methods (transrectal aspiration vs transurethral resection (TUR)/deroofing) of treating prostatic abscess. PATIENTS AND METHODS: A retrospective study was conducted, from 2007 to 2016, of patients with prostatic abscesses not responding to antibiotics and/or with large (>2 cm) or multiple abscesses. Patients were divided into two groups depending on treatment received: Group A, transrectal aspiration; and Group B, TUR/deroofing of abscess. RESULTS: The most common clinical presentation was dysuria (81.8%), followed by urinary frequency (68.2%), and fever (36.4%). Acute urinary retention occurred in seven patients. The most common infective organism in both groups was Escherichia coli (43.9%). The mean (SD, range) prostate volume was 36 (6.4, 17-68) mL and 37 (7.3, 21-72) mL in Groups A and B, respectively. The mean (SD, range) volume of the abscess was 51.24 (12.6, 21-215) mL and 48.34 (15.4, 15-240) mL in Groups A and B, respectively. Overall, 37 (84.1%) patients responded to treatment (68.4% in Group A and 96.0% in Group B, P < 0.23) after the first treatment session. Six patients in Group A and one patient in Group B had recurrence of abscess (P < 0.03). Of the six patients in Group A with recurrence, four patients had complete resolution after repeat aspiration (average 1-3 times). The mean (SD) follow-up duration was 17.25 (6.3) months. CONCLUSION: TUR of prostatic abscess is more effective (96%) than transrectal aspiration with a lesser hospital stay. However, transrectal aspiration was successful in 89% of cases, is less invasive and can be performed under local anaesthesia and or sedation.

Haematuria in ADPKD: not always benign. Be aware!

Haematuria in patients with autosomal dominant polycystic kidney disease (ADPKD) is a very common manifestation. The cause of haematuria is often benign with the most common cause being haemorrhage within the renal cyst. But haematuria may also be caused by a coincident malignancy, the diagnosis of which may be missed if not investigated thoroughly. Herein, we present a case of ADPKD who presented to us with haematuria and was later found to have bladder cancer.

Evaluation of Impact of Voiding Posture on Uroflowmetry Parameters in Men.

PURPOSE: To evaluate the impact of voiding position on uroflowmetry parameters and to assess its potential clinical implications. MATERIALS AND METHODS: We conducted a prospective study from 2013 to 2015 and included men between 18 and 77 years old who were either healthy volunteers with an International Prostate Symptom Score (IPSS) ≤7 or men with benign prostate enlargement that were on alpha-blocker medication and had an IPSS <10. Participants underwent uroflowmetry and post-void residual urine (PVRU) measurements twice, once in a sitting position and once in a standing position. The participants were divided into 4 groups based on age (35 years or younger, 36 to 50 years, 51 to 60 years, and older than 60 years). RESULTS: A total of 740 men with a mean age of 40.35 years were evaluated. There was no significant difference in uroflowmetry parameters until the age of 50 years between the voiding positions. However, in those older than 50 years, PVRU volume was significantly lower in the sitting position than the standing position, whereas voiding time was significantly higher in the sitting position than the standing position. Other uroflowmetry parameters, including maximal and average urine flow rates, were non-significant. CONCLUSIONS: The voiding position plays an important role in the uroflowmetry parameters of elderly men. Voiding in the sitting position was found to be optimal for elderly men, whereas the role of the voiding position in healthy young men could not be determined. More research is needed to further study this issue.

Nephrolithisis in a newborn: a rare case and review of literature.

Nephrolithiasis, although a common entity in adults, is less common in children and rare in newborns. The evaluation and management strategies of renal stones in neonates are unclear. We report a rare scenario of renal calculus in a newborn aged 3 days presenting with decreased urine output, fever and crying during micturition. Patient was thoroughly investigated and managed conservatively. Further follow-up showed increase in stone size with recurrent urinary tract infections, hence shock wave lithotripsy was performed to successfully break and clear the stone fragments. Patient recovered well and was doing fine until last follow-up.

Priapism due to essential thrombocythaemia: a rare causation.

Priapism is rarely caused by essential thrombocytosis, a disorder characterised by increased number of megakaryocytes. We report a case of a 21-year-old man who presented with priapism and on investigation was found to have essential thrombocytosis as the cause.

Giant hydronephrosis in a case of ureterocele with duplex system: an entity yet not reported.

Ureterocele, which is a cystic dilatation of the terminal ureter, is usually associated with the upper moiety in a case of the duplex system. Giant hydronephrosis, a rare entity, is usually due to pelviureteric junction obstruction and is usually diagnosed in infants and children. We report a unique case of a unilateral complete duplex system with ureterocele with giant hydronephrosis of the upper moiety in an adult woman presenting as an abdominal lump. To the best of our knowledge, this is the first case of giant hydronephrosis associated with ureterocele in an adult patient.

Outcome analysis of transurethral resection versus potassium titanyl phosphate-photo selective vaporization of the prostate for the treatment of benign prostatic hyperplasia; a randomized controlled trial with 4 years follow up.

OBJECTIVE: Photovaporization of prostate (PVP) is a newer surgical modality of benign prostatic hyperplasia (BPH) which is gaining importance recently. There are a few randomized controlled trials that showed safety and efficacy of PVP in comparison with transurethral resection of prostate (TURP) with limited follow-up period (<2 years). Here, we are presenting a comparative study performed on potassium titanyl phosphate (KTP) PVP laser versus TURP for the treatment of BPH with long-term follow-up period. MATERIAL AND METHODS: After institutional ethical clearance, 150 patients were prospectively included in the study from January 2010 to March, 2012. Improvement of International Prostate Symptoms Score (IPSS), Qmax, post-void residual (PVR) urine, International Index of Erectile Function (IIEF)-5 score and complications were assessed at 12, 24, 36 and 48 months. RESULTS: Mean age of the study group was 65.3±7.86 years in the TURP and 63.6±8.12 years in the PVP groups (p=0.45). IPSS symptom score improved significantly in both TURP and KTP groups (p<0.003). There was improvement in Q max during follow-up in both groups (p<0.001) which was maintained at 48 months. Most of the patients in both groups were satisfied with symptoms and bothersome at 48 months. All the sexual parameters are similar to both groups except retrograde ejaculation. Overall complication noted in 23 patients (15.33%). CONCLUSION: Both KTP Laser PVP and TURP afford durable relief from symptoms of BPH at 48 months follow-up. Both procedures are safe and associated with minimal complications. Both procedures do not have any detrimental effect on sexual function on long-term follow-up. Quality of life remains high even at 4 years in both groups.

Emphysematous pyelonephritis: Changing trend of clinical spectrum, pathogenesis, management and outcome.

OBJECTIVE: To highlight changing trend of clinical spectrum, comparing management options and predictors of outcome of emphysematous pyelonephritis. MATERIAL AND METHODS: This study included patients who were diagnosed as emphysematous pyelonephritis between August, 2001 to July, 2015. We excluded other possible causes of gas in renal system. Baseline patient characteristics, clinical spectrum, serum and urinary biochemical parameters, radiological findings, management and outcomes were recorded. Patients were classified as "responders" and "non-responders". RESULTS: We studied a total of 74 patients and categorised them as responders (62 patients) and non-responders (12 patients). Women outnumbered men constituting 62.16% of the study population (M: F; 1: 1.6). Fever was the most common presenting symptom followed by flank pain. Diabetes mellitus (85.14%) was the most common comorbidity followed by urolithiasis (32.43%). Escherichia coli was the commonest organism grown in urine culture (79.73%). Non-responders had distinct laboratory findings relative to responders as low hemoglobin (7.8±2.1/11.2±3.2 g/dL; p=0.0007), thrombocytopenia (91.67% vs. 11.29%; p=0.0001), proteinuria >3 g/L (50% vs. 6.45%; p=0.0008) and positive blood culture (100% vs. 67.74%; p=0.0288). CONCLUSION: Advanced age, higher body mass index, renal impairment, thrombocytopenia, altered sensorium, shock at presentation can be used as scores for poor prognosis. Emphysematous pyelonephritis management requires multidisciplinary collaboration including hydration and electrolyte management, broad spectrum antibiotics, strict glycaemic control, effective urinary drainage and lastly it may require emergency nephrectomy as a salvage procedure.

Vesical dermoid: a rare bladder tumour.

Dermoid cysts are benign developmental lesions consisting of tissues of more than one germ cell lineage origin. The urinary bladder is a very rare location of dermoid cysts. We report a case of an 18-year-old woman who presented with suprapubic pain, dysuria and turbid urine. Blood and serum chemistry was normal. Contrast-enhanced CT revealed a heterogeneously enhancing mass of 2.5×2 cm within the urinary bladder infiltrating fundus of urinary bladder with extraluminal extension. At cystoscopy, an irregular mass arising from the dome of the urinary bladder with a covering of hair and whitish scales was seen. The patient was managed by transperitoneal laparoscopic partial cystectomy with left oophorectomy. Histology revealed dermoid cyst arising from the urinary bladder and simple serous cyst in the ovary. Postoperative course was uneventful.

Transurethral resection of prostate in benign prostatic enlargement with underactive bladder: A retrospective outcome analysis.

PURPOSE: The purpose of this study was to evaluate the clinical outcome and efficacy of transurethral resection of the prostate in patients of benign prostatic enlargement (BPE) with underactive bladder. MATERIALS AND METHODS: Retrospective study of 174 patients, who underwent transurethral resection of prostate (TURP) between 2008 and 2015, for lower urinary tract symptoms with BPE with bladder underactivity. Clinical history, physical examination, renal function test, urinalysis, cystourethroscopy, transabdominal or transrectal ultrasonography, and urodynamic study were recorded. Patients having a history of neurologic conditions, spinal trauma or surgery, pelvic trauma or surgery, diabetes mellitus with end organ damage, urethral pathology or surgery, and prostatic cancer were excluded from the study. RESULTS: The mean follow-up period was 22.4 ± 6.2 months. Mean prostate volume was 42.8 ± 6.4 ml and mean serum prostate-specific antigen was 2.3 ± 1.8 ng/ml. The International Prostate Symptom Score changed from 24.6 ± 4.2 preoperatively to 10.8 ± 5.8 postoperatively which was found statistically significant. Quality of life (QOL) score changed from 4.8 ± 1.2 to 2.6 ± 0.4. Twenty-two patients out of 174 remained on a per-urethral catheter or clean intermittent catheterization due to voiding failure after TURP beyond 1 month. CONCLUSIONS: TURP should be considered a viable treatment option in men with enlarged prostate with underactive detrusor who had poor response to medical treatment. Preoperative counseling and postoperative follow-up are crucial in the management of such patients.

Rare Occurrence of Giant Metastatic Inguinal Lymph Nodes in Carcinoma Bladder.

Inguinal lymph node metastasis of a bladder cancer is a rare scenario. As of today, only 4 cases of inguinal lymph node metastasis from bladder cancer have been reported in the literature. We report a rare giant inguinal lymph node metastasis of transitional cell carcinoma of the bladder in a patient after radical cystoprostatectomy. Chemotherapy and radiotherapy were given, but the metastatic tumor remain unchanged.

Giant Hydronephrotic Kidney Masquerading as Urinoma: A Rare Presentation with Review of Literature.

Giant hydronephrosis (GH) is a condition in which pelvicalyceal system contains more than 1000 ml of urine. Common causes of GH are uretero-pelvic junction obstruction, renal calculus, abdominal trauma. We are reporting a case of 45 years' male, who presented with abdominal trauma and haematuria and was suspected a urinoma secondary to renal trauma. Examination revealed soft, cystic abdominal lump. Computed tomography of the abdomen revealed grossly hydronephrotic right kidney. The patient was managed by pyeloplasty after renal scan (estimated plasma renal flow- 91.92 ml/minute). Giant hydronephrotic kidney presenting with history of trauma may be confused with post traumatic urinoma.

Urethrocutaneous fistula mimicking vesicocutaneous fistula: a rare entity.

Urethral fistulas arising from the anterior urethra usually open on the ventral aspect and are located in the penile, scrotal or perineal region. A diabetic 65-year-old man presented with suprapubic urinary fistula that was communicating with a dorsally located internal urethral opening located in the bulbar region. Such unusual fistula has not been described before.