Is circumferential urethral mobilisation an overdo? A prospective outcome analysis of dorsal onlay and dorso - lateral onlay BMGU for anterior urethral strictures.

INTRODUCTION: For dorsal onlay graft placement, unilateral urethral mobilization is less invasive than standard circumferential urethral mobilization. Apart from success in terms of patency of urethra, other issues like sexual function, overall quality of life and patient satisfaction remain important issues while comparing outcomes of urethroplasty. AIM: To prospectively compare the objective as well as subjective outcomes of two approaches. MATERIALS AND METHODS: Between July 2011 and January 2015, 136 adult males having anterior urethral stricture with urethral lumen ≥ 6 Fr. were prospectively assigned between two groups by alternate randomization. Operative time, complications, success rate (no obstructive symptoms, no need of any postoperative intervention, Q max > 15mL/sec), sexual functions (using Brief Male Sexual Function Inventory) were compared. RESULTS: Baseline parameters were similar in both groups (68 in each group). Overall success rate was similar in both groups (89 % and 91 % respectively). Improvement in total LUTS scores was similar in groups. Changes in overall health status (VAS and EQ 5D) was equal in both groups. Erectile function score was significantly decreased in DO than DL group while ejaculatory function and sexual desire remained stable after urethroplasty in both groups. CONCLUSIONS: In anterior urethral stricture buccal mucosa graft provides satisfactory results as onlay technique. No technique whether dorsolateral and dorsal techniques is superior to other. Dorsolateral technique needs minimal urethral mobilization and should be preferred whenever feasible.

Intraoperative breakage of Sachse's knife blade: A rare complication of optical internal urethrotomy (one case managing experience).

Optical internal urethrotomy (OIU) is the most common procedure performed for short segment bulbar urethral stricture worldwide. This procedure most commonly performed using Sachse's cold knife. Various perioperative complications of internal urethrotomy have been described in literature including bleeding, urinary tract infection, extravasation of fluid, incontinence, impotence, and recurrence of stricture. Here we report a unique complication of breakage of Sachse knife blade intraoperatively and its endoscopic management.

Outcome analysis of holmium laser and pneumatic lithotripsy in the endoscopic management of lower ureteric calculus in pediatric patients: a prospective study.

OBJECTIVE: To analyse outcomes of holmium laser and pneumatic lithotripsy in treatment of lower ureteric calculus in pediatric patients. MATERIALS AND METHODS: Prospective study conducted between August 2013 and July 2015. Inclusion criteria were lower ureteric calculus with stone size ≤1.5cms. Exclusion criteria were other than lower ureteric calculus, stone size ≥1.5cms, congenital renal anomalies, previous ureteral stone surgery. Patients were divided into two groups. Group A underwent pneumatic and group B underwent laser lithotripsy procedure. Patient's baseline demographic and peri-operative data were recorded and analysed. Post operatively X-ray/ultrasound KUB (Kidney, ureter and bladder) was performed to assess stone free status. RESULTS: A total of 76 patients who met the inclusion criteria to ureteroscopic intracorporeal lithotripsy were included. Group A and B included 38 patients in each. Mean age was 12.5±2.49 in Group A and 11.97±2.74 years in Group B respectively (p=0.38). Overall success rate was 94.73% in Group A and 100% in Group B, respectively (p=0.87). CONCLUSION: Holmium Laser lithotripsy is as efficacious as pneumatic lithotripsy and can be used safely for the endoscopic management of lower ureteric calculus in pediatric patients. However, holmium laser requires more expertise and it is a costly alternative.

Primary emphysematous adrenal hydatid: Unusual site for presentation with rare pathology.

Hydatid disease of the adrenal gland is uncommon. We present images and description a case of emphysematous hydatid cyst of the adrenal gland that had an unfavourable intraoperative outcome.

Grading of complications of transurethral resection of bladder tumor using Clavien-Dindo classification system.

INTRODUCTION: Clavien-Dindo classification system is used for grading complications of various oncological, renal, and endourological procedures. We applied this system for grading the severity of perioperative complications in patients undergoing transurethral resection of bladder tumor (TURBT) and identify parameters predicting these complications. MATERIALS AND METHODS: Data of 984 patients who underwent TURBT from 2006 to 2014 were included in this study. All data was retrospectively collected and analyzed for complications occurring within the first postoperative month. All complications were classified according to the five grades of modified CCS (.Clavien classification system). RESULTS: A total of 172 complications were observed in 138 patients. Majority were low grade complications (Grade 1 [77.3%] and Grade 2 [12.7%]). Higher grade complications were rare (Grade 3 [6.4%] and Grade 4 [3.0%]). There was one death (Grade 5 0.6%), with an overall mortality rate of 0.1%. The incidence of complications was significantly greater for age >60 years, baseline serum creatinine >1.4 mg/dl, size of tumor >4 cm, tumor located at dome, resection time >60 min, incomplete resection and if surgery performed by a resident urologist. CONCLUSIONS: Clavien-Dindo classification system can be easily applied to grade the complications of TURBT, and it is easily reproducible. We observed that TURBT was a safe procedure. Majority of complications were Grade 1-2 (90%) and Grade 3-5 were rare (10%). Postoperative bleeding is the most common complication. A greater rate of complications of TURBT was associated with patient age, size of tumor, location of tumor, surgeon experience, resection time, and completion of tumor resection.

Factors affecting response to medical management in patients of filarial chyluria: A prospective study.

INTRODUCTION: Filarial chyluria is a common problem in filarial endemic countries. Its management begins with medical therapy but some patients progress to require surgery. The present study aimed to determine factors affecting response to medical management in patients of filarial chyluria. MATERIALS AND METHODS: This prospective study conducted between August 2008 and November 2012, included conservatively managed patients of chyluria. Demographic profile, clinical presentation, treatment history and urinary triglycerides (TGs) and cholesterol levels at baseline were compared between the responders and non-responders. Apart from the clinical grade of chyluria, hematuria was evaluated as an independent risk factor. RESULTS: Out of the 222 patients (mean age, 37.99 ± 13.29 years, 129 males), 31 patients failed to respond while 35 had a recurrence after initial response; the overall success rate being 70.3% at a mean follow-up of 25 months. No difference was observed in demographics, clinical presentation, presence of hematuria, disease duration and mean urinary TGs loss between responders and non-responders. On multivariate analysis, patients with treatment failure were found to have a higher-grade disease (14.3% Grade-I, 36.6% Grades-II and 60% Grade-III), higher number of pretreatment courses (1.59 ± 1.08 vs. 1.02 ± 0.79) and heavier cholesterol (26.54 ± 23.46 vs. 8.81 ± 8.55 mg/dl) loss at baseline compared with responders (P < 0.05). CONCLUSION: Conservative management has a success rate in excess of 70%, not affected by the disease chronicity, previous episodes and recurrent nature. However, higher-grade disease, extensive pre-treatment with drugs and higher urinary cholesterol loss at baseline are the predictors of poor response. Hematuria is not an independent poor risk factor for conservative management.

Prospective evaluation of complications using the modified Clavien grading system, and of success rates of percutaneous nephrolithotomy using Guy's Stone Score: A single-center experience.

INTRODUCTION AND OBJECTIVES: To prospectively document the perioperative complications of percutaneous nephrolithotomy (PCNL) using the modified Clavien grading system. Evaluation of complications and clearance rates according to stone complexity using the validated Guy's Stone Score (GSS) was also done. MATERIALS AND METHODS: A total of 221 renal units underwent 278 PCNL procedures at a urology resident training center between September 2010 and September 2011 and data were recorded prospectively in our registry. Patients with co-morbidities like diabetes, renal failure, hypertension and cardiopulmonary diseases were excluded. Stone complexity was classified according to the GSS while peri-operative complications were recorded using the modified Clavien grading system. RESULTS: Two hundred and forty-five complications were encountered in 278 PCNL procedures involving 116 renal units (41.72%). Complications of Grades 1, 2, 3a, 3b, 4a, 4b and 5 were seen in 52 (18.7%), 122 (43.8%), 42 (15.1%), 18 (6.4%), 6 (2.1%), 4 (1.4%) and 1 (0.3%) renal units respectively. There were 68, 98, 50 and 5 renal units in GSS I, II, III and IV groups, respectively. All grades of complications were more common in GSS III and IV (P<0.05). For GSS I, II, III and IV 100%, 74%, 56% and 0% of renal units, respectively, were stone-free after one session and 0%, 24%, 44% and 60% respectively needed two sessions to be stone-free. CONCLUSION: Although the complication rates were higher most were of low grade and self-limiting. Complications were significantly more common with higher GSS and the GSS effectively predicted stone-free rates.

Changing profiles of patients undergoing transurethral resection of the prostate over a decade: A single-center experience.

CONTEXT: Patients with benign prostatic hyperplasia (BPH) usually form the bulk in urology outpatient departments. The management options include medical therapy or surgery. Transurethral resection of the prostate (TURP) has been the mainstay of surgical management. The use of medical therapy has increased over the years. This has led to a shift in the profiles of patients undergoing surgical management of BPH. AIMS: We conducted this study to analyze the differences in profiles of patients undergoing TURP over a decade. SETTINGS AND DESIGN: This was a retrospective study. SUBJECTS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent TURP from January 1 to December 31 in 2006 and 2016. The age, preexisting comorbidities, prostate volume, operative time, mean prostatic tissue removed, duration of hospitalization, and complications were evaluated among the two groups of patients. Charlson comorbidity index was used to evaluate the preexisting comorbidities, and the modified Clavien classification system was used for evaluating the perioperative and postoperative complications. RESULTS: A total of 114 and 125 patients underwent TURP in 2006 and 2016, respectively. The mean age of the patients was 62.1 ± 8.22 and 66.94 ± 9.12 years in 2006 and 2016, respectively. The serum prostate-specific antigen levels increased from 4.39 ± 4.425 to 5.59 ± 7.61 ng/ml a decade apart. A number of patients taking medical therapy before surgical intervention increased from 62.23% to 75.2% (P < 0.05). There was a significant increase in the mean prostatic volume and weight. There was only a modest increase of 1.94% in the total number of complications (P > 0.05) and no significant change in the rates of complications. CONCLUSIONS: Medical therapy for BPH patients has resulted in delayed surgical interventions. The complication rates have not increased. Thus, the increased use of medical therapy in BPH patients is justified though TURP may still be considered the gold standard.

Rectal duplication cyst causing acute urinary retention with bladder outlet obstruction: an unusual presentation.

Anterior rectal duplication cyst is rare entity with <50 reported cases to date. It has myriad presentations like bleeding per rectum, constipation, rectal prolapsed and intestinal obstruction due to extrinsic compression of rectum. However, the association of enlarged duplication cyst compressing the bladder neck or ureter, and leading to bladder outlet obstruction or hydroureteronephrosis is extremely rare with only a handful of reported cases. We report a rare case of large anterior rectal duplication cyst in a young girl leading to acute urinary retention with bladder outlet obstruction which was eventually managed by laparoscopic-assisted transabdominal surgical excision of the cyst. The authors believe that such an association has not been previously reported in this age group.

Air in the urine: a mystified patient and a concerned surgeon.

Appendicovesical fistula is a rare type of enterovesical and a very rare complication of acute appendicitis. Herein, we report a case of a 22-year-old man who presented with cloudy urine and pneumaturia with a prior history of acute appendicitis. Imaging techniques including ultrasonography, CT and cystoscopy were performed to diagnose the abnormality. Diagnosis of this fistula is challenging and relies on detailed history and radiological imaging.

The effects of preoperative blood pressure on early failure rate of distal arteriovenous fistulas for hemodialysis access.

INTRODUCTION: The first choice of vascular access for hemodialysis in patients with end-stage renal disease is a distal radiocephalic arteriovenous fistula (AVF). Early failure rates for these AVFs vary from 10% to 53%. The effects of predialysis hypotension on failure of AVFs have been described in the literature. Weather lower blood pressures affect early AVF failure has not been extensively studied. We conducted this study to evaluate the effects of preoperative blood pressures on early AVF failure. METHODS: Ours was a prospective observational study over a period of 2 years that included 224 patients who underwent distal radiocephalic AVF creation. Only those patients were included whose fistulas were made by surgeons with an experience of greater than five cases. The systolic, diastolic, and mean arterial pressures (MAPs) were recorded preoperatively. Early failure was defined as failure to achieve vascular access from the fistula within first 4 months of its creation. FINDINGS: The overall early failure rate was 27.7%. Early failure was more common in females and diabetic patients. The systolic, diastolic, and MAPs were significantly lower in patients with early failure (P < 0.05). In a multivariable adjusted analysis, lower preoperative diastolic and MAPs were predictors for early failure of distal radiocephalic AVF. DISCUSSION: Our study shows that patients with early failure of AVFs have lower preoperative blood pressure. A larger study is required to substantiate our findings and define target preoperative blood pressure for AVF creation.

A prospective study evaluating impact on renal function following percutaneous nephrolithotomy using Tc99m ethylenedicysteine renal scan: Does multiplicity of access tracts play a role?

PURPOSE: A prospective study evaluating impact of percutaneous nephrolithotomy (PCNL) on renal function following PCNL using ethylenedicysteine (EC) renal scan. Does multiplicity of access tracts play a role? MATERIALS AND METHODS: A prospective observational study was done and patients undergoing PCNL for renal calculi at our urology department were selected. Renal Tc99m EC scan was done pre-surgery and at 3 months follow-up. An assessment was done on decline in glomerular filtration rate (GFR) in postoperative period based on number of access tracts required. RESULTS: A total of 110 patients were enrolled in the study. The total number of punctures was 170 with 141 being supra-costal puncture and 29 infra-costal. The total number of single punctures were 60 and classified as Group I whereas patients with double puncture and triple puncture (40 and 10 patients, respectively) were classified as Group II. Mean postoperative split renal function (in Tc99m EC scans) of patients of Group I (40.93±19.62%) was found to be higher than that of Group II (32.82±16.98%). Mean change (decline) in GFR for single, double and triple tracts were 2.68 mL/min, 3.80 mL/min, and 4.2 mL/min, respectively. CONCLUSIONS: PCNL used for stone removal can improve renal function by eradicating obstruction; however, this procedure may itself negatively impact the functions of the targeted kidney. Our study showed post PCNL decrease in GFR which worsens with an increasing number of accesses.

Metastatic adenocarcinoma of bladder presenting with skin and visceral metastasis.

A 62-year-old male patient presented with multiple subcutaneous swellings over neck, axilla and scapular region for last 3 months. Further evaluation revealed the presence of bladder mass, deranged kidney function tests with multiple rounded opacities in lung. The patient was stabilised with haemodialysis and bilateral percutaneous nephrostomy tube placement. The patient was planned for multiagent chemotherapy after stabilisation but died within 2 weeks due to progressive disease. Fine needle aspiration cytology (FNAC) from the above-mentioned skin and lymph nodes swellings was suggestive of adenocarcinoma. We herein report this rare case of a metastatic adenocarcinoma of the bladder with extensive skin and visceral metastasis. The presence of skin metastasis confers a poor prognostic sign to the patient. They are usually resistant to available treatment modalities. To our knowledge, this is the first reported case of adenocarcinoma metastatic to skin and viscera.

Spontaneous renal infarct heralding bowel ischaemia in an adult male: lessons to learn from a rare clinical association.

Spontaneous renal artery dissection (SRAD) is a rare entity with less than 200 cases reported in literature. It usually affects middle-aged men and the clinical presentation is non-specific. Many times it is associated with conditions such as hypertension, fibromuscular dysplasia or vasculitides. We report the case of a patient who initially had renal infarct due to SRAD and then progressed to have bowel ischaemia. The renal infarct preceded bowel ischaemia in this patient and to the best of our knowledge this is the first such association reported in literature. Our report emphasises the point that whenever this condition is diagnosed in a patient one should be vigilant for other vascular disorders.

Vesicovaginal fistula and vesicocutaneous fistula in a patient having pelvic ectopic kidney with pyonephrosis: a unique therapeutic challenge.

Patients with ectopic kidney require special considerations in their management due to the anatomic characteristics predisposing the kidney to obstruction and related complications. Pelvic ectopic kidneys have the added disadvantage of being confined in the bony pelvis giving less manoeuvrability during surgery of that unit. Vesicovaginal fistulas are usually managed surgically and careful surgical dissection has to be carried out because the highest success rates are usually seen at the first operation. It is rare to find a combination of such challenging diseases in a single patient. We present the case of a young woman who developed iatrogenic vesicovaginal and vesicocutaneous fistulae during an attempt to surgically manage a pyonephrotic ectopic pelvic kidney.

Benign fibroepithelial bladder polyp: a rare cause of childhood haematuria.

Haematuria in paediatric population is common yet alarming. It warrants a thorough physical examination and other investigations. Of late, a number of extremely rare aetiology of childhood haematuria have come to forefront. One such uncommon cause is benign fibroepithelial urinary bladder polyp. The presentation is of a child with intermittent haematuria exacerbated by physical/sports activity associated with or without suprapubic pain. Diagnosis is usually made by ultrasonography and cystoscopy and confirmed by histopathological examination. Treatment is surgical and involves cystoscopic transurethral resection of the mass. The exact aetiology of benign fibroepithelial polyp is uncertain with no clear guidelines on long-term surveillance. However, these cases should be subjected to cystourethroscopy if haematuria recurs. Treatment is surgical with good long-term prognosis. Not much is written in literature about benign fibroepithelial bladder polyp.

Posterior urethral valve associated with a foreign body in posterior urethra: a first of its kind report.

Posterior urethral valve and foreign body are among the important causes of male urethral obstruction. Although one is congenital and the other is acquired, both entities are rare in children with only a few reported cases. Because of myriad of symptoms associated with both conditions, a conclusive diagnosis requires both physical examination and radiological imaging. We report a first of its kind association of posterior urethral valve with foreign body in the posterior urethra in a 6-year-old male child which was eventually managed by endoscopic intervention.

Horseshoe kidney with unilateral single ectopic ureter.

The horseshoe kidney (HSK) is not an uncommon entity with an incidence of about 1 in 400 or 0.25% of the general population. It is also more commonly found in men as compared with women in a ratio of 2:1.An increased association of genitourinary anomalies have been found with HSK.Duplication of ureters occurs in 10% of HSKs. However, the association of HSK with single-system ectopic ureter is extremely rare. To our knowledge, no case with similar presentation has been reported in literature. Most cases of HSK with bilateral single ectopic ureters have been described. The aim of this report is to highlight the radiological and surgical findings in a case of HSK with unilateral single ectopic ureter.

Foreign body urethra misdiagnosed as stricture leading to inadequate management and prolonged treatment duration: a lesson to learn.

Misdiagnosis of a urethral foreign body (FB) as urethral stricture leads to inadequate management and prolonged treatment duration. A 55-year-old male patient was referred with complaints of difficulty in voiding and poor urinary stream for 2 months. He initially presented at a primary healthcare centre and was misdiagnosed as urethral stricture and was scheduled for urethroplasty. Surprisingly, intraoperative cystourethroscopy performed by us revealed that the urethra had been obstructed by an FB. The FB was gently pushed into the bladder and retrieved. The postoperative course was uneventful. The present case represents a rare occurrence of polyembolokoilamania or insertion of a FB into any bodily orifice for sexual gratification.