Establishing initial resting abdominal pressure in children undergoing urodynamics.

INTRODUCTION: The International Continence Society recommends zeroing of transducers to the atmospheric pressure for invasive urodynamics. The range of abdominal pressure relative to atmospheric pressure is well-known in adults but has not been described in children. This prospective observational study was carried out to establish baseline abdominal in children. MATERIALS AND METHODS: Prospective, multicenter, observational study of 100 children aged 0-18 years undergoing invasive urodynamics using water-filled systems. Initial resting abdominal pressure, intravesical pressure and detrusor pressure were recorded in supine, sitting, and standing position (as age- and diagnosis-appropriate). This data was analyzed using SPSS 20.0.0 with regard to age, gender, height, weight, body mass index, and underlying diagnosis (classified as neurogenic or non-neurogenic). Nonparametric tests were used (2-sided p < 0.05, significant). RESULTS: Initial resting abdominal pressure (inter-quartile range) in children was between 5 and 15 cmH2 O in the supine, 13-20 cmH2 O in the sitting, and 15-21 cmH2 O in the standing position. These pressures were not consistently influenced by age, gender, height, weight or underlying diagnosis. The initial resting detrusor pressure was noted to be 0-4 cmH2 O without any difference based on posture. Limitations include use of two-tube technique, relatively small number of subjects across each age group, wide range of underlying diagnoses and need for manual smoothing of some traces. CONCLUSION: This study defines initial resting abdominal pressure at urodynamics in children and notes that, as with adults, it is possible to define widely applicable ranges regardless of individual characteristics. These pressures appear lower than those noted historically in adults.

Casale's tube with VQZ stoma: An alternative to "double Monti".

In situations requiring an ileal segment for performing a Mitrofanoff cathetrisable urinary diversion, occasionally a "Double Monti" is needed to achieve a length for the cathetrisable channel to conveniently reach the abdomen of an adult. Casale's tube is an alternative where it can provide a jointless tube with adequate length. The video demonstrates the procedure in an adult with a neurogenic acontractile bladder who had developed a panurethral stricture because of years of self catheterization. "VQZ" technique of stoma formation is helpful in prevention of stenosis.

Everted saphenous vein graft for long anterior urethral strictures in men with tobacco-exposed oral mucosa: A prospective nonrandomized study.

INTRODUCTION: Oral mucosal graft (OMG) is the gold standard for urethral substitution but has poor results in long anterior urethral strictures and chronic tobacco-exposed oral mucosa. Saphenous vein has been recently described for long-segment anterior urethral stricture with successful initial results. Our objective was to compare the early outcomes of everted saphenous vein graft (eSVG) substitution urethroplasty in patients with tobacco-exposed oral mucosa and OMG urethroplasty in patients with nontobacco-exposed oral mucosa for long anterior urethral strictures. MATERIALS AND METHODS: 30 patients with long anterior urethral strictures underwent substitution urethroplasty using Dorsolateral onlay approach. Fifteen patients with healthy oral mucosa underwent OMG urethroplasty (Group 1) and 15 patients who had unhealthy oral mucosa due to chronic tobacco exposure underwent eSVG urethroplasty (Group 2). Outcomes were assessed with the International Prostate Symptom Score (IPSS); uroflowmetry; donor and recipient site complications at 1, 3, and 6 months; and symptomatic assessment thereafter. Retrograde urethrogram was done at 3 months in both the groups. Successful urethroplasty was defined as satisfactory voiding (Qmax>15 ml/s) and no need for endoscopic dilatation/direct vision internal urethrotomy in follow-up. RESULTS: Mean stricture and harvested graft length were 10.8 cm and 12.33 cm in Group 1, while in Group 2 were 13.6 cm and 15.73 cm, respectively. Nine of 13 patients in Group 1 (69.2%) and 11 of 14 in Group 2 (78.5%) with a minimum follow-up till 18 months had successful outcome at an average follow-up of 23.13 months. Donor and recipient site complications were comparable in both the groups. At 18 months, mean IPSS and Qmax in successful patients were 7.9 and 25.6 ml/s in Group 1, while in Group 2 were 8.0 and 22.6 ml/s. CONCLUSIONS: Outcomes of great saphenous vein graft urethroplasty are comparable to OMG, and it is an acceptable option in long-segment anterior urethral stricture patients with chronic tobacco-exposed oral mucosa.

Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft.

INTRODUCTION: Both dorsal and ventral approaches are acceptable options for the surgical reconstruction of female urethral strictures (FUS), but damage to the sphincter and the clitoral nerves resulting in sexual dysfunction is the chief argument against the dorsal approach. Most of the reported case series are retrospective and none has evaluated sexual functions. This study prospectively evaluates the early sexual and functional results after dorsal onlay vaginal graft urethroplasty (DVGU) for FUS. MATERIALS AND METHODS: All women with a history of obstructive voiding symptoms and previous urethral dilatation were evaluated with urodynamic study, voiding cystourethrography, and cystoscopy for the presence of FUS, which was defined as visual demonstration of anatomical narrowing on urethro-cystoscopy. DVGU was offered as a definitive management for all those identified with FUS. Surgical outcomes were assessed at 3 and 6 months with the International Prostate Symptom Score (IPSS), uroflowmetry, and postvoid residual (PVR) estimation. For sexually active females, sexual function was assessed using the Female Sexual Function Inventory (FSFI) score both preoperatively and at 3 months following surgery. RESULTS: Seventy-one women were evaluated. FUS was identified in 29 women (flimsy in 12 and dense in 17). Thirteen women with dense strictures underwent DVGU. The mean improvement in the IPSS score, Qmax, and PVR was 12.6, 16.64 ml/s, and 103.08 ml at 3 months, respectively. The FSFI score improved with a mean of 6.42 points after urethroplasty. None of the patients developed incontinence. There were three failures after a mean follow-up of 8.5 months. CONCLUSION: The early functional results after DVGU are good without any negative impact on the continence or the sexual functions.

Management of female congenital short patulous urethra with urethral tapering and pubovaginal sling: A report of two cases.

Congenital short patulous urethra is a rare entity and may be associated with developmental anomalies of mullerian ducts or urogenital sinus. We report the management of two cases of congenital short patulous urethra with stress urinary incontinence (SUI). Both the patients presented with SUI; one was diagnosed with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome and the other had uterus didelphys with longitudinally septated vagina. Both patients were successfully managed by excisional tapering of the urethra and pubovaginal sling placement. SUI with congenital short patulous urethra can be managed with excisional tapering of urethra and pubovaginal sling placement.

Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion.

Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.

The Urological Society of India survey on urinary incontinence practice patterns among urologists.

INTRODUCTION: The Urological Society of India guidelines panel on urinary incontinence (UI) conducted a survey among its members to determine their practice patterns in the management of UI. The results of this survey are reported in this manuscript. METHODS: An anonymous online survey was carried out among members of the USI to determine their practice patterns regarding UI using a predeveloped questionnaire on using SurveyMonkey®. A second 4-question randomized telephonic survey of the nonresponders was performed after closure of the online survey. Data were analyzed by R software 3.1.3 (P < 0.05 significant). RESULTS: A total of 468 of 2109 (22.2%) members responded to the online survey. Nearly 97% were urologists, 74.8% were working at a private, and 39.4% were in an academic institution. Almost all were managing UI. 84.2% had local access to a urodynamics (UDS) facility. 85.8% would check postvoid residual urine for all the patients. Voiding diary, symptom scores, quality of life scores, pad test, Q-tip test, stress test, uroflow, and cystoscopy were ordered as part of evaluation by 86.0%, 49.8%, 24.4%, 22.0%, 6.0%, 71.8%, 69.2%, and 34.7%, respectively. 47.6% would order a UDS for patients with urgency UI who fail conservative treatment. 36.9% would get UDS prior to all stress UI surgery. Seventy-five percent would make a diagnosis of intrinsic sphincter deficiency. Solifenacin was the first choice for urgency UI in general and darifenacin was preferred in elderly. Botulinum was the first choice for refractory urgency UI. Midurethral sling was the commonest procedure for surgical management of SUI (95.1%). 147 of the 1641 non responders were randomly sampled telephonically. Telephonic respondents had similar access to UDS facility but had performed fewer lifetime number of post-prostatectomy incontinence (PPI) surgeries. Combining data from both surveys, total number of artificial sphincters and PPI surgeries ever performed by USI members was estimated at 375 and 718 respectively. CONCLUSION: This survey provides important new data and elicits critical differences in management practices based on demographics.

Bladder pseudodiverticulum and debilitating dyspareunia: diagnostic and management dilemmas of a rare case.

Dyspareunia in a woman often lacks a well-defined cause with complex etiology. Similarly wide-mouthed nonobstructive bladder diverticula are mostly managed conservatively with no single etiology. Herein a rare case of dyspareunia and urinary symptoms is described, which started following a lower segment cesarean section (LSCS). Ultrasonography, micturating cystogram, and cystoscopy revealed a large wide-mouthed bladder diverticulum. After 3 years of failed and varied conservative therapy and management dilemmas, exploration was done for diverticulectomy which revealed a diagnostic surprise. A post-LSCS thick adhesive band was found between the uterus and anterior abdominal wall as a direct cause for both the bladder diverticulum and dyspareunia. Adhesions after LSCS may cause varied symptoms which may be difficult to diagnose and leave the patient refractory to conservative therapy. Laparoscopy or exploration may be useful in such cases.

[Benign prostatic hyperplasia related content on YouTube: unregulated and concerning].

INTRODUCTION: Information derived from social media sources is being used to save lives and take vital life altering decisions. You Tube is one of the most widely used social media for seeking medical information. Quality of information available to patients and medical professionals on YouTube with regards to benign prostatic hyperplasia (BPH), a common urological condition, w.as assessed. MATERIALS AND METHODS: First 1 00 videos results on BPH were analysed by three independent observers and graded based on the quality of information provided using an indigenous grading system of five points ranging from not useful to Informative for the Medical Professional. Correlation of this score with rank, number of views and "likes" was performed. Source of videos was identified along with analysis of comments. RESULTS: A large proportion of videos (63%) was found to be irrelevant to the search, projected wrong facts or provided very basic · information about prostate and the disease. A small but significant number of videos contained useful and relevant information. Only a handful of videos were useful for the urologist and adequate to guide the patient. A negative correlation between the quality of videos and their ranking on search was observed. CONCLUSIONS: YouTube offers very few high quality resources for patients and physicians. There is a significant negative correlation between useful videos and higher ranks in search results, but no correlation with number of views and likes. The first video in such results should be issued by a governing body that serves as the gold standard for patients and physicians.

Defining the "Cutoff" on the Urethral Caliber in Diagnosing a Female Urethral Stricture.

Introduction The rarity in detecting female urethral stricture (FUS) backed by the inconsistency regarding the cutoff on the caliber to direct any treatment for its increase poses a challenge to its existence. Therefore, the present study was conducted to determine the caliber of the urethra that clearly identifies a FUS. Materials and method In this prospective observational study conducted between November 2015 and July 2017, women with obstructive lower urinary tract symptoms (LUTS) and a history of relief on at least a single urethral dilatation were included if the American Urological Association (AUA) score was more than seven and the maximum flow rate (Qmax) was less than 20 mL/sec. Of the 71 women recruited, 10 women had recognizable external causes: caruncle (five), mucosal prolapse (three), and meatal stenosis (two). The remaining 61 underwent voiding cystourethrogram (VCUG) and urodynamics followed by urethrocystoscopy, if the findings suggested a stricture. A definitive diagnosis was sought in those without stricture disease. We categorized all patients as either having a "true" stricture or an alternate etiology. Categorical variables were presented in number and percentage (%) and continuous variables as mean ± standard deviation (SD). Results The mean dilatation ranged between one and six; the mean AUA score, ~17.82 ± 3.59; mean Qmax, ~10.21 ± 3.39 mL/sec; and the mean post-void residue (PVR), 106.65 ± 51 mL. A total of 29 patients were diagnosed to have stricture (dense = 17; flimsy = 12). None of the patients in this group had a urethral caliber of more than 14 French (Fr). Other etiologies were dysfunctional voiding (17), underactive bladder (seven), cystocele (four), and primary bladder neck obstruction (PBNO) (four). Conclusion Women with voiding LUTS should be screened for FUS only if the urethral caliber is ≤14 Fr.

Case for resurgence of radical perineal prostatecomy in Indian subcontinent.

INTRODUCTION: Radical perineal prostatectomy was the first surgery described for prostatic carcinoma (Young, 1904) but it lost its eminent status after Walsh's description in 1982 of anatomic radical retropubic prostatectomy followed by the enthusiasm in laparoscopy and now robotics. It made resurgence after it was realized in early 1990s that the pelvic lymph node dissection is needed only in selected cases. Last decade witnessed over 80 publications addressing the results and advances in the perineal approach. Strangely, centres from the subcontinent have chosen to ignore this resurgence. We describe our early experience with the technique in 35 patients and present the case for its more widespread usage. PATIENTS AND METHODS: Thirty five patients of clinically localized carcinoma prostate were operated by perineal route in our institution from December 2006 onwards. All patients had serum prostate specific antigen levels less than 10 ng/ml. RESULTS: Operating time was 2 to 3.5 hours (mean 2.5 hours). Rectal injury occurred in three patients but was closed primarily in all and none required a colostomy. Mean duration of hospital stay was four days. The disease was organ confined in 25(71%). Positive margins were seen in 5(14%) patients. Biochemical recurrence occurred in 17% patients at one year. Seventy six percent patients had achieved continence at one year. CONCLUSIONS: As the world is taking note of radical perineal prostatectomy again, with a very small learning curve, minimal invasion and good oncological control urologists from Indian subcontinent should also embrace this procedure in view of the relative limited resources available.

A prospective study comparing side-firing KTP laser enucleation vs bipolar transurethral resection of bladder tumor for small bladder tumors in an outpatient setting.

INTRODUCTION: Laser therapy provides an alternative option for treating non-muscle-invasive bladder cancer. The clinical evidence for potassium-titanyl-phosphate (KTP) laser en bloc resection is still limited. Here, we evaluated the efficacy, safety profile, and outcomes of side-firing KTP laser enucleation with bipolar transurethral resection of bladder tumor (TURBT) in carefully selected patients with small bladder tumors in an office setting. MATERIAL AND METHODS: A total of 83 patients with small bladder tumors were treated with either side-firing KTP laser enucleation (Group A; n = 40) or bipolar TURBT (Group B; n = 43). Intraoperative and postoperative parameters of interest were recorded and analyzed as per the study so as to evaluate the efficacy, safety profile, and outcome of KTP laser enucleation. RESULTS: The mean enucleation time was 23 ±5.24 min in Group A and the mean operative time was 21.98 ±4.77 min in Group B (p = 0.207). Group A had a lower risk of obturator reflex (0 vs 8; p = 0.005) and lesser amount of irrigation used intraoperatively as compared to Group B (6.2 ±0.61 L vs 7.65 ±0.75 L; p <0.0001). There were no perioperative complications. The recurrence rate at 6 months was none in Group A and 2.3% in Group B. CONCLUSIONS: The present study shows that, in patients with small bladder tumors (<3 cm), KTP laser enucleation is an effective and feasible alternative to bipolar TURBT in an office setting and can be carried out safely with comparable treatment outcomes, lesser use of irrigation fluid and lower risk of obturator reflex. However, further studies in larger cohorts are warranted.

The correlation between erectile dysfunction and metabolic syndrome in an Indian population: A cross-sectional observational study.

Objective: To evaluate the relationship between erectile dysfunction (ED), based on the five-item International Index of Erectile Function questionnaire (IIEF-5), and presence of metabolic syndrome (MetS) or its components based on Adult Treatment Panel III guidelines. We also explored the impact of increasing insulin resistance (IR), as calculated using the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) equation, on severity of ED. Pathophysiological links between ED and testosterone were re-evaluated. Patients and methods: In all, 357 patients with ED were evaluated; 53 patients with primary, psychogenic, surgical, post-traumatic or drug-induced ED were excluded. The remaining 304 patients were evaluated after obtaining written informed consent. The Institutional Review Board approved the study. We assessed comorbidities, IIEF-5 scores, lower urinary tract symptoms (LUTS) based on International Prostate Symptom Score (IPSS), blood sugars, lipid and hormonal profiles, and vitamin D3 levels. Further evaluation was done when indicated. Results: In all, 171 patients had MetS and 134 had pre-existing comorbidities (diabetes mellitus, 58; hypertension, 73; coronary artery disease, 13). The mean (SD) age was 44.6 (9.21) years and IIEF-5 score was 13.81 (3.17). ED severity was significantly correlated with presence of MetS. On multivariate analysis, there were significant correlations between ED and waist circumference, serum triglycerides, and fasting blood sugar. There was a statistically significant positive correlation between serum testosterone and IIEF-5 score (r = +0.292). The mean (SD) IR value (using the HOMA-IR formula) was 2.64 (2.87), which was statistically and negatively correlated with IIEF-5 scores (r = - 0.398). Receiver operating characteristic analysis showed that an IIEF-5 score of <14 predicted MetS and a HOMA-IR value of >2.1778 predicted MetS. Conclusion: MetS or its components were present in 56.25% of the patients. Therefore presence of ED merits further evaluation for presence of MetS. This may help to prevent catastrophic and life-threatening consequences of MetS. Abbreviations: BMI: body mass index; CRP: C-reactive protein; CVD: cardiovascular disease; DBP: diastolic blood pressure; DM: diabetes mellitus; ED: erectile dysfunction; FBS: fasting blood sugar; HDL: high-density lipoprotein; HOMA-IR- Homeostatic Model Assessment for Insulin Resistance; HTN: hypertension; IIEF-5: five-item version of the International Index of Erectile Function; IR: insulin resistance; LDL: low-density lipoprotein; LUTS: lower Urinary Tract Symptoms; MetS: metabolic syndrome; NO: nitric oxide; OR: odds ratio; PPBS: post-prandial blood sugar; ROC: receiver operating characteristic; SBP: systolic blood pressure; TG: triglyceride; WC: waist circumference.

Single-stage correction of urinary incontinence and vaginoplasty in a case of urethral coitus with vaginal agenesis.

Urethral coitus is a very rare entity which usually presents as urethral incontinence during intercourse and is most commonly seen with intact vagina. Only about 24 cases have been reported in the literature. A presentation in vaginal agenesis is exceedingly rare and poses the surgical challenge of restoring continence without interfering with sex life. Here we report a case of urethral intercourse with vaginal agenesis presenting with incontinence that we treated with McIndoe's vaginoplasty and urethral plication in a single stage, with satisfactory result. To the best of our knowledge, this method of reconstruction has not yet been reported for this condition.

Latzko repair for vesicovaginal fistula revisited in the era of minimal-access surgery.

Latzko repair is a technique described for repair of post-hysterectomy supratrigonal vesicovaginal fistulas (VVF) and is often practised by gynecologists, but it has not figured in the armamentarium of urologists the world over. Recently urologists have taken to laparoscopic repair of such fistula but laparoscopic repair is technically demanding with a steep learning curve. We reviewed our experience with the technique of Latzko repair. The study is a review of 10 patients operated by this technique between June 2000 and May 2005, with age ranging from 33 to 55 years (average 39 years). Fistula size ranged from 2 mm to 1 cm. There was no recurrence or sexual dysfunction due to shortening of vaginal length. The results were comparable with laparoscopic VVF repair in terms of morbidity, operative time, blood loss, and patient discomfort. Also, the learning curve involved is minimal. Thus this technique deserves wider adoption by the urological community and should be a benchmark for comparison with laparoscopic repair of VVF rather than the abdominal approach. Bearing in mind the simplicity of the procedure, urologists should feel encouraged to adopt this excellent age-old technique that has stood the test of time rather than exploring more-complex operations such as laparoscopic VVF repair and transurethral suture cystorrhaphy.

Can preoperative clinicoradiological parameters predict the difficulty during laparoscopic retroperitoneal simple nephrectomy? - A prospective study.

INTRODUCTION: Urologists tend to prefer retroperitoneal approach for open nephrectomy and transperitoneal route for laparoscopic nephrectomy. Urologists consider retroperitoneal laparoscopic approach difficult to learn and perform. There is a need to objectively define predictors of difficulty during laparoscopic retroperitoneal simple nephrectomy (LRSN) for the proper preoperative selection. To the best of our knowledge, this is the first study to prospectively assess the factors associated with difficulty during LRSN. MATERIALS AND METHODS: All adult patients of nonfunctioning kidneys (due to benign causes) planned for simple nephrectomies from November 2014 to January 2017 were included in the study. Various clinical and radiological parameters were noted along with intraoperative difficulty parameters (difficulty score, total operative time, and estimated blood loss). Renal and perirenal parameters were assessed and noted on computed tomography scan. Difficulty scale was calculated based on the three difficulty parameters and was used to objectively categorize the patients in easy and difficult group. RESULTS: A total of 44 patients were included in the study. There were 23 patients in Group I (Easy) and 21 patients in Group II (Difficult). Various preoperative clinical and radiological parameters were analyzed and compared between these two groups. History of pyonephrosis and presence of nephrostomy tube were the only two statistically significant factors associated with difficult cases (Group II). None of the factors were statistically significant in multivariate analysis. CONCLUSION: Based on the findings of our study, history of pyonephrosis and presence of nephrostomy are the most significant factors predicting difficulty during LRSN.

Generalized seizure: A rare etiology of intraperitoneal rupture of the urinary bladder.

Seizures can lead to different types of injuries which can be as simple as minor lacerations and at times as serious as fractures and head injuries. We are reporting a case wherein a female patient presented with a history of abdominal pain and not passing urine for 24h following an attack of seizure. After catheterization the urine drained was blood-stained. On clinical suspicion a cystogram was done which showed intraperitoneal rupture of the bladder. At laparotomy an isolated rent in the dome of the bladder was found which was repaired in three layers. Postoperative period was uneventful. To our knowledge this is the second case of its kind reported in the literature. Our case illustrates that a thorough abdominal examination is desirable while examining a patient following an episode of generalized seizure.

How practical is the application of percutaneous nephrolithotomy scoring systems? Prospective study comparing Guy's Stone Score, S.T.O.N.E. score and the Clinical Research Office of the Endourological Society (CROES) nomogram.

OBJECTIVE: To prospectively compare the Guy's Stone Score (GSS), S.T.O.N.E. [stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E)] score and the Clinical Research Office of the Endourological Society (CROES) nephrolithometric nomogram to predict percutaneous nephrolithotomy (PCNL) success rate and assess the correlation with perioperative complications. PATIENTS AND METHODS: We prospectively evaluated all consecutive PCNL patients at our institute between 1 November 2013 and 31 May 2015. The above scoring systems were applied to preoperative non-contrast computed tomography and the practical difficulties in such applications were noted. Perioperative complications and the stone-free rate (SFR) were also recorded. Receiver operating characteristic curves were drawn and the areas under curves were compared and appropriate statistical analysis done. RESULTS: In all, 48 renal units were included in the study. The overall SFR was 62.2%. The presence of staghorn stones (ß = 27.285, 95% confidence interval 1.19-625.35; P = 0.039) was the only significant variable associated with the residual stones on multivariate analysis. Stone-free patients had significantly lower median GSS (2 vs 4) and S.T.O.N.E. scores (6 vs 10) and higher median CROES scores (83% vs 63%) (all P < 0.001) compared to residual-stone patients. All scoring systems were significantly associated with SFR (all P < 0.001). There was no significant difference in the areas under curves of the scoring systems (0.858, 0.923, and 0.931, respectively). Furthermore, all scoring systems had weak correlations with Clavien-Dindo classified complications (r = 0.29, P = 0.045; r = 0.40, P = 0.005 and r = -0.295, P = 0.04, respectively). We found no standardisation for the measurement of stone dimensions, tract length, Hounsfield units, and staghorn definition. CONCLUSIONS: All scoring systems equally predicted SFR and had a weak correlation with Clavien-Dindo complications. Standardisation is needed for the variables in which they have been found deficient.