'Pee'BuSt Trial: A single-centre prospective randomized study comparing functional and anatomic outcomes after augmentation urethroplasty with penile skin graft versus buccal mucosa graft for anterior urethral stricture disease.

PURPOSE: To assess the surgical outcomes of augmentation urethroplasty (AU) using penile skin graft (PSG) compared to buccal mucosa graft (BMG) in anterior urethral stricture disease. METHOD: Between January 2018 and January 2019, 100 patients with anterior urethral stricture planned for AU were randomized into PSG or BMG arms (CTRI/2018/07/015028). Anatomic and functional variables were compared pre-operatively and post-operatively. Primary outcome was success rate at 18 months and it was defined if any of the three criteria were met, i.e. either maximum urinary flow (Qmax) > 15 ml/s or urethral calibration of 16 French or ability to traverse the repair with 17 French cystoscope. Secondary outcomes were functional parameters such as International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF) Score, Male Sexual Health Questionnaire for Ejaculatory Dysfunction (MSHQ-EJD), and Urethral Stricture Surgery-Patient Related Outcome Measure (USS-PROM). RESULTS: Pre-operative variables were comparable between both the arms. Median duration of follow-up was 22 months (18-24 months). At 18 months, the success rates of AU with PSG and BMG were comparable (89% v/s 91%; p = 0.70, 95% CI-0.33 to 5.21). The improvements in Qmax (p = 0.06), IPSS (p = 0.43) and USS-PROM (p = 0.49) were comparable between the two arms. There was no statistically significant difference in the IIEF-Erectile domain (p = 0.07), IIEF-Orgasmic domain (p = 0.11) and MSHQ-EJD (p = 0.20) following AU at 18 months. Clavien-Dindo grade I complications were 12.7% in PSG and 16.7% in BMG. CONCLUSION: This study provides level 1 evidence of no statistical significant difference in outcomes of AU using BMG or PSG.

Unusual endophytic non-enhancing tumour in the renal pelvis: a diagnostic dilemma.

Renal cell cancer (RCC) is incidentally detected on imaging in 50%-60% of cases. Among the RCCs, clear cell variant is most common and classically seen as heterogenous enhancing lesion on CT imaging. Hypoenhancing mass presents a diagnostic dilemma with differential diagnosis being urothelial carcinoma, fat poor angiomyolipoma, oncocytoma or rarer variants of RCC. Such cases require further evaluation in form of urine cytology or newer molecular diagnostic techniques. Here, we present a case of renal mass with minimal enhancement on CT scan and imaging features suggestive of upper tract urothelial cancer. Final histopathology revealed the mass to be chromophobe variant of renal cell carcinoma.

Adrenal pheochromocytoma with involvement of aorta and left renal artery: salvaged with adrenalectomy and nephrectomy.

Large adrenal pheochromocytomas encasing the renal artery are a rare entity. The management of such challenging cases is surgical resection. The involvement of renal tissue and renal artery may necessitate meticulous dissection and concomitant nephrectomy. Here, we present a case of 41-year-old man diagnosed with left adrenal pheochromocytoma with complete encasement of left renal artery and partial encasement of aorta. Open left adrenalectomy and nephrectomy was performed after adequate preoperative optimisation. The patient is doing well at 6-month follow-up. Large adrenal pheochromocytoma with renal involvement is a rare presentation and requires optimal preoperative imaging, adequate preoperative alpha and beta blockade and meticulous surgical technique.

Does Miniaturization Actually Decrease Bleeding After Percutaneous Nephrolithotomy? A Single-Center Randomized Trial.

Introduction: Miniaturization of percutaneous nephrolithotomy (mPCNL) was proposed to decrease postoperative bleeding, as there is decreased parenchymal injury compared with standard percutaneous nephrolithotomy (SPCNL). Published randomized controlled trials (RCTs) evaluating bleeding after mPCNL have shown conflicting results. Hence, the evidence to say that mPCNL offers less postoperative bleeding is not robust. Materials and Methods: Prospective RCT was done by comparing mPCNL and SPCNL for treatment of renal stones of size 1 to 3 cm. Patients with active urinary tract infection, renal malformation, uncorrected coagulopathy, and raised serum creatinine (>1.5 mg/dL) were excluded. Blood loss was evaluated by measuring fall in hemoglobin and hematocrit on postoperative day 1. Postoperative pain was evaluated by visual analogue scale (VAS) score at 6, 24, and 48 hours. Results: A total of 60 patients (30 in each arm) were enrolled during the study period. All the baseline preoperative variables were comparable in both the groups. The SPCNL group had a significantly higher drop in hematocrit level as compared with mPCNL (4.6 ± 3.1% vs 3.1 ± 2.1%, p = 0.02). The mean fall in hemoglobin was higher in SPCNL as compared with mPCNL (1.61 ± 0.9 gm% vs 1.21 ± 0.7 gm%, p = 0.07), but it was not significant. Blood transfusion (BT) rate was comparable in both the groups (one patient in each group). The mPCNL group had significantly less VAS scores at 6 hours (3.27 ± 1.20 vs 4.40 ± 1.52, p = 0.002) and 24 hours (2.10 ± 0.54 vs 2.83 ± 1.05, p = 0.001) after surgery. Postoperative complications and hospital stay were comparable in both the arms. Conclusion: mPCNL is associated with less postoperative bleeding and pain than SPCNL. However, the small tract size does not prevent against the clinically significant bleeding requiring BT.

Dismembered extravesical reimplantation of ectopic ureter in duplex kidney with incontinence.

Ectopic ureter is a rare but pertinent cause of incontinence in young women. We report a 12-year-old girl who presented with reports of incontinence since birth. She was evaluated and found to have complete duplication of the left ureter, with the upper moiety ureter opening into the vestibule of the vagina just below the external urethra meatus. She was managed surgically by dismembered extravesical reimplantation of the upper moiety ureter instead of the conventional method of common sheath reimplantation, sparing the patient a wide cystostomy and intravesical dissection. One year postsurgery, the patient is asymptomatic and dry. Dismembered reimplantation of the ectopic ureter is a simple and reproducible technique which avoids manipulation of the normal lower moiety ureter and its associated potential complications. At the same time, it ensures that the patient is dry without any adverse effect on the lower moiety or its ureter.

Robot-assisted Repair of Complex Vesicovaginal Fistulae: Feasibility and Outcomes.

OBJECTIVE: To share our experience and techniques of robot-assisted repair of complex vesicovaginal fistulae. METHODS: Prospectively maintained data of patients undergoing robot-assisted repair of complex vesicovaginal fistula (VVF) from December 2014 to October 2019 were analyzed. Patient characteristics, operative data, postoperative events, and follow-up outcomes were noted. All cases underwent preoperative cysto-vaginoscopy and upper tract imaging. The procedure was completed in a standard fashion. Additional procedures included Boari flap reimplantation, Burch-colposuspension, ureteric reimplantation and Vaginal flap incorporation. On follow-up, successful repair was defined as no urine leak after removal of catheter. RESULTS: Out of 73 patients undergoing robot-assisted VVF repair at our institute, 33 were classified as complex VVF. Mean age was 42.7 ± 7.2 years. The most common cause of VVF was posthysterectomy (81.8%) with 21 (63.1%) recurrent VVFs. Thirty patients (90.0%) had supratrigonal fistulae; multiple fistulae were present in 3 cases. Two patients underwent Boari flap ureteric reimplantation for concomitant ureteric stricture and ureteric neocystostomy was required in another patient. One patient underwent our novel technique of vaginal flap incorporation and a Burch colposuspension was performed simultaneously in one patient with stress incontinence. The median follow-up was 35 months (interquartile range 8.5months). Successful outcome was noted in 31 (93.9%) patients; recurrence requiring further repair in 2 patients. CONCLUSION: The current series presents the largest number of complex VVFs repaired by robotic assistance. Robot-assisted repair can be considered as one stop procedure for such complex and vexing problems.

Large spontaneous perirenal haematoma following percutaneous transluminal coronary angioplasty.

Perirenal haematoma is a rare and life-threatening condition in view of severe and ongoing blood loss. Most common causes are renal cancer, angiomyolipoma and vasculitis. Spontaneous causes of this rare entity may occur with use of anticoagulants and antiplatelets. We report a 61-year-old male patient diagnosed with large perirenal haematoma following percutaneous transluminal coronary angioplasty for myocardial infarction under heparin cover that was managed conservatively.

Simple adrenal cyst masquerading clinically silent giant cystic pheochromocytoma.

Pheochromocytoma (PCC) may present as a cystic or solid tumour. Cystic PCCs are difficult to differentiate from simple cysts in the absence of classic symptoms of PCCs. Cystic nature develops due to intralesional bleeding and necrosis. We present a case of young man without any comorbidity who was diagnosed as a simple adrenal cyst and planned for laparoscopic excision but found to be functional PCC during the time of surgery only. The patient was managed with extensive monitoring and use of multiple drugs to control blood pressure. Surgery was completed without any complication laparoscopically and postoperative period was also uneventful. Histopathology confirmed the diagnosis of cystic PCC. Our case also shows the importance of functional imaging like metaiodobenzylguanidine (MIBG) scan in doubtful cases of adrenal cysts when other biochemical markers are unremarkable to diagnosis. We emphasise the importance of meticulous preparation for any intraoperative disasters even for apparently simple adrenal cyst.

Rare case with plethora of upper urinary tract anomalies associated with pelviureteric junction obstruction: a surgical challenge managed with robot assistance.

The genitourinary system for reasons unknown is more likely to have birth defects than any other system. The anomaly of collecting system draining the kidney represent mystifying subset of congenital anomalies. Pelviureteric junction obstruction (PUJO) is most common. Chronic obstruction can lead to stasis, urinary infection and stone formation in PUJO. Extrarenal calyces, which is characterised by presence of calyces and renal pelvis outside the renal parenchyma is one of the rare anomalies seen among the collecting system right gonadal vein drains into inferior vena cava. Its altered drainage into right renal vein is rarely seen and reported. Glut of these multiple anomalies in a single case is an extremely rare event. We hereby discuss a case of 40-year-old male patient with combination of all these anomalies and discuss the embryology, presentation and management.

Paraneoplastic hepatic dysfunction with jaundice in a case of primary renal synovial sarcoma: A very rare scenario.

Nonmetastatic hepatic dysfunction known as Stauffer's syndrome is a rare entity. It is commonly associated with clear cell carcinoma of kidney. Rarely it has been reported in cases of prostatic carcinoma, bronchogenic tumor and lymphoproliferative diseases. Stauffer s syndrome presents as elevated alkaline phosphatase, aminotransferases, and prolonged prothrombin time without jaundice. However a very rare variant of Stauffer's syndrome presenting with jaundice has been reported in few case reports of clear cell carcinoma of kidney. But such a presentation in cases of renal sarcomas has not been reported so far. Here we report a unique case of primary synovial sarcoma of kidney presenting as nonmetastatic cholestatic jaundice.

Isolated asymptomatic metastasis in the myocardium: a rare scenario in case of carcinoma penis.

Penile cancer is a common malignancy in developing countries. It commonly metastasizes to the lymph nodes, lung, liver, and bones. Myocardial metastasis is rare. A 40-year-old male patient presented with ulcerative growth over glans penis. Histologic evaluation of the biopsy sample diagnosed the lesion as squamous cell cancer. Assessment of the stage of the disease revealed cardiac metastasis. Patient received six cycles of chemotherapy. He partially responded, but later succumbed to cardiac failure due to pericardial and pleural effusion.

Human epidermal growth factor receptor 2/neu overexpression in urothelial carcinoma of the bladder and its prognostic significance: Is it worth hype?

AIMS: In urothelial tumors of the urinary bladder, human epidermal growth factor receptor 2 (HER-2)/neu expression has been reported over 10 years, but there is no clear correlation between prognosis and recurrence rate. The present study evaluates prognostic implication of HER-2/neu expression. SUBJECTS AND METHODS: In this study, 100 formalin-fixed paraffin-embedded specimens of primary transitional cell carcinoma of the bladder were processed. HER-2/neu monoclonal antibody immunohistochemistry staining procedure used for the study. RESULTS: A total of 70 (70%) patients were positive for overexpression of HER-2/neu. HER-2/neu was positive in patients with 42 (70%) superficial tumor, 28 (70%) muscle invasive tumor, 41 (75.9%) high-grade tumor, 29 (63%) low grade tumor, 31 (68.9%) recurrent tumor, and 6 (66.6%) had positive lymph nodes. CONCLUSIONS: Human epidermal growth factor receptor 2/neu over expression was not correlated with the tumor stage, lymphnode metastasis or recurrence of the disease. HER-2/neu overexpression was statistically insignificantly correlated with the differentiation grade (P < 0.161) as compared to previous studies. Future studies on HER-2 expression with chemo-sensitivity and efficacy of HER-2-targeted therapies in urothelial carcinomas is needed.

Pelvic pheochromocytoma mimicking as urinary bladder pheochromocytoma: looking beyond the obvious.

Pheochromocytomas located outside the adrenal glands are called paragangliomas. A pelvic location is rare, the most common location for a paraganglioma being the retroperitoneal space. Paragangliomas arise from neural crest cells. Pelvic pheochromocytomas may mimic urinary bladder pheochromocytomas on imaging studies. Patients may present with hypertensive crisis during micturition. We present a 26-year-old female who presented to us with accelerated hypertension with episodes of severe headache and palpitation during micturition. Based on imaging studies, she was diagnosed to have a urinary bladder pheochromocytoma. However, on exploration, the patient was found to have an extravesical pheochromocytoma arising from the left posterolateral pelvic wall, which was excised while preserving the bladder. We present this case report as pelvic pheochromocytomas can mimic bladder pheochromocytomas and are difficult to differentiate on radiological imaging and can lead to inadvertent cystectomy.