Safety and Efficacy of Trans-Perineal Urethroplasty for Management of Post-Traumatic Urethral Strictures in Pediatric Age-Group.

INTRODUCTION: Trans-perineal urethroplasty is the preferred treatment for distraction urethral injuries in adults. However, management of such injuries in children is challenging because of functional implications in a growing child. In the present study, we aim to evaluate the safety and efficacy of perineal urethroplasty for distraction urethral injuries in children. METHODS: The medical records of prepubertal pediatric patients (age <14 years) with traumatic urethral distraction injuries managed by perineal urethroplasty were retrospectively reviewed and analyzed with respect to demographics, stricture characteristics, management, complications, follow-up, and outcome. RESULTS: A total of 14 patients were included in the study. Ten had membranous, and 4 had bulbar urethral strictures. All membranous strictures were secondary to pelvic trauma; bulbar strictures were secondary to blunt perineal trauma; 7 patients had associated pelvic fractures. Anastomotic urethroplasty was used in 10 patients (71.4%) and buccal mucosal graft urethroplasty was done in 4 patients (38.6%). The mean follow-up duration was 56 months (range 24-76). Surgery was primarily successful in 85.7%. Failed repair in 2 patients was successfully managed with augmented anastomotic urethroplasty. Post-operatively, the mean maximal urinary flow rate was 26.4 mL/s. No significant complications occurred. All boys are continent. There was no chordee or urethral diverticula, during follow-up. CONCLUSION: In pediatric patients, bulbar and membranous strictures can be treated successfully with urethroplasty using the perineal approach. Longer follow-up is needed to confirm that these good results are maintained as these patients cross into adulthood, especially as these repairs were done before puberty.

Cystitis glandularis: Management and challenges in a renal transplant recipient.

Cystitis cystica or glandularis is a clinical and pathological entity of the bladder mucosa occurring secondary to inflammation or chronic obstruction. Its premalignant nature remains controversial, especially in an immunocompromised transplant recipient. We present a rare case where a chronic kidney disease patient was found to have cystitis glandularis while being worked up for living-related donor renal transplant and describe its subsequent management.

Comparison of single-step renal dilatation and serial renal dilatation in percutaneous nephrolithotomy: A retrospective case-control study.

BACKGROUND: Access to the pelvi-calyceal system and subsequent dilatation of the tract are among the initial important steps in percutaneous nephrolithotomy (PCNL). In this study, we share our experience with single-step renal dilatation when compared to multiple serial renal dilatation in PCNL. MATERIALS AND METHODS: This is a retrospective study wherein 35 patients who underwent PCNL by single-step renal dilatation by appropriate size Amplatz Dilator were compared with 35 patients who underwent multi-step serial renal dilatation using serial metallic Alken dilators. These patients were analyzed on the basis of demographic profile, total intra-operative time, fluoroscopic time, intra-operative and postoperative complications, stone clearance, requirement of blood transfusion, duration of hospital stay, and follow-up. RESULTS: There were no significant differences in the demographic profile among the patients in these two groups. The mean total operative duration and fluoroscopic duration were less in single step renal dilatation group, and these have been found to be statistically significant (P < 0.05). There were no statistically significant differences in the rates of other complications - incomplete stone clearance, bleeding and hematoma formation, requirement of blood transfusion, duration of hospital stay, and follow-up. CONCLUSION: Operative duration and rate of radiation exposure are significantly less in PCNL by single-step renal dilatation; however, there is no statistically significant difference in the rates of other complications.

Hung up with a Huang class 4: our experience with bilateral emphysematous pyelonephritis in a COVID 19 patient.

The COVID 19 pandemic has forced us to rethink our management strategies for surgical diseases. Patients with COVID 19 have increased risk of morbidity and mortality after surgical intervention. Emphysematous pyelonephritis (EPN) is often seen in diabetics and can be a life threatening condition. All patients require immediate treatment with antibiotics and close monitoring. Bilateral EPN is a rare entity seen in less than 10% of patients. We present a case of bilateral EPN in a COVID positive patient which was successfully managed conservatively. A 70 year old hypertensive female, presented to us with fever, breathlessness, loss of appetite, generalised weakness requiring oxygen supplementation & was diagnosed with COVID 19. Bilateral EPN (Grade 4) with perinephric collections was found on evaluation for acute kidney injury. She underwent bilateral pig tail insertion followed by bilateral DJ stenting after stabilization. She recovered dramatically, blood parameters improved and was discharged. At 1 year of follow up, patient was doing well. In the present COVID-19 pandemic where case selection for surgical intervention is crucial, we would like to highlight how a conservative approach for even Class 4 EPN is feasible after weighing the risks and benefits of the same. Patients can be spared the immediate morbidity and mortality risks due to surgical intervention during COVID 19 infection. Triaging surgical intervention can also help in better utilization of critical care facilities and man power, both invaluable in the ongoing crisis.

Urodynamic evaluation of urinary disturbances following traumatic brain injury.

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

The use of gracilis muscle flap as a cover of tabularized buccal mucosal graft in the posterior urethral injury.

This is a case report of 35-year-old male patient, who underwent abdominoperineal resection for rectal cancer. There was postoperative wound complication which resulted in the formation of sinus in the perineal wound. During excision of the sinus tract, there was injury to the posterior urethra which leads to the formation of urethrocutaneous fistula presenting as urinary incontinence. These findings were confirmed by ascending urethrogram and cystoscopy. We describe the use of gracilis muscle flap as support and cover for buccal mucosal graft which has been used for the repair of the posterior urethral injury. On removal of Foley's catheter after 3 weeks of the surgery, there was no leakage of urine from the perineal wound, and the patient was continent. The highly vascularized muscle flap is beneficial in patients with a poor graft bed secondary to prior radiotherapy, avoiding urinary diversion in most patients.

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

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

Safety and efficacy of percutaneous nephrolithotomy in the pediatric population.

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

Comparison of contrast-enhanced voiding urosonography with voiding cystourethrography in pediatric vesicoureteral reflux.

OBJECTIVE: Voiding cystourethrography (VCUG) has been considered as the gold standard technique for the diagnosis of vesicoureteral reflux (VUR). But, it requires fluoroscopic guidance which expose children to radiation. Voiding urosonography (VUS) is technically analogous to VCUG and has the major advantage of zero radiation exposure. This study aims to determine the efficacy of contrast enhanced-VUS (ce-VUS) with respect to VCUG in diagnosing VUR. MATERIAL AND METHODS: This study involves 30 children over a period of 3 years. All patients underwent a VCUG followed by the ce-VUS on the same day. All VUS studies were done by the same sonologist in the sonography department. The images were recorded and reviewed by the same sonologist before reporting. RESULTS: The median age of the patients was 51.53 months. There were 21 males and 9 females. On VCUG, 16 patients had no reflux, and 14 patients had reflux. On ce-VUS, 14 patients had no VUR, and 16 patients had VUR. Of the total 58 kidney-ureter units (KUUs), VUR was detected in 17 KUUs on VCUG and in 21 KUUs on ce-VUS. Thus, ce-VUS detected 4 refluxing units that were not seen on VCUG. In right KUUs, ce-VUS detected VUR in 3 units where no reflux was found in VCUG. In the 28 left KUUs, 25 units on ce-VUS showed concordance with the grade of VUR as detected by VCUG; 3 were discordant. Two units on ce-VUS showed a VUR one grade higher than the corresponding grade on VCUG and in one unit it was one grade lower. Thus, in total, ce-VUS picked up 4 cases which were missed by VCUG. CONCLUSION: ce-VUS is a good imaging modality when compared to voiding cystourethrography to assess pediatric vesicoureteral reflux, in view of its superior diagnostic performance, feasibility and radiation safety for children.

Intravesical Migration of an Intrauterine Contraceptive Device with Secondary Calculus Formation.

Intrauterine contraceptive devices (IUCDs) are a common form of reversible contraception owing to fewer systemic side effects and low cost, especially in a developing country like India. However, IUCDs are not without complications. Migration of a device into adjacent organs is the most morbid of all the documented complications. A patient who presents with a history that suggests loss or disappearance of an IUCD thread associated with urinary symptoms should raise suspicions that a device may have migrated into the bladder. Physicians should also be aware of possible secondary vesical calculus formation. Further radiological investigations and appropriate management are warranted. We present a case report describing the migration of an IUCD into the bladder with secondary calculus formation.

A rare presentation of cystic nephroma in a young adult.

Cystic nephroma is a rare benign renal lesion with non-specific presenting symptoms. This tumour has a bimodal age distribution presenting in children between 3 months and 2 years and in adults over 30 years of age. There is male preponderance with a 2:1 male to female ratio in the childhood whereas it is commoner in females in adults. It is uncommon in the age-group of 5 years-30 years. We describe a case of cystic nephroma in a 25-year-old female which was managed by partial nephrectomy.

Laparoscopy-assisted transperitoneal percutaneous nephrolithotomy for recurrent calculus in isthmic calix of horseshoe kidney.

BACKGROUND AND PURPOSE: Management of urolithiasis in a horseshoe kidney (HSK) poses a unique challenge. Although most patients can be managed by a combination of percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (SWL), calculi in the isthmic calix remain difficult to treat, as this area is out of reach during rigid PCNL, and, owing to the poor evacuation of the fragments, the results of SWL are suboptimal. CASE REPORT: A 59-year-old man known to have an HSK presented with right-sided lower-abdominal pain and episodes of urinary infection. In the past, he had undergone pyelolithotomy and lithotripsy for lithiasis in the kidney. Imaging studies identified a large recurrent calculus in the anteriorly directed isthmic calix. This was treated successfully by a laparoscopy-assisted transperitoneal PCNL. The laparoscopic view allowed the bowel to be retracted away from the site of the HSK, and PCNL guided by fluoroscopy and laparoscopy was performed. Complete stone clearance was achieved in a single stage. The patient remains free of symptoms and recurrence 3 months later. CONCLUSION: We believe this to be the first report describing this novel approach to lithiasis in an HSK.

Buccal mucosal graft onlay repair for a ureteric ischemic injury following a pyeloplasty.

A 38-year-old female presented with long stricture in the left upper ureter following a pyeloplasty causing persistent flank pain. A left PCNL with an antegrade endopyelotomy was attempted in view of a concomitant left renal 1.5 cm calculus in the lower calyx but it failed. Subsequently, a buccal mucosal onlay graft was applied on the strictured ureter. Follow-up at 3 months showed good uptake of the graft with patent passage for urine drainage.

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

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

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

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

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

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