Ajay Kumar Guntaka

Flexible Ureteroscopy for Upper Ureteral Calculi in Children

INTRODUCTION Ureteroscopy is one of the therapeutic options in the management of urinary stone disease in children. Previous literature has described ureteroscopy primarily in mid to distal ureteral calculi. We report our experience with flexible ureteroscopy in the management of upper ureteral calculi. PATIENTS AND METHODS All children with upper ureteral stones were included prospectively in the study. Stone burden was measured in millimeters. Presentation, operative access, intraoperative complications, stone-free rates, and postoperative complications were evaluated. RESULTS A total of 80 children (69 boys and 11 girls) underwent 88 ureteroscopic procedures. In 72 (90%) children, complete stone clearance was achieved after a single ureteroscopic session. In 6 (7.5%) others, complete stone clearance was achieved after the second ureteroscopic session. CONCLUSIONS Complete stone clearance after single ureteroscopy is possible if the calculi are single, small (<10 mm), and below the level of the pelviureteral junction.

Staged buccal mucosa urethroplasty in reoperative hypospadias

Introduction: Repeated attempts at surgical repair of serious complications involving either the partial or complete breakdown of the hypospadias repair are less likely to succeed because the penis is densely scarred, or significantly shortened, and the skin over the penis is immobile and hypovascular. Buccal mucosa (BM) has become the preferred material for reconstruction, whenever a child with skin-deficient hypospadias needs reoperation. We report the results of our surgical experience with staged reoperation using BM, in the repair of hypospadias in children with complications after multiple failed repairs. Materials and Methods: Children needing reoperation for hypospadias underwent a staged repair using buccal mucosa. The complications were noted. Results: Twenty-one children aged 3 – 16 years underwent this staged repair during the period May 2000 – April 2010. Two of these 21 children had a failed first stage. One child developed a urethro-cutaneous fistula following the second stage, which was corrected in an additional stage. Conclusions: The use of the buccal mucosa graft for urethral reconstruction in a child with hypospadias, needing a reoperation, is a successful method, with a low incidence of complications.

Type 2 diabetes mellitus and renal stones

Background: The incidence of urinary stone disease has shown a steep rise in recent decades along with marked modifications in dietary habits and life- style. There has been an increased prevalence of urinary stone disease in patients with diabetes. We took up this study to determine the association of diabetes mellitus with kidney stones in patients undergoing surgical treatment. Materials and Methods: Patients presenting with renal stones for surgical management formed the study group. Body mass index (BMI) was calculated by noting the weight and height of the patient. The extracted stone/stone fragments were analyzed to determine the chemical composition. Urinary pH was similarly noted in all. Results: The mean BMI among the diabetics was 26.35 ± 5.20 (range 17.75-35.60), whereas the mean BMI among the non-diabetics was 23.41 ± 2.85 (range 17.71-31.62) (P < 0.0004). The incidence of uric acid calculi in the diabetics was significantly high (P < 0.03). The mean urinary pH among the diabetics was 5.61 ± 0.36 and among the non-diabetics was 6.87 ± 0.32, which was significantly lower (P < 0.000044). Conclusions: There is a strong association between type 2 diabetes and uric acid stone formation. There is also a strong association between diabetes mellitus, BMI, and also with lower urinary pH.

Adrenal cysts: Our laparoscopic experience

INTRODUCTION: Cystic lesions of the adrenals are rare with an incidence of 0.06% in autopsies, and the most frequently found are either the endothelial cysts or the pseudocysts. We report our series of patients presenting with adrenal cysts. MATERIALS AND METHODS: The case records of patients presenting with adrenal cysts were reviewed and analyzed. Age, gender, presenting symptoms, physical examination findings, laboratory investigations and imaging records were all noted and analysed. RESULTS: During the 10-year study period, 14 patients, with a mean age of 41.36 ± 5.57 years, were diagnosed to have adrenal cysts. Laparoscopic excision of cysts was performed in three and laparoscopic adrenalectomy in the remaining eleven. CONCLUSIONS: Adrenal cysts are rare, and intervention is indicated whenever they are large (>5 cm), symptomatic, functional, and potentially malignant. Laparoscopic management of these cysts in the form of either decortication/excision is safe, effective, minimally invasive, with minimal blood loss and shorter duration of hospitalization.

Tumor doubling time of renal cell carcinoma measured by CT

Introduction: Increasing numbers of patients are now being incidentally detected with small-sized renal cell carcinoma (RCC). The natural history of small renal masses is not completely understood. Currently, there are no specific tumor markers to determine initial risk or progression to metastatic disease. Growth rate and tumor size are factors shown to be predictive of tumor biology. In this study, we attempted to examine the natural history of RCC and calculated the doubling times (DTs) of untreated RCC at the primary site. Materials and Methods: We retrospectively reviewed the records of all patients with RCC who had at least two measurements of the same tumor mass obtained on computed tomography (CT) imaging on two different dates (at least 6 months apart) during periods of non-treatment. The tumor volume was calculated at two points in time using images yielded by the CT imaging. The tumor DT was calculated using the following equation: DT = (T – T0) × log2/logV – logV0. Results: Twenty-two (13 male and nine female) patients with ages ranging from 32 to 71 years (mean 52.22 years) were included in the study. The initial maximum tumor diameter ranged from 2.8 to 6.8 cm (mean 3.93 cm) and the last maximum tumor diameter ranged from 3.2 to 7.8 cm (mean 4.39 cm). The DT for the entire population was 460.01 days (range 174-913 days). Conclusions: RCC is a diverse disease process, with the majority of lesions demonstrating malignant disorder. In our study, the DT for the patient population was 460.01 days (range 174-913 days).

Penile growth in response to hormone treatment in children with micropenis.

Introduction: Micropenis is defined as a stretched penile length 2.5 standard deviations less than the mean for age without the presence of any other penile anomalies, such as hypospadias. The term refers to a specific disorder that has a known set of causative factors and defined treatment modalities. The purpose of this study was to determine the effect of hormonal therapy on the gonadal response and penile growth in children who presented with micropenis. Materials and Methods: Children (<18 years) who met the criteria for micropenis were included in this study. Children more than 11 years old were treated using a standard protocol of 1,500 to 2,000 IU human chorionic gonadotrophin administrated intramuscularly, once per week, for 6 weeks. Children less than 11 years old were treated with parenteral testosterone enanthate 25 mg once a month for 3 months. Response was evaluated in terms of change in testosterone levels and size of penis. Results: Serum testosterone levels at baseline and after 8 weeks of hormonal treatment were <20 and 449.4 ng/mL, respectively (P < 0.0001) in all children more than 11 years old. Stretched penile length after hormonal treatment increased from 15.54 to 37.18 mm in children less than 11 years old and from 26.42 to 64.28 mm in children more than 11 years old (P < 0.001). Conclusions: Management of isolated micropenis revolves around testosterone (direct administration or encouraging the patients body to make its own), and results with respect to increase in penile length are promising.

Genital reconstruction in exstrophy patients.

Introduction: Surgery for bladder exstrophy has been evolving over the last four to five decades. Because survival has become almost universal, the focus has changed in the exstrophy-epispadias complex to improving quality of life. The most prevalent problem in the long-term function of exstrophy patients is the sexual activity of the adolescent and adult males. The penis in exstrophy patients appears short because of marked congenital deficiency of anterior corporal tissue. Many patients approach for genital reconstruction to improve cosmesis as well as to correct chordee. We report our series of male patients seeking genital reconstruction following exstrophy repair in the past. Materials and Methods: Fourteen adolescent/adult male patients attended urology services during the period January 2000-December 2009 seeking genital reconstruction following exstrophy repair in the past. Results: Three patients underwent epispadias repair, four patients had chordee correction with cosmetic excision of skin tags and seven patients underwent chordee correction with penile lengthening. All patients reported satisfaction in the answered questionnaire. Patients undergoing penile lengthening by partial corporal dissection achieved a mean increase in length of 1.614 ± 0.279 cm dorsally and 1.543 ± 0.230 cm ventrally. The satisfactory rate assessed by the Short Form-36 (SF-36) showed that irrespective of the different genital reconstructive procedures done, the patients were satisfied with cosmetic and functional outcome. Conclusions: Surgical procedures have transformed the management in these patients with bladder exstrophy. Bladders can be safely placed within the pelvis, with most patients achieving urinary continence and cosmetically acceptable external genitalia. Genital reconstruction in the form of correction of chordee, excision of ugly skin tags and lengthening of penis can be performed to give the patients a satisfactory cosmetic and functional system.

Forgotten/retained double J ureteric stents: A source of severe morbidity in children.

Background: The increase in the usage of double J (DJ) ureteral stents in the management of a variety of urinary tract disease processes mandates familiarity with these devices, their consequences and their potential complications, which at times can be devastating. We retrospectively reviewed our series of children with forgotten/retained DJ ureteric stents. Materials and Methods: Hospital records of all patients′ <18 years old who underwent removal of forgotten/retained DJ ureteral stent at our hospital were reviewed for age, gender, indication for insertion of DJ stent, duration of stent insertion, radiological images and surgical procedures performed. Results: During the study period, January 2000 to December 2014 (a 15-year period), a total of 14 children underwent removal of forgotten/retained DJ ureteral stent. A combination of extracorporeal shock wave lithotripsy, cystolitholapaxy and percutaneous nephrolithotomy was done to free the DJ stent and extract it. Conclusions: Forgotten/retained stents in children are a source of severe morbidity, additional/unnecessary hospitalisation and definitely financial strain.

Transvesicoscopic Repair of Vesicovaginal Fistula: Short Term Follow-Up

Introduction: We report our series of patients with VVF treated by transvesicoscopic approach. We analyzed the outcome of this repair in women of reproductive age group. Materials and methods: Patients of reproductive age group with VVF formed the study group. Only single fistulas which were <10 mm in diameter and situated in the supratrigonal region were included. Patients were randomized to undergo either laparoscopic transperitoneal or transvesicoscopic repair. Results: During the study period Jan 2009 to Dec 2012, 15 women underwent laparoscopic repair of VVF. Eight of these women underwent laparoscopic transperitoneal repair, whereas the remaining seven underwent transvesicoscopic repair. Conclusions: Transvesicoscopic as well as laparoscopic transperitoneal repair of VVF carries all the advantages of laparoscopy including minimal invasiveness, less morbidity, shorter hospital stay, early recovery, and better cosmetic appearance. Women in the reproductive age group return to early sexual activity and have a decreased incidence of urinary voiding dysfunction at 6 months follow-up.

Inflammatory pseudotumor of the bladder in a child

Inflammatory pseudotumors of the bladder are rare in children. We report here the case of an 11-year-old child who presented with lower urinary tract symptoms. Ultrasonography and computed tomography imaging of abdomen showed an intravesical mass/thickening arising from the right lateral wall. Biopsy of the lesion revealed a lesion that showed uniform elongated spindle cells within a background of myxoid stroma. The cells were loosely packed from a smooth muscle lesion, which had a densely packed cellular stroma. The child improved with a course of antibiotics and a repeat imaging showed disappearance of the lesion.