Amit Goel

Urinary tract endometriosis: Review of 19 cases.

Aim: The aim of our study was to evaluate the treatment outcomes of medical and surgical management of urinary tract endometriosis. Materials and Methods: Urinary tract endometriosis patients enrolled between Jan 2006 and May 2010 were retrospectively reviewed. Preoperative datas (mode of presentation, diagnosis, imaging), intraoperative findings (location and size of lesion), postoperative histopathology and follow-up were recorded and results were analyzed and the success rate of different modalities of treatment was calculated. Results: In our study, of nineteen patients, nine had vesical involvement and ten had ureteric involvement. Among the vesical group, the success rate of transurethral resection followed by injection leuproide was 60% (3/5), while among the partial cystectomy group, the success rate was 100%. Among patients with ureteric involvement, success rate of distal ureterectomy and reimplantation was 100%, laparoscopic ureterolysis with Double J stenting followed by injection leuprolide was 75% while that of Gonadotropin- releasing hormone (GnRh) analogue alone was 67%. Conclusion: One should have a high index of suspicion with irritative voiding symptoms with or without hematuria, with negative urine culture, in all premenopausal women to diagnose urinary tract endometriosis. Partial cystectomy is a better alternative to transurethral resection followed by GnRh analogue in vesical endometriosis. Approach to the ureter must be individualised depending upon the severity of disease and dilatation of the upper tract to maximise the preservation of renal function.

Emphysematous pyelonephritis: Our experience with conservative management in 14 cases.

Context: Emphysematous pyelonephritis (EPN) is a rare, severe, acute, necrotizing infection of the kidney. In this study, we present the clinical details, the management strategies, and the outcome of fourteen patients of EPN managed at our center. Materials and Methods: A retrospective analysis of the hospital records was done. A total of fourteen patients with EPN were admitted in our hospital from August 2007 to February 2011. All the patients were managed conservatively. Follow-up ranged from six months to one year. Results: Of the fourteen patients, four belonged to class I, five to class II, four to class IIIA and one to class IIIB. All the patients had history of fever, 43% had localized flank pain while 36% had vague abdominal discomfort. Renal angle tenderness was the most common sign, seen in 86% of the patients. E. coli was the most common bacteria, which was isolated from urine in 57% of the patients. On the risk factor stratification, three patients had simultaneous presence of 2 or more risk factors (thrombocytopenia-2 patients; renal function impairment-7 patients; shock-1 patient). All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad spectrum antibiotics. Intervention, in the form of percutaneous drainage or DJ stenting, was done in six patients. One patient failed to respond to this minimally invasive modality of treatment and had to undergo an open drainage. Thus, the acute episode was managed with conservative management strategies in all the patients; however, three patients underwent nephrectomy due to poorly-functioning kidney during follow-up. Conclusions: EPN is now being more readily diagnosed, at an early stage, making conservative management of EPN a safe, effective, and feasible option.

Buccal mucosal graft urethroplasty in long segment anterior urethral stricture - Is it gold standard?

To assess the success of dorsal onlay buccal mucosal graft (BMG) urethroplasty in long segment anterior urethral stricture extending from external meatus to bulbar urethra). We studied 40 patients with long segment anterior urethral stricture, who underwent substitution urethroplasty using dorsal onlay BMG from January 2002 to December 2007. The patients were in the age range of 15-65 years (mean 35 years) in the LS group and 16-63 years (mean 34 years) in the non-lichen sclerosus (NLS) group. The cause of stricture was LS in 20 and NLS (inflammatory and idiopathic) in the other 20 patients. The mean stricture length was 14.5 cm (range 12-17 cm) in the LS group while it was 14.0 cm (range 12-16 cm) in the NLS group. The patients were evaluated with antegrade, retrograde urethrograms and sono-urethrograms and they were followed- up with uroflometery at three months for one year, then six- monthly for two years and then annually. The contrast studies were repeated at six-monthly intervals for one year and then annually for one year. Success was defined as normal voiding pattern without any intervention post-operatively. Median follow-up was 48 months (18-72 months) in the LS group, while it was 42 months (12-72 months) in the NLS group. Among the NLS group patients, three patients developed restricture on follow-up, while seven patients among the LS group developed restricture. We conclude that the high percentage of recurrence of strictures (35%) among the LS group renders BMG urethroplasty in long segment anterior urethral stricture an unacceptable solution, and it needs further study.

Sutureless circumcision - An Indian experience

Context: Traditionally, circumcision wounds are closed by absorbable sutures. However, certain alternative methods are also being utilized to overcome the shortcomings of the conventionally used method for circumcision wound closuring. In the current study, the use of tissue glue ((iso amyl 2-cyanoacrylate) has been compared with traditional suturing for the approximation of circumcision wounds. In our study, both the methods were found to be comparable with significantly less time consumed in glue group. Aims: The purpose of the present study has been to compare directly cyanoacrylate as a better alternative to conventional suture material in terms of cosmetic result, time consumed and incidence of infection (comparative study). Materials and Methods: The results of all the patients seen in outpatient department for circumcision were included in this study. The study was conducted from Aug 2009 to May 2010. The tissue glue (iso amyl 2-cyanoacrylate) was compared to sutures as a method of wound approximation in circumcision. Results: Tissue glue group has been observed to have less wound inflammation, bleeding or hematoma rate and was cosmetically superior as compared to suture group; however, none of these findings could reach statistically significant level. The mean time taken for circumcision was 14.2 min (SD 2.42), when tissue glue was used for wound approximation. However, it was 24.4 min (SD 5.06) in case of the use of sutures. This difference was found as highly significant (P value < 0.001). However, regarding postoperative pain no significant reduction was observed when glue was used. Conclusions: This study showed that the use of tissue glue in comparison to sutures is having the following advantages: Cosmetically superior Less time consuming All other parameters measured were nearly the same and statically insignificant.

Bilateral Duplex collecting system in Horse shoe kidney: An unusual association

A 17 years unmarried female presented to Gastroenterology Department of our hospital for nonspecific symptoms of epigastric pain. The Ultrasonographic examination of the patient re-vealed triple kidney with horseshoe anomaly. She was then referred to us for further evaluation. We further proceed with Intravenous Urography (IVU) which demonstrated a bilateral duplex system in a asymmetrical horseshoe kidney (L shaped fusion). Left side kidney was vertically placed while the right side kidney was horizontally placed. One of the moieties was on the right side of vertebral col-umn while the other moiety was overlying the ver-tebra and isthmus was on the left side of vertebra (Figure-1). A contrast enhanced computed tomog-raphy (CECT) scan confirmed the diagnosis of bilat-eral duplex system in horseshoe kidney (Figure-2). As the patient had non-specific, unrelated symp-toms, patient was give symptomatic treatment for the same and was advised regular follow-up. Du-plicated collecting systems (also known as duplex collecting systems) can be defined as renal units containing two pyelocaliceal systems that are as-sociated with a single ureter or with double ureters. The prevalence of Partial duplication is 0.6%, while complete duplication of ureters occurs in 0.2% of live births (1). When a single ureteral bud bifurcates before the ampulla bifurcates, a duplex kidney with a bifid renal pelvis or bifid ureter results (2). Con-genital anomalies of the kidneys include a group of so-called fusion anomalies, in which both kidneys are fused together in early embryonic life. Fusion anomalies of the kidneys can generally be placed into 2 categories: [1] horseshoe kidney and its vari-ants and [2] crossed fused ectopia. Horseshoe kid-ney is probably the most common fusion anomaly. The term horseshoe kidney refers to the appearance of the fused kidney, which results from fusion at one pole. Horseshoe kidney is the most common renal fusion anomaly, the incidence being about 1

Extragenitourinary retroperitoneal primary hydatid cyst: a rare cause of bilateral lower ureteric obstruction and unilateral limb edema

Hydatid cyst is an endemic disease in our country. Most commonly, it occurs in the liver and lungs. Bilateral hydroureteronephrosis is one of the rare presentations of hydatid disease. Herein, we are reporting an unusual case of hydatid disease where the primary mode of presentation was external iliac vein compression with chronic renal failure because of bilateral ureteric involvement. The patient was treated with bilateral double-J stenting to improve the renal function and operated later for removal of hydatid cyst under albendazole drug treatment.

Foreign Bodies in Lower Urinary Tract: Case Report and Review of Literature

Foreign bodies in lower urinary tract may present in a different number of ways. We report four cases of such unusual presentation. Physical examination and plain radiograph was sufficient enough to confirm our diagnosis in all cases. The cases belonged to different age groups and three out of four cases were managed by open surgical approach. One foreign body was removed using cystoscope. Prompt surgical management prevented urinary tract infections and long term complications in these patients.

Unusual Renal Tumors — Report of Four Cases

Collecting duct carcinoma, plasmocytoma and malignant fibrous histocytoma are rare but aggressive tumors of the kidneys. We present four cases we have recently encountered in our practice. In most of the cases imaging did not help in the pre-operative diagnosis. Surgery is the mainstay of treatment when recognized early. Clinician should be aware about these rare varieties of renal tumors whose prognoses may be worse than that of renal cell carcinoma. The Annals of African Surgery, Volume 6, 2010