Ankur Jhanwar

Outcome of percutaneous nephrolithotomy in anomalous kidney: Is it different?

Introduction: Various anomalous kidneys such as horseshoe kidney, crossed ectopic kidney, simple ectopic kidney, pelvic ectopic kidney, kidney with duplex system, and malrotated kidney are frequently associated with stone disease. Percutaneous nephrolithotomy (PCNL) is a challenging procedure in these patients because of abnormal orientation of kidney. Patients and Methods: Since 2005–2015, 86 patients underwent PCNL for stone removal in anomalous kidneys. Stone characteristics, type of calyceal puncture, number of punctures, need of relook procedures, mean hemoglobin drop, blood transfusion, mean operative time complications, mean hospital stay, stone free rate, and auxiliary procedure were analyzed. Results: Totally 91 sessions of PCNL was done in 86 patients including five of horseshoe kidney who had bilateral stone disease. Mean age, duration of symptoms, stone size, and hospital stay was 29.6 ± 12.6 years, 2.18 ± 1.41 years, 4.40 ± 1.16, and 4.17 ± 2.11 days, respectively. Sixteen patients underwent relook procedure, out of which only 6 could have complete stone clearance. Conclusion: PCNL in anomalous kidney is a safe and feasible procedure similar to normally located kidney, but requires careful preoperative planning and intra- and post-operative vigilance.

Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: A prospective randomized study

Aim: Transurethral resection of prostate (TURP) is considered a gold standard surgical procedure. The management of benign prostatic hyperplasia (BPH) has undergone tremendous change in recent years and shifted from open to minimal invasive procedure. With the advancement in technology and skills of surgeons, lasers have been used more liberally, particularly holmium laser. Holmium laser enucleation of prostate (HoLEP) is seen as close rival of TURP. The objective if this study is to observe long- and short-term outcomes of transurethral resection and holmium laser enucleation in the prostate of more than 60 g. Materials and Methods: This prospective randomized study includes 164 patients. Inclusion criteria were age <75 years after failed or poor response to medical therapy, prostatic size >60 g, gross hematuria secondary to BPH, recurrent urinary tract infection, acute urinary retention, postvoid residual >150 ml, and Schafer Grade II or more. BPH associated with neurogenic bladder, stricture urethra, and carcinoma prostate were excluded from the study. Group 1 comprises patients who underwent TURP and Group 2 comprises who underwent HoLEP. Follow-up was done at 1, 3, 6, 12, and 24 months after the surgery. Results: Data of 144 patients were analyzed. The mean age of patients in TURP and HoLEP group was 66.78 ± 7.81 and 67.70 ± 7.44 years, respectively (P = 0.47), mean prostatic volume was 74.5 ± 12.56 and 75.6 ± 12.84 g, respectively (P = 0.60), operative time was 73.10 ± 10.49 and 89.56 ± 13.81 min, respectively (P = 0.0001). Mean resected tissue was 44.80 ± 9.87 and 48.49 ± 10.87, respectively (P = 0.03). The sexual function did not changed significantly in postoperative follow-up. Conclusion: HoLEP is associated with less blood loss, lower transfusion rates, and a shorter hospital stay. The disadvantage of HoLEP is longer operative time and postoperative dysuria.

Foreign Bodies in the Urinary Bladder and Their Management: A Single-Centre Experience From North India

Purpose This study was performed to characterise the nature, clinical presentation, mode of insertion, and management of intravesical foreign bodies in patients treated at our hospital. Methods Between January 2008 and December 2014, 49 patients were treated for intravesical foreign bodies at King George Medical University, Lucknow. All records of these patients were retrospectively analysed to characterise the nature of the foreign body, each patient’s clinical presentation, the mode of insertion, and how the case was managed. Results A total of 49 foreign bodies were retrieved from patients’ urinary bladders during the study period. The patients ranged in age from 11 to 68 years. Thirty-three patients presented with complaints of haematuria (67.3%), 29 complained of frequency of urination and dysuria (59.1%), and 5 patients reported pelvic pain (10.2%). The circumstances of insertion were iatrogenic in 20 cases (40.8%), self-insertion in 17 cases (34.6%), sexual abuse in 4 cases (8.1%), migration from another organ in 4 cases (8.1%), and assault in 4 cases (8.1%). Of the foreign bodies, 33 (67.3%) were retrieved by cystoscopy, while transurethral cystolitholapaxy was required in 10 patients (20.4%), percutaneous suprapubic cystolitholapaxy was performed in 4 patients (8.1%), and holmium laser lithotripsy was performed in 2 patients (4.08%). Conclusions Foreign bodies should always be included in the differential diagnosis when evaluating a patient who presents with chronic lower urinary tract symptoms. A large percentage of foreign bodies can be retrieved using endoscopic techniques. Open surgical removal may be performed in cases where endoscopic techniques are unsuitable or have failed.

Crossed fused renal ectopia with chyluria: a rare presentation

Fusion anomalies of the kidney are uncommonly encountered in clinical practice. These are broadly divided into two distinct varieties: horseshoe kidney (most common) and crossed fused renal ectopia (second most common).1 Crossed fused renal ectopia has an incidence of 1:1000 to 1:7500 and is more common in males (2:1), with left to right ectopia being three times more common than right to left ectopia.2 According to Turkvatan et al ,3 the most common variant of crossed fused renal ectopia forms when the upper pole of the inferiorly positioned crossed-ectopic kidney is fused to the lower pole of the superior, normally placed kidney. The presence of chyluria in the setting of crossed fused ectopic kidney is uncommonly reported. We report a unique case of chyluria in a middle-aged man with crossed fused renal ectopia associated with a large calculus in the middle one-third of the crossed ureter. A 35-year-old man presented with intermittent mild left flank pain and milky urine, with no history of urinary tract infections, trauma or instrumentation. Chyluria was confirmed by the presence of chyle and triglycerides in postprandial urine. A plain X-ray KUB and intravenous pyelography (IVP) showed non-opacification of the right kidney and a malrotated left kidney with mid-ureteric calculus in the crossed ureter (figure 1). On ultrasonography of the kidney, ureter and urinary bladder, the right kidney was present on the left side, fused at its upper pole with the lower pole of the left, normally located kidney (figure 2). Contrast-enhanced CT of the kidney, ureter and urinary bladder showed a slightly smaller sized right kidney (crossed to the left side and fused with the lower pole of the normal placed left kidney at its upper pole), revealing moderate hydroureteronephrosis as a result of 17 mm calculus present in the middle one-third of …

Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the literature

OBJECTIVE The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cosmetically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of performing laparoscopic ureteral reimplantation with Boari flap in 3 patients. MATERIAL AND METHODS This prospective study was conducted between January 2011 December 2014. The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruction were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the manangement of long segment ureteral defect was evaluated. RESULTS The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilateral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range 8.2-9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was 100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19 months (range 17-22 months). None of the patients experienced any complication related to the procedure in perioperative period. CONCLUSION Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term results. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing.

Autonephrectomy due to urogenital tuberculosis

A 45-year-old male presented with history of left flank pain for 1 year, which was mild dull aching in nature. Plain X-ray film of the urinary tract (Fig. 1) was suggestive of diffuse calcification in the left renal area (broad arrow) along with calcification in the ipsilateral ureter region (thin arrows). Chest X-ray was normal. Non-contrast computed tomography (CT) of kidney, ureter and bladder (axial section) showed replacement of entire left kidney with calcification (Fig. 2A). After contrast injection, the left kidney was not visualised while normal contrast uptake was seen in the right kidney (Fig. 2B) (coronal section). CT urogram showed calcification of the left kidney and ureter and normal excretion of contrast by the right kidney (Fig. 3). Urine report was positive for acid fast bacilli staining. Purified protein derivative skin test for tuberculosis was positive. Patient was managed with 6 months of multi-drug antitubercular therapy (ATT) along with opioid analgesics, as and when required. Nephrectomy was not required in this patient. Patient is symptom free and doing well at 1 year of follow-up. Our case illustrates classical radiological imaging of urogenital tuberculosis (UGTB) with autonephrectomy which is rare nowadays. Management of such patients Figure 1 Plain X-ray film of urinary tract is suggestive of diffuse calcification in left kidney (broad arrow) along with calcification in ipsilateral ureter region (thin arrows). * Corresponding author. E-mail address: rahuljanaksinha@gmail.com (R.J. Sinha). Peer review under responsibility of Second Military Medical University.

Primary tuberculosis of urethra presenting as stricture urethra and watering can perineum: A rarity.

A young man presented with irritative lower urinary tract symptoms and multiple fistulae (watering can) in the perineum since 6 months. Micturating cystourethrogram and retrograde urethrogram was performed after 12 weeks following suprapubic cystostomy which showed bulbar urethral stricture with multiple urethrocutaneous fistulae. He underwent anastomotic urethroplasty and excision of the urethrocutaneous fistulae. Histopathology of the excised fistulous tract showed granulomatous pathology suggestive of tuberculosis. Antitubercular treatment was given for 9 months. The patient is voiding well at 12 months follow-up.

Holmium Laser vs Monopolar Electrocautery Bladder Neck Incision for Prostates Less Than 30 Grams: A Prospective Randomized Trial

OBJECTIVE To compare the efficacy and results of bladder neck incision (BNI) in bladder outlet obstruction (BOO) in men with a small prostate using holmium laser vs conventional monopolar electrocautery technique. MATERIALS AND METHODS This study included 140 patients of BOO (prostate size ≤ 30 cc, American Urological Association (AUA) score ≥ 8, Qmax ≤ 15 mL/sec, and Schäfer grade ≥ 2) who were randomly assigned to holmium laser BNI (HoBNI) or conventional BNI (C-BNI). AUA score and Qmax were assessed preoperatively and postoperatively at 3, 6, and 12 months. At 6 months, detrusor pressure at Qmax, Schäfer grade, and postvoid residual were assessed. RESULTS The incidence of postoperative hematuria and blood transfusion in the C-BNI group were 4.2% and 2.8%, respectively. No patient in the HoBNI group developed hematuria or required blood transfusion. Qmax and AUA score at each follow-up, and Pdet Qmax, Schäfer grade, and postvoid residual at 6 months were comparable between two groups but showed significant improvement when compared to baseline in both the groups. At 6 months, 2.9% patients in the HoBNI group and 4.3% in the C-BNI group remained obstructed urodynamically and underwent reoperation (P > .05). The incidence of retrograde ejaculation was significantly higher in HoBNI (22.9% vs 6.1%, P -.02) CONCLUSION: Both procedures are equally efficient in relieving BOO in patients with prostate size < 30 cc and have similar success rates. The risk of postoperative hematuria is less with HoBNI because of its better hemostatic properties, but its use must be counterbalanced with significant increase in incidence of retrograde ejaculation.

Retroperitoneoscopic pyeloplasty for the management of pelvic-ureteric junction obstruction in horseshoe kidney: our initial experience

Horseshoe kidney (HSK) is the most common congenital renal fusion anomaly with approximate incidence of 1:400 to 1:1000 births. Pelvic-ureteric junction obstruction (PUJO) occurs in 15–33% of patients in this population. Herein, we report our experience of management of PUJO in HSK by retroperitoneoscopic pyeloplasty.

Female hypospadias presenting with urinary retention and renal failure in an adolescent: uncommon and late presentation with significant hidden morbidity

An 11-year-old girl presented with poor urinary stream with vaginal voiding since childhood. She had palpable bladder and raised serum creatinine (671 µmol/L). Suprapubic catheterisation was performed after a failed urethral attempt. Following catheterisation she improved symptomatically. She underwent cystoscopy through the suprapubic portal as a guide wire could be negotiated through bladder neck; external urethral meatus was found as a dimple higher up in anterior vaginal wall. Female hypospadias is usually an incidental diagnosis during catheterisation for various reasons. Diagnosis could be established only after antegrade cystoscopy. Anecdotal cases have been reported in the literature with similar presentation. Early diagnosis is essential as renal failure could be a late presentation if patients continue to void with stenosed meatus. Long-term follow-up is needed as these patients may need definitive management later on.