nan Ansari

Management of vesicovaginal fistula: An experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach

Purpose: We aim to present our experience for the repair of vesicovaginal fistula (VVF) with special reference to surgical approach. Materials and Methods: From January 1999 to June 2005, 52 VVF patients with mean age of 32 years underwent operative treatment. Fistulas were divided into two groups, simple and complex, depending on site, size, etiology and associated anomalies. Simple VVFs were approached through the vaginal route and complex VVFs via the transabdominal route. Patients were evaluated at two to three weeks initially, three-monthly twice and later depending on symptoms. Results: Thirty-two (61.5%) had simple fistulas and 20 (38.5%) complex fistulas. The most common etiology was obstetric trauma in 31 (59.6%) patients, while the second most common cause was post hysterectomy VVF. Thirty-two (61.5%) patients were managed by transvaginal route, of which 17 had supratrigonal and 15 trigonal fistulas. Twenty (38.5%) patients with complex fistulas were managed by abdominal route. The mean blood loss, postoperative pain and mean hospital stay were shorter in transvaginal repair. Eleven (21.2%) patients required ancillary procedures for various other associated anomalies at the time of fistula repair. Three patients failed repair giving a success rate of 94.2%. At a mean follow-up of three years 48 women were sexually active, of these 10 (19.2%) complained of mild to moderate dyspareunia. Conclusion: Most of the simple fistulas irrespective their locations are easily accessible transvaginally while in complex fistulas we recommend the transabdominal approach. Depending on the clinical context both the approaches achieved comparable success rates.

Clinical presentation and diagnostic approach in cases of genitourinary tuberculosis.

Objective: We herein describe the various modes of presentation in genitourinary tuberculosis (GUTB) and a simple diagnostic approach to it. Materials and Methods: We made a literature search through Medline database and various other peer-reviewed online journals to study the various modes of presentation in GUTB. We reviewed over 100 articles published in the last 10 years (1998 -- 2007), which were tracked through the key words like GUTB and extrapulmonary tuberculosis. Results: GUTB has varied presentation and the most common way of presentation is in the form of irritative voiding symptoms, which are found in more than 50% of the patients. The usual frequency of organ involvement is: kidney, bladder, fallopian tube, and scrotum. The usual tests used to diagnose GUTB are the demonstration of mycobacterium in urine or body fluid and radiographic examination. Intravenous urography (IVU) has been considered to be one of the most useful tests for the anatomical as well as the functional details of kidneys and ureters. In cases of renal failure, MRI can be used. Newer examinations such as radiometric liquid culture systems (i.e., BACTEC®, Becton Dickinson, USA) and polymerase chain reaction (PCR) give rapid results and are highly sensitive in the identification of mycobacterium. Conclusion: GUTB can involve any part of the genitourinary system and presentation may vary from vague urinary symptoms to chronic kidney disease. Newer tests like radiometric liquid culture systems and polymerase chain reaction give rapid results and carry high diagnostic value.

Vascular complication in live related renal transplant: An experience of 1945 cases

Introduction and Objective: Among the surgical complications in renal transplantation, the vascular complications are probably most dreaded, dramatic, and likely to cause sudden loss of renal allograft. We present our experience and analysis of the outcome of such complications in a series of 1945 live related renal transplants. Materials and Methods: One thousand nine hundred and forty five consecutive live related renal transplants were evaluated retrospectively for vascular complications. Complications were recorded and analyzed for frequency, time of presentation, clinical presentation, and their management. Results: The age of patients ranged from 6 to 56 years (mean = 42). Vascular complications were found in 25 patients (1.29%). Most common among these was transplant renal artery stenosis found in 11 (0.58%), followed by transplant reznal artery thrombosis in 9 (0.46%), renal vein thrombosis in 3 (0.15%), and aneurysm formation at arterial anastmosis in 2 (0.10%) patient. The time of presentation also varied amongst complications. All cases of arterial thrombosis had sudden onset anuria with minimal or no abdominal discomfort, while venous thrombosis presented as severe oliguria associated with intense graft site pain and tenderness. Management of cases with vascular thrombosis was done by immediate surgical exploration. Two patients of renal artery stenosis were managed with angioplasty and stent placement. Conclusions: Major vascular complications are relatively uncommon after renal transplantation but still constitute an important cause of graft loss in early postoperative period. Aneurysm and vessel thrombosis usually require graft nephrectomy. Transplant renal artery stenosis is amenable to correction by endovascular techniques.

Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis

AIM To study the impact of delay in inguinal lymph node dissection (LND) in patients with squamous cell carcinoma of the penis, who have indications for LND at the time of presentation. MATERIALS AND METHODS In total, 28 patients (mean age 52.1 +/- 12.8 years) with squamous cell carcinoma of the penis, treated from January 2000 to June 2008, were retrospectively studied with regard to clinical presentation, time of LND, and the outcome. The patients were divided into two groups based on the time for LND. Group 1 patients had LND at mean of 1.7 months (range 0-6 months) of treatment of the primary lesion, and group 2 had LND at a mean of 14 months (range 7-24 months) after treatment of the primary lesion. STATISTICAL ANALYSIS The statistical analysis of survival was done using the Kaplan-Meier method and the Log Rank test, with p < 0.05 considered to be statistically significant. The Mann-Whitney test and Fishers exact test were used for univariate comparison. RESULTS Twenty-three of the 28 patients had inguinal LND. In group 1, of 13 patients, 12 were alive, with no recurrence of disease at a mean follow-up of 37 months (8-84) months. In group 2, only two patients were alive and disease-free, at a mean follow-up of 58 months (33-84 months). The five-year cancer-specific survival rates for early and delayed LND were 91 and 13%, respectively, (p = 0.007). CONCLUSIONS When compliance with follow-up is suspect, patients with high grade or T stage (greater than T1) tumor are better treated by inguinal LND during the same hospital admission or within two months of primary treatment.

Does the type of steinstrasse predict the outcome of expectant therapy

OBJECTIVES: To determine the outcome of expectant therapy in steinstrasse according to its type. MATERIALS AND METHODS: A chart review was performed on patients who underwent extracorporeal shock wave lithotripsy (SWL) between 1995 and June 2004. Demographic profile, stone size, site, characteristics of steinstrasse (type 1; multiple small fragments, type 2; lead fragment of 5 mm or more with small fragments proximal to it and type 3; multiple fragments of 5 mm or more) and mode of treatment used, were noted. Patients of steinstrasse, diagnosed on X-Ray KUB were kept on expectant treatment for 4 weeks. Patients with high grade fever and infected hydronephrosis were treated with percutaneous nephrostomy (PCN) insertion. Non responders at 4 weeks, were treated with SWL and/or ureterorenoscopy (URS). RESULTS: 1000 patients of mean age 37.85 years, with urinary stones, received SWL (827 renal stones and 173 ureteric stones). Sixty patients (6%) developed steinstrasse. Mean stone size was 2.03 cm (0.6-4 cm). Type 1, 2 and 3 steinstrasse was present in 32 (53%), 20 (33%) and 8 (13%) patients, respectively. Conservative management was successful in 30 (50%) patients at 4 weeks. 3 patients who presented with infected hydronephrosis, required PCN. The remaining (27 patients) were subjected to repeat SWL. 24 of these 27 patients could be successfully treated with SWL, whereas the remaining 3 required URS. Of non- responders to conservative treatment i.e., 30 patients, 17 (56%) and 8 (26%) patients had type 2 and 3 steinstrasse respectively, whereas only 3 out of 30 (10%) responders had type 2 and none of the responders had type 3 steinstrasse, P value < 0.01. CONCLUSION: Type 2 and 3 steinstrasse have 90% (25 out of 28 failed) chance of not responding to the conservative treatment at 4 weeks. To avoid the risk of infected hydronephrosis (5%), active intervention should be done in patients with lead fragment of 5 mm or more (type 2 and 3 steinstrasse), as early as possible. SWL is successful in most of these patients and should be the primary modality of treatment.

Single-centre experience of laparoscopic nephrectomy: Impact of learning curve on outcome.

Aim: To present our experience of laparoscopic nephrectomies done for benign and malignant conditions; and the impact of learning curve on outcome. Settings and Design: Retrospective study. Materials and Methods: Between January 2000 and September 2006, 396 laparoscopic nephrectomies were performed at our institute for various benign and malignant conditions. These included 250 simple nephrectomies, 48 nephroureterectomies, 95 radical nephrectomies, two partial nephrectomies and one hemi-nephrectomy. For the purpose of self-evaluation, we have divided our experience into two groups. Group 1 (learning phase) comprised the first 100 cases; Group 2 (consolidation phase) comprised cases performed after the initial learning phase. Retrospective evaluation of the case records was done to evaluate the differences in the operative and postoperative outcome. Statistical Analysis Used: Students ‘t’ test using SPSS 14.0 software. Results: Demographic profile of the patients and relative indications of procedures performed were similar in the two groups. Mean operative time in Group 1 was 262 ± 37 min, which reduced to 184 ± 44 min in Group 2 (P<0.001). Mean operative blood loss was 310 ± 58 ml and 198 ± 88 ml (P<0.001); and blood transfusion was required in 38% and 13.5% of patients (P<0.001) of Group 1 and Group 2 respectively. There was a significant reduction in the intraoperative and postoperative complications from 16% in Group 1 to 3.4% in Group 2 (P<0.001). Similarly, conversion to an open procedure was required in 17% cases of Group 1 and 5.4% cases of Group 2 (P<0.01). Conclusions: Laparoscopic nephrectomy is a viable option which can be performed safely with increasing experience.

A randomized trial comparing low dose (40 or 80 mg) with standard dose (120 mg) of bacillus Calmette-Guerin for superficial bladder cancer

Objective: Intravesical bacillus Calmette-Guerin (BCG) therapy is considered to be the most effective therapy for high-risk superficial cancer of bladder. Reduction in dose has been tried to decrease the toxicity following instillations of BCG while maintaining efficacy. This study compares the efficacy and toxicity of three different doses of modified Danish 1331 strain of BCG in patients with high risk superficial bladder cancers. Materials and Methods: A prospective randomized study was undertaken between January 2000 to March 2005 to include all patients with superficial bladder cancer who received BCG after fulfilling one or more of the appropriate criteria (grade above 1, stage above Ta, size >1 cm, multiple or recurrent). One hundred and six patients received 40 mg, 80 mg or 120 mg Danish 1331 strain BCG weekly for six weeks. The recurrence rates, tumor progression, toxicity and long-term outcome of three different doses of BCG were studied. No maintenance therapy was given. Results: Of the 106 patients, 28 received 40 mg, 37 received 80 mg and 41 received 120 mg of intravesical BCG for six weeks. The mean follow-up was three years (range one to six years). Overall, 77.4% patients responded to a single cycle of BCG, with a recurrence rate of 32.1% in 40 mg, 13.5% in 80 mg and 24.3% in the 120 mg groups. Median time to recurrence was seven months, eight months and nine months in the three groups respectively. Overall, six patients (5.6%) developed disease progression, two (7.1%) in the 40 mg, one (2.7%) in the 80 mg and three (7.3%) in the 120 mg arm. Kaplan - Meier analysis for time to recurrence ( P =0.1839) and time to progression ( P =0.595) was not significantly different in the three treatment arms. Adverse effects were seen in 55.6% patients with most being of class 1 severity. Significantly less patients developed severe adverse effects in the 40 mg group as compared to the higher dose groups. Conclusions: We conclude that 40 mg dose of intravesical BCG is as effective as the standard dose in reducing the risk of recurrence and progression. Moreover this dose is associated with significantly less toxicity.

Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center

Introduction: Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair. Materials and Methods: We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997–2004 by multiple surgeons, Group II, between 2005–2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications. Results: Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III. Conclusion: There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.

The challenges and outcomes of living donor kidney transplantation in pediatric and adolescent age group in a developing country: A critical analysis from a single center of north India.

Introduction: Renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD). We evaluated the outcome of renal transplantation in the pediatric and adolescent age groups in the perspective of a developing country as compared with developed nations while highlighting the challenges we have faced in a pediatric transplant programme. Materials and Methods: Seventy live related pediatric and adolescent renal transplantations were reviewed retrospectively. Variables analyzed were etiology of ESRD, pre-transplant renal replacement modality, donor relationship, surgical complications, rejection episodes, immuno-suppression regimens, compliance to immunosuppression, graft survival and overall survival. Results: The cohort consisted of 13 (18%) female and 57 male (82%) recipients. The mean age was 14 ± 1.4 years. The etiology of ESRD was chronic glomerulonephritis (n = 43), chronic interstitial nephritis (n = 26) and Alport′s syndrome (n = 1). Fifty-six (80%) children were on hemo-dialysis and 10 (14%) on peritoneal dialysis prior to transplantation. 80.5% and 61% patients were strictly compliant to immunosuppresant medications at 1 and 5 years. The 1, 3 and 5 year graft survival rates were 94.3%, 89.2% and 66.8%, respectively. The overall survival rates were 95.7%, 96.4% and 94.1% for 1, 3 and 5 years, respectively. Conclusions: The spectrum of etiology of ESRD differs in our patients from the west, with chronic glomerulonephritis being the most common etiology. Early graft survival is comparable, but the 5-year graft survival is clearly inferior as compared with developed countries.

Managing disorder of sexual development surgically: A single center experience

Introduction: Ambiguous genitalia are a major cause of parental anxiety and create psychological and social problems to patient, if not managed properly. Here we present our experience in managing patients with ambiguous genitalia. Material and Methods: We retrospectively reviewed clinical records of all patients with ambiguous genitalia managed surgically at out institute between December 1989 and January 2011. Relevant history, clinical examination, investigations and surgical procedures performed were analyzed and results were evaluated in terms of anatomical, functional and psychosexual outcomes. Results: Female pseudohermaphroditism was the most common cause of genital ambiguity in our patients. Male and female genitoplasty was done according to gender of rearing, genital anatomy and parental choice. Twenty six patients (86.6%) reported satisfactory cosmetic outcome and 22 (73.3%) satisfactory functional outcome on long term follow-up. Among the 24 patients diagnosed as male pseudohermaphroditism 14 (82.3%) patient have reported satisfactory cosmetic outcome and 13 (76.4%) have reported satisfactory functional outcome. In patients with mixed gonadal dysgenesis and true hermaphroditism satisfactory cosmetic and functional outcome was seen in 70% patient. Conclusion: Managing patients of genital ambiguity according to gender of rearing, genital anatomy and parental choice carries good prognosis in terms of anatomical, functional and psychosexual outcome.