Bimalesh Purkait

Prospective randomized comparison between fluoroscopy-guided ureteroscopy versus ureteroscopy with real-time ultrasonography for the management of ureteral stones

Context and Aims: Ureteroscopy is the definitive management for ureteric stone. Conventional ureteroscopy uses fluoroscopy guidance which has radiation exposure to patients as well as hospital staff. Ultrasound is a good radiation-free alternative for using in the urological procedure. With this background, we executed a prospective randomized trial comparing fluoroscopy-guided ureteroscopy versus ultrasound-guided ureteroscopy. Subjects and Methods: Patients were randomized into two groups (41 into fluoroscopy and 41 into ultrasound group after exclusion) in a single center from July 2014 to March 2015. Semi-rigid ureteroscopy was used in all cases. Ultrasound was used to place guide wire and postprocedure stents placement in ultrasound group. Patients characteristics; intra- and post-operative parameters were compared between the two groups. Statistical Analysis Used: SPSS version 16.0 (Chicago, IL, USA) was used for statistical analysis. The results were presented as percentages and means (± standard deviation). The categorical/dichotomous variables were analyzed using Chi-squared test. Continuous variables were analyzed using unpaired t-test. Results: A total of 102 adult patients were randomized in this trial and eighty patients undergo the final analysis. Mean stone burden was 41.75 ± 13.44 (17.94–79.20 mm2). Mean operative time was 43.90 ± 12.99 (25–82 min) in fluoroscopy group versus 45.61 ± 11.62 (28–78 min) in ultrasound group. The initial success rate was 93.75% (92.30% in fluoroscopy vs. 95.12% in ultrasound group). Overall complications noted in 8.75% and most of the complications were minor in nature. Conclusions: Ultrasound-guided ureteroscopy is safe and effectively for ureteric stone. Fluoroscopy can be avoided during ureteroscopy for uncomplicated stone. No radiation ureteroscopy is feasible with good success and minimal complication. Larger sample size with multicentric trial needed for its greater applicability.

Long-term outcome of laparoscopic vesicouterine fistula repair: Experience from a tertiary referral centre

Objective Vesicouterine fistula (VUF) is an uncommon cause of female genito-urinary fistula. Most of these fistulas are due to lower segment uterine cesarean section (LSCS). Traditionally, open surgical repair has been the traditional treatment. However, laparoscopic repair of VUF is a minimally invasive technique and few case reports have been published with short term follow up. In the present study, we are presenting our long- term outcome of laparoscopic repair of VUF. Material and methods A retrospective analysis of 8 patients with VUF was performed from 2010 to 2015. Approval of Institutional Review Committee was obtained. All had history of LSCS of whom 3 had history of prolonged obstructed labor. Radiological imaging included ultrasound of kidney, ureter and bladder for all patients and hysterosalphingography in 4 patients and contrast enhanced computed tomography scan in 4 patients. Results Median age of the patient was 25.5 years (range, 22-32), and median follow up was 2.3 years (range, 1 -4). The most common presentation was cyclical menstrual bleeding through urine (menouria) in all, associated amenorrhea in 6 and vaginal leakage of urine in 2 cases. All patients underwent laparoscopic repair with successful outcomes. The mean operating time was 155±14.5 min (range, 135-186 min) with a median blood loss of 100 mL (range, 50-210 mL). Successful pregnancy was completed in 2 patients and other patients were taking contraceptives. Conclusion Laparoscopic repair of VUF is a safe and effective minimally invasive technique with successful pregnancy in long- term follow up.

Giant hydronephrosis: still a reality!

OBJECTIVE Giant hydronephrosis (GH) is a rare entity in both developed and developing countries with less than 500 cases reported in the literature. Delayed diagnosis and management of GH, can result in long-term complications like hypertension, rupture of the kidney, renal failure and malignant change. We aim to highlight the importance of this often neglected entity and build a consensus for its early diagnosis and management. MATERIAL AND METHODS Patients with GH were thoroughly worked up, managed and followed up between June 2013 and December 2015 and epidemiologic, radiological, perioperative and follow-up data was recorded. RESULTS A total of 35 patients (adults and children) were reported. Flank pain in adults and abdominal lump in children were the most common clinical presentation. Percutaneous nephrostomy tube was placed in all patients and detailed work up was done to reach final diagnosis. Pelvi-ureteric junction obstruction (PUJO) was the final diagnosis in 32 patients (91.4%). Kidneys were non-functioning in 13 cases (37.1%) so nephrectomies were performed. Reduction pyeloplasty with nephropexy was done in 21 patients (60%) with 81% success and 23.1% complication rates. CONCLUSION GH requires early diagnosis and management to prevent higher nephrectomy rate along with poor success rate of conservative surgery like pyeloplasty.

WITHDRAWN: Transurethral Resection of Prostate and Bleeding: A Prospective Randomized, Double-blind, Placebo-controlled Trial to See Efficacy of Short-term Use of Finasteride and Dutasteride on Operative Blood Loss and Prostatic Microvessel Density

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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.

Transurethral resection of prostate in benign prostatic enlargement with underactive bladder: A retrospective outcome analysis

Purpose: The purpose of this study was to evaluate the clinical outcome and efficacy of transurethral resection of the prostate in patients of benign prostatic enlargement (BPE) with underactive bladder. Materials and Methods: Retrospective study of 174 patients, who underwent transurethral resection of prostate (TURP) between 2008 and 2015, for lower urinary tract symptoms with BPE with bladder underactivity. Clinical history, physical examination, renal function test, urinalysis, cystourethroscopy, transabdominal or transrectal ultrasonography, and urodynamic study were recorded. Patients having a history of neurologic conditions, spinal trauma or surgery, pelvic trauma or surgery, diabetes mellitus with end organ damage, urethral pathology or surgery, and prostatic cancer were excluded from the study. Results: The mean follow-up period was 22.4 ± 6.2 months. Mean prostate volume was 42.8 ± 6.4 ml and mean serum prostate-specific antigen was 2.3 ± 1.8 ng/ml. The International Prostate Symptom Score changed from 24.6 ± 4.2 preoperatively to 10.8 ± 5.8 postoperatively which was found statistically significant. Quality of life (QOL) score changed from 4.8 ± 1.2 to 2.6 ± 0.4. Twenty-two patients out of 174 remained on a per-urethral catheter or clean intermittent catheterization due to voiding failure after TURP beyond 1 month. Conclusions: TURP should be considered a viable treatment option in men with enlarged prostate with underactive detrusor who had poor response to medical treatment. Preoperative counseling and postoperative follow-up are crucial in the management of such patients.

Does 24bp Duplication of Human CHIT1 Gene (Chitotriosidase1) Predispose to Filarial Chyluria? A Case-Control Study.

INTRODUCTION Chyluria which is endemic in many parts of the world is mainly caused by Wuchereria bancrofti. CHIT1 (chitotriosidase) is produced by macrophages and plays an important role in the defense against chitin containing pathogen such as filarial parasite. Variation in the coding region with 24 bp duplication allele results in reduced CHIT1 activity that enhance the survival of parasite which may play a role in the occurrence of disease. AIM To examine the role of 24bp duplication of CHIT1 gene in patients of filarial chyluria (FC). MATERIALS AND METHODS A case-control study was carried out where 155 confirmed FC patients and equal number of age-, sex- and residence-matched controls without any symptoms or signs of lymphatic filariasis, confirmed by negative immunochromatographic card test (ICT) and IgG/IgM combo rapid antibody test, from a hospital-based population were enrolled. Filarial aetiology was confirmed on the basis of DEC-provocative test (Giemsa staining), ICT and IgG/IgM- antifiarial antibody test. The patients positive by either of these tests were enrolled as FC cases. 24bp duplication in CHIT1 gene in FC was detected by the product size 99bp of amplified gene using polymerase chain reaction. RESULTS The mean ages of patients and controls were 38.25±12.09 and 35.45±12.53 years, respectively while male: female ratio was 2.4:1. The mean duration of illness in chyluria patients was 62.81±60.83 months and mean number of episodes was 2.54±1.11. Homozygous wild type, heterozygous and homozygous mutant frequencies were 10.3%, 81.3% and 8.4% in FC patients and 18.7%, 75.5%, and 5.8% in controls, respectively. The 24bp duplication in CHIT1 gene showed a significant association in Heterozygous (HT) genotype with Odd Ratio (OR) of 1.95, 95% Confidence Interval (CI) (1.01-3.77); p=0.04. However, the homozygous mutant genotype (TT) was found to be non-significant with OR of 2.61, 95% CI (0.91-7.45); p=0.07. The combination of both HT+TT was also found to be significant with OR of 2.00, 95% CI (1.03-3.85); p=0.03. CONCLUSION In this study from Northern India, CHIT1 gene polymorphism showed an influence as a possible risk factor for susceptibility to FC. Further studies need to be done on a larger number of FC patients in different regions of the country.

Grading of complications of transurethral resection of bladder tumor using Clavien–Dindo classification system

Introduction: Clavien–Dindo classification system is used for grading complications of various oncological, renal, and endourological procedures. We applied this system for grading the severity of perioperative complications in patients undergoing transurethral resection of bladder tumor (TURBT) and identify parameters predicting these complications. Materials and Methods: Data of 984 patients who underwent TURBT from 2006 to 2014 were included in this study. All data was retrospectively collected and analyzed for complications occurring within the first postoperative month. All complications were classified according to the five grades of modified CCS (.Clavien classification system). Results: A total of 172 complications were observed in 138 patients. Majority were low grade complications (Grade 1 [77.3%] and Grade 2 [12.7%]). Higher grade complications were rare (Grade 3 [6.4%] and Grade 4 [3.0%]). There was one death (Grade 5 0.6%), with an overall mortality rate of 0.1%. The incidence of complications was significantly greater for age >60 years, baseline serum creatinine >1.4 mg/dl, size of tumor >4 cm, tumor located at dome, resection time >60 min, incomplete resection and if surgery performed by a resident urologist. Conclusions: Clavien–Dindo classification system can be easily applied to grade the complications of TURBT, and it is easily reproducible. We observed that TURBT was a safe procedure. Majority of complications were Grade 1–2 (90%) and Grade 3–5 were rare (10%). Postoperative bleeding is the most common complication. A greater rate of complications of TURBT was associated with patient age, size of tumor, location of tumor, surgeon experience, resection time, and completion of tumor resection.

Spontaneous extrusion of staghorn renal calculus with nephrocutaneous fistula in a child

Renal stone disease may present as nephrocutaneous fistula. Spontaneous extrusion of renal stone with nephrocutaneous fistula is rare. Most of the cases have been reported in adults. We present a case of nephrocutaneous fistula with spontaneous extrusion of staghorn renal calculus in a paediatric patient.

Re: Nasser et al.: Dismembered Pyeloplasty in Infants 6 Months Old or Younger With and Without External Trans-anastomotic Nephrostent: A Prospective Randomized Study (Urology 2016;101:38-44)

Please cite this article as: Sunny Goel, Apul Goel, Ajay Aggarwal, Bimalesh Purkait, Nasser FM, Shouman AM, ElSheemy MS, Lotfi MA, Aboulela W, El Ghoneimy M, Abdelwahab M, Shoukry AI, Ghoneima W, Morsi H, Badawy H. Dismembered Pyeloplasy in Infants Six Months Old or Younger with and Without External Trans-Anastomotic Nephrostent: a Prospective Randomized Study Urology. 2016 Sep 28 doi: 10.1016/j.urology.2016.09.024, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.11.007.