Deepak Sharanappa Nagathan

Clavien Classification of Semirigid Ureteroscopy Complications: A Prospective Study

OBJECTIVE To prospectively report and grade the perioperative complications of ureteroscopy (URS) for stone removal using a semirigid ureteroscope with the modified Clavien classification system and to identify the determinants of the complications. METHODS From August 2010 to November 2011, the prospective data from 120 consecutive patients (71 men and 49 women) who had undergone primary unstented URS at a resident training center were analyzed. Patients with renal failure, pyonephrosis, diabetes mellitus, hypertension, and congenital ureteral abnormalities were excluded (n = 29). The data recorded included patient demographics, stone size and location, and complications according to the modified Clavien classification system. RESULTS Of the 120 patients, 36 (30%) experienced 79 complications. The stone size was ≤ 10 mm in 56 and >10 mm in 64 patients. The stone location was the lower, mid-, and upper ureter in 62, 58, and 3 patients, respectively. The latter 3 were excluded because of the small sample size. Grade 1, 2, 3a, 3b, 4a, and 4b complications were encountered in 46 (38.3%), 18 (15%), 3 (2.5%), 10 (8.3%), 1 (0.8%), and 1 (0.8%) patient, respectively. The incidence of complications was greater for stones >10 mm, a mid- versus distal ureteral location, impacted stones, and surgery performed by a resident. The incidence was not affected by patient sex, stone laterality, or lithotripter type. The patients with complications had a longer operative time (75 vs 46.5 minutes), longer hospitalization (4.8 vs 1.5 days), and lower stone-free rate (64% vs 97%). CONCLUSION Most complications were grade 1-3 (98%), and grade 4 complications were rare (<2%) with URS. The present study is probably the first to prospectively study the complications of URS using the modified Clavien classification system.

Anticoagulant-induced priapism progressing to penile gangrene: a devastating complication!

A 35-year-old man developed priapism with the use of low-molecular-weight heparin and warfarin following repair of left brachial artery sustained after gunshot injury. Priapism progressed to penile gangrene despite decompression and distal shunt procedure leading to total penectomy and perineal urethrostomy. We describe the mechanism of anticoagulant (heparin and warfarin)-induced penile gangrene and the possible methods to avert such a devastating complication.

Leiomyosarcoma, a nonurothelial bladder tumor: a rare entity with therapeutic diversity.

A 22-year-old young woman presented with dysuria and lower urinary tract symptoms that had persisted for 6 months. She was diagnosed with a tumor near the bladder neck. Transurethral resection was done under anaesthesia. The histopathological examination with immunohistochemical staining showed the tumor to be a low-grade leiomyosarcoma. Adjuvant chemoradiation was given, and the patient has been doing well for 12 months of follow-up. Nonurothelial tumors of the bladder are rare and consensus is lacking regarding their definitive treatment. Furthermore, little is known about the natural history and prognosis of this type of bladder sarcoma. We present a minimally invasive treatment for this relatively rare tumor in which bladder preservation was achieved with no evidence of local or distant recurrences during the follow-up to date.

Re: Postureteroscopic Lesion Scale (PULS): A New Management Modified Organ Injury Scale—Evaluation in 435 Ureteroscopic Patients

We read the article with great interest and congratulate the authors for recommending an easy, memorizable, user friendly, and applicable classification for the use and duration of postoperative stent placement after ureteroscopy. The authors have mentioned that grade 2 injury (a submucosal lesion with complete tearing of mucosa) as per the postureteroscopy lesion scale was managed by Double-J stent placement for 2 weeks. The Double-J stent, however, was removed by flexible cystoscopy under local anesthesia. Therefore, we are of the opinion that grade 2 injury, although uncomplicated, should be classified as grade IIIa as per the Dindo-modified Clavien classification of surgical complications.

Hutch diverticulum presenting as acute urinary retention in early life.

There are only a few reports of recurrent acute urinary retention caused by obstruction from congenital paraureteral diverticulum. We review the literature and present a case of a 14-month-old boy with bilateral hutch diverticuli who had his first episode of acute urinary retention in the neonatal period caused by left-sided diverticulum. We emphasised the fact that hutch diverticulum should be considered as one of the possible differential diagnoses in a child presenting with acute urinary retention.

Duplex Ultrasound-guided Direct Percutaneous Management of Pseudoaneurysm of Branch of Segmental Renal Artery: Technique and Its Outcome

OBJECTIVE To describe the role of duplex ultrasound imaging (DUI) in prompt diagnosis of pseudoaneurysm (PSA) of a branch of the segmental renal artery (b-SRA) and to evaluate outcomes of DUI directed percutaneous embolization. MATERIALS AND METHODS Forty-five patients were referred to us for the management of intractable renal hematuria. A total of 20 cases (44.44%) had developed PSA after nephrolithotomy, 12 cases (12.66%) had developed PSA after guided renal biopsies, 6 cases (13.33%) had developed PSA following road side trauma, and 2 cases (4.44%) of the tuberous sclerosis complex had developed PSA. Three cases (6.66%) of arteriovenous and 2 cases (4.44%) of arteriocalyceal fistulae had been excluded from the study. DUI-guided direct percutaneous management (DPM) was done as a 4-step process. First is the identification of PSA sac in the neck and offending b-SRA. Second is the puncture of PSA sac with 18 g puncture needle under DUI. Subsequently, manual injection of temporary embolic agent was done followed by N-butyl cyanoacrylate glue. Thrombosis of the PSA sac was confirmed by absent flow on DUI. RESULTS Forty cases of b-SRA were managed successfully in a single session and followed up by clinical findings, DUI, and computed tomography angiography. There was no need for the second session of DPM, transarterial embolization, or surgery in this cohort. Twelve cases (30%) had developed a mild fever and were managed conservatively. All 40 cases had no evidence of renal hematuria after follow-up of 3 months. CONCLUSION DUI-guided DPM is a safe, feasible, cost-effective, and nephron-sparing promising alternative to TAE or surgery for management of PSA of b-SRA.

Tricholithobezoar: An Unusual Late Complication of Neourethral Reconstruction in Aphallia

An 18-year-old man born with aphallia had undergone phallic reconstruction in childhood followed by total urethral reconstruction with a buccal mucosal graft and groin-based pedicle (Singapore) flap urethroplasty at 13 years of age. The patient presented with obstructive voiding symptoms lasting 6 months followed by acute urinary retention. The results of a voiding cystourethrogram showed a filling defect in the distal urethra that had been reconstructed by use of the skin flap. On urethroscopy, a 3 cm×2 cm sized tricholithobezoar was seen in the distal urethra. Pneumatic lithotripsy followed by bulbar urethrolithotomy was performed in the same operation to extract the bezoar. The remaining hairs were mechanically epilated. The patient has been doing well for 6 months of follow-up.

Cross-leg lithotomy: is it a better position for digital rectal examination of the prostate?

Objectives To evaluate whether “cross-leg lithotomy” (CL) is better position for digital rectal examination (DRE) than left lateral (LL) position from urologist and patients perspective. Materials and methods Two urologists performed DRE in 120 patients in LL and CL positions. Each patient was randomised, sequentially examined in both positions and responses were objectively assessed using a questionnaire and statistically analysed. Results Men found DRE uncomfortable [LL (81.7%), CL (85.0%)] and embarrassing [LL: (81.7%), CL (78.3%)] in both the positions. DRE was painful [LL (11.7%), CL (8.3%)] with a mean pain score of 1.92 and 1.85 respectively. Patient apprehension regarding pain was significantly higher [LL (62.5%) vs. CL (21.7%), p < 0.001] in LL position. Overall, men preferred CL to LL position [CL (78.3%), LL (21.75%), p < 0.001] for DRE. From urologist perspective, the extent of prostate felt in CL position was significantly higher (CL: 11.15 ± 1.96/12 vs. LL: 9.25 ± 2.50/12, p < 0.001). Withdrawal response was significantly higher in LL and urologist had to sit down to perform DRE in LL position. Conclusions Men preferred CL to LL position for DRE and CL allowed more complete examination of the prostate from urologist perspective. CL position is a better alternative for performing DRE of the prostate.

Bilateral Double J Stent Removal: The way to do it!.

There are many urological and non-urological indications which require bilateral double J stenting. We describe a point of technique for simultaneous removal of both the Double J stents. Both the stents are held by stent removing forceps at a point where they cross each other and then removed in one go with the help of cystoscope. Medline search did not reveal any techniques of removing two DJ stents in one go.