F. Anjum

Fournier's Gangrene Associated with Intradermal Injection of Cocaine

INTRODUCTION Cocaine abuse is associated with a number of medical complications, most notably arrhythmias, myocardial infarction, and cerebral hemorrhages. The injection of cocaine in the penis has been predominantly recorded into the corpus cavernosae and is associated with priapism. AIM Here we describe the injection of subcutaneous cocaine within the penile shaft skin producing ischemic necrosis and Fourniers gangrene. MAIN OUTCOME MEASURES We sought to highlight the effects of cocaine use within the penis and emphasize the different effects that may ensue. METHODS We reviewed a recent clinical case and conducted a literature review on the use of cocaine within the penis. RESULTS The use of cocaine has been reported previously within the literature and is mainly limited to case reports. Cocaine use within the corpora and the subcutaneous tissues produces significantly different consequences ranging from priapism to Fourniers gangrene. CONCLUSIONS The case illustrates the growing use of cocaine and other illicit drugs and emphasizes the importance of this issue to all clinicians.

CT imaging is invaluable in diagnosing emphysematous pyelonephritis (EPN): a rare urological emergency

Emphysematous pyelonephritis (EPN) is an acute, fulminant and potentially fatal necrotising process with varying clinical presentations and a radiological classification. Most cases occur in diabetics with poor glycaemic control, while a minority are due to urinary tract obstruction. Early CT imaging is vital in diagnosing highly morbid EPN, with mortality rates of up to 69% described, and can necessitate nephrectomy.1 ,2 A 79-year-old woman, with non-insulin-dependent diabetes mellitus presented with confusion, fever, rigours and diffuse abdominal pain. Laboratory tests revealed …

Efficacy of flexible ureteroscopy and laser lithotripsy for lower pole renal calculi

Objective: Our aim was to determine whether flexible ureterorenoscopy and laser lithotripsy is efficacious and safe in treating lower pole renal calculi. Materials and methods: Patient, procedure and stone data of patients who underwent flexible ureterorenoscopy and laser lithotripsy at our referral centre were collected prospectively between November 2005 and November 2011 and entered into a designated database. In all, 242 procedures were performed in 198 patients. Results: The mean age was 51.2 years. The mean calculi size was 10.51 mm (range 4–27 mm). Thirty seven patients had more than one stone in the lower pole. An access sheath was used in 19 patients (9.6%), 171 (86.4%) had a ureteric stent inserted after the procedure, and 165 patients had a single procedure. Re-operation rate was 16.7%. Stone-free rates after one procedure were 89%, 80% and 41%, respectively, for calculi measuring 4–10 mm (n=107), 11–20 mm (n=76) and > 20 mm (n=15). The overall stone-free rate was 83%, 91% and 95% after one, two and three procedures, respectively. Conclusion: Flexible ureterorenoscopy and laser lithotripsy is a safe and effective minimally invasive treatment option for patients with 4–20 mm lower pole calculi. Staged procedures, however, become necessary as the size of the stone increases greater than 20 mm, and this should be mentioned when counselling patients for their primary procedure.

Evaluation of the pressure leak test in increasing the lifespan of flexible ureteroscopes

Flexible ureteroscopes are expensive and delicate instruments that are integral in the offering of a minimally invasive technique of diagnosis and treatment of urolithiasis. Published literature has identified the importance of early damage recognition in preventing frequent use of the scope that would lead to further damage and high repair and replacement costs. Our study was designed to examine the outcome of the pressure leak test on the condition of flexible ureteroscopes after every use and analysing the damage and costs of maintenance.

Bipolar Transurethral Resection of Prostate: Current Status in the Management of Bladder Outflow Obstruction

Monopolar transurethral resection of prostate has been the preferred surgical treatment of benign prostatic hyperplasia. Even in modern series there are significant risks such as haemorrhage requiring transfusion and TUR syndrome, although their incidence is lower than previously. Over the last decade or so newer technologies have emerged that have proven to be at least equivalent to monopolar TURP. Bipolar transurethral resection of the prostate in normal saline is a potentially safer option to monopolar resection but with equivalent efficacy in the medium term. This is supported by 2 recent meta-analyses. This review describes the technology, efficacy and safety profile of bipolar transurethral resection of the prostate.

Synchronous presentation of acute appendicitis and left ureteric stone

A 12-year-old Caucasian boy presented to our institution with a one week history of nausea, lower abdominal pain, diarrhoea and dysuria. Patient denied any flank pain. He was mildly pyrexial and on clinical examination, there was tenderness in the right iliac fossa. Urine dipstick was positive for 2 plus blood and urine microscopy confirmed microscopic haematuria. Urine cultures later on revealed no growth. The white cell count and C-reactive protein were raised at 14.3 × 109/l and 150 mg/l, respectively. Initial Abdominal Ultra-sonography (USG) was normal. Appendicectomy was performed through a Lanz incision, for a distally inflamed appendix. The histology of the appendix later confirmed the diagnosis of acute suppurative appendicitis with serositis (Fig. 1). Post-operatively, the patient had persistent vomiting, abdominal pain and prolonged ileus. Repeat abdominal USG one week after appendicectomy, revealed mild to moderate left hydronephrosis with a possible vesicoureteric junction (VUJ) stone (Fig. 2). Intravenous Urogram (IVU) was performed as per departmental protocol to reduce radiation exposure, which showed no excretion of contrast from the left kidney at 2 h; immediate unenhanced Computerised Tomography (CT) confirmed a 12 mm stone at the VUJ (Fig. 3). Rigid ureteroscopy, endoscopic fragmentation and extraction of ureteric stone was performed. Symptoms completely resolved after stone treatment. At 3 months, the patient was asymptomatic and an IVU and technetium-99m labeled mercapto acetyl triglycine (MAG 3) scan were normal.

Accordion—Music to the endourologist

age analgesic requirement in the post-operative period was 47.2 mg morphine equivalent and 162 mg diclofenac equivalent respectively. 11.8% developed post-operative pyrexia which settled with antibiotics. Compared to the BAUS outcome, this series had a higher percentage of staghorn stones and higher stone clearance rates. 75.8% were rendered stone free, while the rest had ancillary procedures (ESWL/flexible ureterorenoscopy). Discussion: ‘Tubeless PCNL’ or ‘nephrostomy free PCNL’ is a safe procedure associated with reduced morbidity and shorter hospital stay when compared to standard PCNL. The analgesic requirements are also diminished with this technique.

Upper Tract Problems and Endourological Solutions in Patients with Ileal Conduits and Neobladders

Episode Statistics (HES) database. Much of the data is available on the HES Online website and can be extracted. We set out to discover whether interrogating this database taught us about trends in stone disease episodes and treatment in the UK. Method: The HES Online database (http://www.hesonline.nhs.uk/) was accessed and data extracted from 1999/2000 to 2009/2010. The operative codes MO9 (therapeutic endoscopic operation on calculus) and M14.1 (ESWL kidney) were investigated as were diagnostic codes N20.0 and N20.1 (calculus of the kidney and ureter respectively) and N20—23 (urolithiasis). Trends in the number of each of these episodes were explored. Results: Stone episodes have increased in every code investigated. Between 1999/2000 and 2009/10 total renal stone diagnoses have increased from 21,234 to 41,119 and ureteric stones diagnoses from 15,517 to 22,265. The total number of hospital episodes attributed to urolithiasis (codes N20—N23) has risen from 54,904 to 89,855 over the same time frame. The number of episodes of ESWL (M14.1) for renal stones has risen from 10,843 to 19,159. Emergency admissions have also risen from 20,630 to 32,751. Conclusion: HES Online is a tremendous source of data. There is an increase in the UK HES recording of stone disease as a diagnosis and interventions for stone disease are similarly rising. Access to this data is time consuming but can be useful in developing a business case for appointing stone surgeons.