Nikhil Khattar

Looking beyond oral mucosa: Initial results of everted saphenous vein graft urethroplasty (eSVGU) in long anterior urethral strictures

Abstract Objective: To prospectively evaluate the feasibility and initial results of an everted saphenous vein graft (eSVG) as a dorsolateral onlay, in patients with long anterior urethral strictures and/or chronic tobacco users. Patients and methods: In all, 20 patients with long anterior urethral strictures (>7 cm) and/or chronic tobacco exposed oral mucosa were included in the study. The harvested SVG was hydro-distended, detubularised, and everted. Substitution urethroplasty using an eSVG was performed using a dorsolateral onlay technique. Symptoms were assessed using the International Prostate Symptom Score (IPSS) and uroflowmetry at 1, 3 and 6 months; and voiding and retrograde urethrograms, and urethroscopy were done at 3 months. Failure was defined as failure to void, need for interventions in form of direct-vision internal urethrotomy or endodilatation. Results: Three patients were excluded because they underwent a staged urethroplasty. In all, 17 patients underwent eSVG substitution urethroplasty. The mean (SD, range) follow-up of our patients was 17.64 (5.23, 10–26) months. The mean (SD, range) length of the strictured segment was 14 (2.5, 10–18) cm and the length of the harvested SVG was 16.3 (2.7, 12–20) cm. The mean (SD) IPSS at 1, 3 and 6 months after catheter removal was 10 (2.8), 10 (3.4) and 10 (1.4) and the quality-of-life score was 1.76 (0.5), 2.05 (1.0) and 2.05 (1.0), respectively. Postoperatively, endodilatation was required in two patients. Complete failure occurred in one patient. Conclusions: An eSVG, as a dorsolateral onlay graft, is a promising and prudent option for long anterior urethral strictures, especially in patients with poor oral hygiene and chronic tobacco use.

Single-Stage Correction of Urinary Incontinence and Vaginoplasty in a Case of Urethral Coitus with Vaginal Agenesis

Urethral coitus is a very rare entity which usually presents as urethral incontinence during intercourse and is most commonly seen with intact vagina. Only about 24 cases have been reported in the literature. A presentation in vaginal agenesis is exceedingly rare and poses the surgical challenge of restoring continence without interfering with sex life. Here we report a case of urethral intercourse with vaginal agenesis presenting with incontinence that we treated with McIndoe’s vaginoplasty and urethral plication in a single stage, with satisfactory result. To the best of our knowledge, this method of reconstruction has not yet been reported for this condition.

Generalized seizure: A rare etiology of intraperitoneal rupture of the urinary bladder

Seizures can lead to different types of injuries which can be as simple as minor lacerations and at times as serious as fractures and head injuries. We are reporting a case wherein a female patient presented with a history of abdominal pain and not passing urine for 24h following an attack of seizure. After catheterization the urine drained was blood-stained. On clinical suspicion a cystogram was done which showed intraperitoneal rupture of the bladder. At laparotomy an isolated rent in the dome of the bladder was found which was repaired in three layers. Postoperative period was uneventful. To our knowledge this is the second case of its kind reported in the literature. Our case illustrates that a thorough abdominal examination is desirable while examining a patient following an episode of generalized seizure.

Cystic retroperitoneal renal hilar ancient schwannoma: Report of a rare case with atypical presentation masquerading as simple cyst

Schwannoma is a benign soft tissue tumor of neural origin arising from the Schwann cells of the neural sheath. It has rarely been reported in renal or perirenal region. The preoperative diagnosis has mostly been confused with renal cell carcinoma in this location in most previous reports. We report a case that presented with a large “simple cystic” mass at the renal hilum. The preoperative differential diagnosis included hilar renal cortical cyst, renal sinus cyst, ureteropelvic junction obstruction (UPJO), or even a hydatid cyst. The final diagnosis was clinched only on histopathological examination.

Pediatric pelvic fracture urethral distraction defect causing complete urethrovaginal avulsion

Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.

Can androgen-deprivation therapy obviate the need of channel transurethral resection of the prostate in advanced prostate cancer with urinary retention? A prospective study

Abstract Objective: To evaluate the efficacy of androgen-deprivation therapy (ADT) in relieving urinary retention in patients with advanced prostate cancer presenting with urinary retention or a high post-void residual urine volume (PVR). Patients and methods: Patients with advanced prostate cancer with an indwelling catheter for acute/chronic urinary retention, or with a high PVR (>200 mL) who had not received any previous treatment were included in the study. Patients with localised prostate cancer eligible for receiving any therapy aimed at cure were excluded. All enrolled patients were managed by ADT (LHRH antagonist/agonist or orchidectomy) combined with α-adrenoceptor antagonist/combined therapy for at least 1 month to a maximum of 3 months; they were given their first trial of voiding without catheter after 1 month, and monthly thereafter. Results: A total of 101 patients received ADT of which 97 were able to void successfully at the end of 3 months. In all, 27 patients could void in the first month, followed by 50 in the second month, and an additional 20 in the third month. There was a significant decrease in prostate volume, PVR, and International Prostate Symptom Score, and maximum urinary flow rates improved with normalisation of renal functions and resolution of upper tract changes noted on ultrasonography. Conclusion: ADT can relieve retention and decrease PVR over a period of time obviating the need for channel transurethral resection of the prostate.

Day care bipolar transurethral resection vs photoselective vaporisation under sedoanalgesia: A prospective, randomised study of the management of benign prostatic hyperplasia

Abstract Objective: To conduct a prospective randomised study comparing the safety, effectiveness and treatment outcomes in patients undergoing bipolar transurethral resection of the prostate (bTURP) and photoselective vaporisation of the prostate (PVP) under sedoanalgesia, as sedoanalgesia is a safe and effective technique suitable for minimally invasive endourological procedures and although studies have confirmed that both TURP and PVP are feasible under sedoanalgesia there are none comparing the two. Patients and methods: Between November 2014 and April 2016, all patients satisfying the eligibility criteria underwent either bTURP or PVP under sedoanalgesia after randomisation. The groups were compared for functional outcomes, visual analogue scale (VAS) pain scores (range 0–10), perioperative variables and complications, with a follow-up of 3 months. Results: In all, 42 and 36 patients underwent bTURP and PVP under sedoanalgesia, respectively. The mean VAS pain score was <2 at any time during the procedure, with no conversions to general anaesthesia. PVP patients had a shorter operating time [mean (SD) 55.64 (12.8) vs 61.79 (14.2) min, P = 0.035], shorter duration of hospitalisation [mean (SD) 14.58 (2.81) vs 19.21 (2.82) h, P < 0.001] and a higher dysuria rate when compared to bTURP patients. However, the catheterisation time was similar and both intraoperative and postoperative complications were minimal and comparable. Improvements in the International Prostate Symptom Score, quality of life, prostate volume, maximum urinary flow rate and post-void residual urine volume at 3 months were similar in both groups. None of our patients required re-admission or re-operation. Conclusion: Both PVP and bTURP can be carried out safely under sedoanalgesia with excellent treatment outcomes.

MP80-15 CAN FUNCTIONAL STUDIES BE OBVIATED IN MANAGEMENT OF URETERIC CALCULUS? A RANDOMIZED STUDY.

INTRODUCTION AND OBJECTIVES: Based on classic teaching, functional studies (Intravenous pyelography or contrast enhanced CT scan) are often considered a prerequisite before proceeding for surgery for urolithiasis. The routine use of imaging is time consuming and associated with real risks. There is no adequate clinical evidence as to whether detailed functional imaging as a routine has any role in management of calculi and at present no randomized controlled trial exists to evaluate the role and need of such investigations. A randomized study was performed to evaluate the role of functional studies in management of ureteric stones. METHODS: 195 patients presenting to the outpatient department with a diagnosis of a demonstrable solitary unilateral ureteric calculus sized 0.5 to 1.5 cm with normal renal function tests and only mild to moderate hydronephrosis were included in the study. Patients with either increased creatinine, gross hydronephrosis with thinned out renal parenchyma, pyonephrosis or pregnancy were excluded. All included patients were randomized using a computer generated table into two groups. In the first group functional imaging was routinely done but in the other group no such study was performed. However, retrograde pyelogram was performed wherever required to delineate the anatomy. All patients were managed initially with medical expulsive therapy for a period of at least two weeks before they were subjected to ureterorenoscopy (URS). All patients were followed up with imaging after 3 months of successful management. The rates of spontaneous expulsion, difficulty or surprises during surgery and incidence of complications were noted. Results and complications in each of these groups were analysed using appropriate statistics. RESULTS: 97 patients were randomized to the functional studies arm and 98 patients managed without any functional studies. The mean age, sex ratio, body mass index, size of calculus and location of calculus were comparable. Rate of spontaneous expulsion with medical expulsive therapy was 88.71%. Only 11 cases in each group required URS and 1 patient in each group had perforation. A weakly positive but clinically insignificant correlation was seen between size of calculus and need for URS. No significant difference was found in the spontaneous stone expulsion rates, difficulty and incidence of complications during URS and stone free rates between the two groups. CONCLUSIONS: Functional studies may be obviated in management of solitary ureteric calculi amenable to endoscopic treatment in the presence of normal kidney function and absence of gross hydronephrosis.

Diverticulocystoplasty with Bilateral Ureteric Reimplantation: Management in a Rare Case of Combined Congenital Large Paraureteric Diverticulum with Bilateral Obstructive Megaureter

A large congenital paraureteric diverticulum has not been reported earlier in combination with bilateral obstructed megaureter. We present one such case in an adolescent male with decreased bladder capacity and renal failure. A single sitting surgical procedure included diverticulocystoplasty with bilateral ureteric reimplantation. The left ureter was implanted into the diverticular wall, which was used as a patch to augment the bladder. Reimplantation into the wall of the diverticulum has also not been reported earlier.

Functional evaluation before stone surgery: Is it mandatory?

Functional evaluation of the renal unit has often been quoted as a standard practice for management of stone disease of the upper urinary tract. However, there is very little available evidence from the existing literature to directly support or refute this practice. Here we try to critically review the existing literature on related questions, put into perspective its clinical utility and attempt to rationalize the concept of functional evaluation in patients of renal stone disease in the contemporary era of minimally invasive surgery.