Nitin S Kekre

Occult stress incontinence in women with pelvic organ prolapse

Objectives: To study the prevalence of occult stress urinary incontinence (SUI) among Indian women with genitourinary prolapse, and determine the risk of developing SUI after vaginal hysterectomy and pelvic floor repair in Indian women with occult SUI. Methods: A prospective cohort study of 78 women with significant genitourinary prolapse without symptoms of SUI was conducted at Christian Medical College, Vellore, India. Before the surgical intervention, the prolapse was repositioned using a pessary and a Pyridium (Parke Davis, Morris Plains, NJ, USA) pad test was performed to detect occult SUI. The primary outcome studied was the risk of developing postoperative urinary incontinence. Results: Preoperatively, 67.9% of women were found to have occult SUI. The prevalence of SUI was 43.6% postoperatively, and 64.2% of the women with a positive result to the preoperative Pyridium pad test after pessary insertion were found to have urinary incontinence postoperatively. Postmenopausal women had twice the risk of developing occult SUI. Conclusion: Preoperative testing is useful to identify women with genitourinary prolapse who have occult SUI. Women with a positive result may need a systematic clinical evaluation and urodynamic studies to characterize the incontinence. They can be then counseled preoperatively regarding concomitant anti‐incontinence procedures.

Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India

BACKGROUND Reports from India on the prevalence and determinants of female sexual dysfunction (FSD) are scant. AIMS To determine the prevalence and risk factors for FSD. SETTINGS AND DESIGN A cross-sectional survey in a medical outpatient clinic of a tertiary care hospital. MATERIALS AND METHODS We administered a Tamil version of the Female Sexual Function Index (FSFI) to 149 married women. We evaluated putative risk factors for FSD. We elicited participants attributions for their sexual difficulties. STATISTICAL ANALYSIS We estimated the prevalence of possible FSD and sexual difficulties from published FSFI total and domain cut-off scores. We used logistic regression to identify risk factors for possible FSD. RESULTS FSFI total scores suggested FSD in two-thirds of the 149 women (73.2%; 95% confidence intervals [CI] 65.5% to 79.6%). FSFI domain scores suggested difficulties with desire in 77.2%; arousal in 91.3%; lubrication in 96.6%; orgasm in 86.6%, satisfaction in 81.2%, and pain in 64.4%. Age above 40 years (odds ratios [OR] 11.7; 95% CI 3.4 to 40.1) and fewer years of education (OR 1.2; 95% CI 1.0 to 1.3) were identified by logistic regression as contributory. Women attributed FSD to physical illness in participant or partner, relationship problems, and cultural taboos but none had sought professional help. CONCLUSIONS Sexual problems suggestive of dysfunction, as suggested by FSFI total and domain scores, are highly prevalent in the clinic setting, particularly among women above 40 and those less educated, but confirmation using locally validated cut-off scores of the FSFI is needed.

Supracostal Approach in Percutaneous Nephrolithotomy: Experience with 102 Cases

PURPOSE To assess retrospectively the safety and efficacy of the supracostal approach in percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS Among 862 patients who underwent PCNL between April 1986 and December 1999, supracostal puncture was performed in 102. Their stones were either solitary (66.5%), multiple (15.7%), or staghorn (19.6%). Upper ureteral calculi were the commonest indication (32.4%). The interspace between the 11th and 12th ribs was used in all cases. After tract dilatation with telescopic metal dilators, pneumatic or ultrasound lithotripsy was used for fragmentation. RESULTS Complete clearance was achieved in 79.5%. Ten patients (9.8%) had pleural violation in the form of hydrothorax, pneumothorax, or hydropneumothorax. All of these patients were managed successfully by intercostal chest tube drainage. CONCLUSION Supracostal puncture in a safe and effective approach with acceptable morbidity in selected cases of staghorn, upper ureteral, and upper caliceal calculi.

Surgical Management of Rectourethral Fistula

OBJECTIVES To present our experience and outcomes with the challenging problem of rectourethral fistula (RUF) using the perineal approach. RUF is a rare occurrence. METHODS This was a retrospective study of patients treated from January 1999 to December 2006. Fifteen patients (aged 16 to 64 years, mean 38) were studied, and their outcomes were assessed after surgical repair. The etiology was iatrogenic in 7, congenital in 5, and traumatic in 3. All patients presented with the passage of urine through the rectum and underwent micturating cystourethrography with retrograde urethrography, followed by preliminary cystoscopy and examination under anesthesia. All patients were treated using the perineal approach and gracilis muscle flap interposition. Six patients had associated urethral pathologic features that were managed simultaneously with RUF repair. Preoperatively, bowel diversion was done at the time of the cystourethroscopy and examination under anesthesia, if not done earlier, and the definitive repair was deferred for at least 12 weeks after bowel diversion. RESULTS RUF closure was successful in all the patients. Postoperatively, 2 patients had minimal urinary leakage through the perineum that resolved after repeat catheterization for 8 weeks. One stricture at the anastomotic site was managed with optical internal urethrotomy. One patient had extrusion of the gracilis flap, for which the muscle was repositioned. CONCLUSIONS The results of our study have shown that RUF closure using the perineal approach with pedicled gracilis muscle interposition is associated with low morbidity and a high success rate (100%). It is the method of choice for urologists because of their familiarity with the approach and because urethral pathologic features can be corrected simultaneously. We emphasize the need for bowel diversion before attempting reconstruction.

Emphysematous Pyelonephritis: Outcome of Conservative Management

OBJECTIVES To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis. METHODS Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics. RESULTS Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%. CONCLUSIONS A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

Monopolar Versus Bipolar Transurethral Resection of Bladder Tumors: A Single Center, Parallel Arm, Randomized, Controlled Trial

PURPOSE We compared the safety and efficacy of bipolar transurethral resection and monopolar resection for bladder tumors. MATERIALS AND METHODS A single center, parallel arm, randomized, controlled trial was performed from May 2011 to August 2012. All patients with suspected bladder tumors were eligible for study inclusion. Those who refused consent and those undergoing routine restaging transurethral resection of bladder tumor were excluded from analysis. The primary end point was the incidence of obturator jerk. Secondary study outcomes included the decrease in hematocrit, rates of recoagulation and transfusion, bladder perforation, decrease in sodium, resection syndrome and resection time. Pathological quality was assessed by comparing deep muscle and the degree of severe cautery artifact in the 2 arms. RESULTS A total of 257 transurethral resections were performed during the study period. After exclusion 147 patients were randomized, including 75 in the monopolar arm and 72 in the bipolar arm. There were 6 and 4 protocol violations in the monopolar and bipolar arms, respectively. Intent to treat and per protocol analyses were performed. The incidence of obturator jerk was greater in the bipolar arm (60% vs 49.2%, p=0.27). There was no significant difference between secondary outcomes. The only significant difference was a significantly lower incidence of severe cautery artifact in the bipolar arm (25% vs 46.7%, p=0.0096). CONCLUSIONS Bipolar transurethral resection of bladder tumor was not superior to monopolar resection with respect to obturator jerk, bladder perforation and hemostasis. There was a significantly lower incidence of severe cautery artifact after bipolar resection.

Postpartum urinary retention after vaginal delivery

To determine the incidence of covert and overt postpartum urinary retention (PUR) after vaginal delivery and to determine obstetric variables contributing to PUR.

Vesicovaginal fistula: An update

Vesicovaginal fistula (VVF) has been a social and a surgical problem for centuries and remains a challenge to surgeons. Though advances have been made in the understanding of the etiology, diagnostic procedures and management of these fistulae, controversies still exist over the ideal approach and time to repair. This review was undertaken to look into the recent literature with regard to the timing and surgical approach to VVF repair. The literature search was done using the Medline database with keywords: vesicovaginal fistula, laparoscopy and robotic repair filtered for the last 5 years.

Changing profile of prostatic abscess

PURPOSE To compare the clinical presentation of prostatic abscess and treatment outcome in two different time frames with regards to etiologies, co-morbid factors and the impact of multidrug resistant organism. MATERIALS AND METHODS We retrospectively assessed the charts of 48 patients with the diagnosis of prostatic abscess from 1991 to 2005. The period was divided arbitrarily into two different time frames; phase I (1991-1997) and phase II (1998-2005). Factors analyzed included presenting features, predisposing factors, imaging, bacteriological and antibiotic susceptibility profile, treatment and its outcome. RESULTS The mean patient age in phase I (n = 18) and phase II (n = 30) were 59.22 +/- 11.02 yrs and 49.14 +/- 15.67 respectively (p = 0.013). Diabetes mellitus was most common predisposing factor in both phases. Eleven patients in phase II had no co-morbid factor, of which nine were in the younger age group (22 - 44 years). Of these eleven patients, five presented with pyrexia of unknown origin and had no lower urinary tract symptoms LUTS. Two patients with HIV had tuberculous prostatic abscess along with cryptococcal abscess in one in phase II. Two patients had melioidotic prostatic abscess in phase II. The organisms cultured were predominantly susceptible to first line antibiotics in phase I whereas second or third line in phase II. CONCLUSION The incidence of prostatic abscess is increasing in younger patients without co-morbid factors. The bacteriological profile remained generally unchanged, but recently multi drug resistant organisms have emerged. A worrying trend of HIV infection with tuberculous prostatic abscess and other rare organism is also emerging.

Detrusor underactivity: to tone or not to tone the bladder?

OBJECTIVES The aim of this review was to review the available evidence in literature for the clinical effectiveness of Bethanechol Chloride in patients with detrusor underactivity. MATERIALS & METHODS We searched all relevant data from Medline and peer-reviewed journals available online on the use of bethanechol in patients with detrusor underactivity. RESULTS Most reports that suggest a therapeutic clinical benefit with use of bethanechol have all been anecdotal reports and there is no definite clinical evidence available till date to support its clinical usefulness. CONCLUSION The current available data have shown to offer no definite benefit with the use of parasympathomimetic agents in patients with DU. One of the meta-analysis has shown bethanechol to be ineffective in promoting bladder emptying.