Rajiv Paul Mukha

Management of adult choledochal cysts – a 15-year experience

BACKGROUND Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. METHODS The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. RESULTS The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. CONCLUSIONS Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary-enteric communication by hepaticojejunostomy form the basis of ideal treatment.

Lower urinary tract symptoms and prostatic calculi: A rare presentation of alkaptonuria

Alkaptonuria is a rare tyrosine metabolic disorder. A deficiency of homogentisic acid oxidase leads to accumulation of homogentisic acid in the body. Dark-colored urine, cutaneous pigmentations and musculoskeletal deformities are characteristic features. Storage and voiding lower urinary tract symptoms due to prostatic calculi is a rare presentation.

A novel computer based stent registry to prevent retained stents: Will patient directed automated short message service and letter generator help?

Objective: The objective of this study was to evaluate the feasibility of a computer based stent registry with patient directed automated information system to prevent retained double J stents. Materials and Methods: A stent registry system was developed in collaboration with our Computerized Hospital Information Processing Service Department. This computer based stent registry with patient directed automated information system was integrated with the existing clinical work station. We reviewed the records retrospectively and assessed the feasibility of the system in reminding clinicians and patients regarding the stent and its date of removal. Results: In a short run at our department, this new system appeared feasible, with patients promptly responding to the short message service and letter alerts. Conclusions: Computer based stent registry with patient directed automated information system is feasible in a clinical setting. A prospective study is needed for evaluation of its efficacy in preventing retained stents.

Isolated Malacoplakia of the bladder: a rare case report and review of literature.

Malacoplakia (from the Greek malacos, soft, and placos, plaques) is a rare granulomatous disease that occurs commonly in the urinary tract. It was first described by Michaelis and Gutmann in 1902 [1]. Malacoplakia in the urinary tract involves the bladder in more than 75% of the cases. Grossly, malacoplakia can present as soft tan-yellow plaques and nodules or in some cases as a bladder mass [2]. The lesion is usually solitary but can be multiple. We report a case of malacoplakia presenting with bilateral hydroureteronephrosis secondary to a small capacity bladder, with no gross mucosal lesion. To our knowledge, this is the first report of malacoplakia presenting without a gross lesion in the bladder.

Acute Gastric Dilatation: A Rare Complication of Nephrectomy

We report the first case of acute gastric dilatation after simple extraperitoneal nephrectomy for benign disease.

Positive ureteric margins at radical cystectomy: Can it be predicted at initial transurethral resection of bladder tumour?

Abstract Objective: To identify primary tumour-related factors at transurethral resection of bladder tumour (TURBT) that may predict positive distal ureteric margins (PUM) at the time of radical cystectomy (RC). Patients and methods: A retrospective, cohort study was conducted using our institution’s data from June 2007 to June 2016. Patients who underwent TURBT followed by RC for non-metastatic urothelial carcinoma (UC) of the bladder were identified. In all, 211 patients underwent RC for UC during the study period. The patients were divided into two groups: Group-I (n = 17) with PUM and Group-II (n = 194) with negative ureteric margins. Univariate and multivariate analyses were performed to determine the predictors of PUM. Results: On univariate analysis, multifocality, tumours involving the ureteric orifice, trigonal tumours, presence of carcinoma in situ (CIS), and lymphovascular invasion at TURBT, were significantly more common in Group-I. On multivariate analysis, tumour involvement in the ureteric orifice(s) and presence of associated CIS significantly predicted PUM. Conclusions: Primary tumour-related factors on initial TURBT that predicted PUM (at RC) were involvement of the ureteric orifice(s) and presence of associated CIS. These results may help to select patients who can be selectively offered intraoperative frozen section analysis.

Visualization of male reproductive tract during urethrography: sequel of intense backpressure

A 36-year-old gentleman presented with right flank pain, poor flow of urine and straining to void for 1 year. He had previously undergone cystolithotomy (1995), bladder neck incision and urethral dilatation for stricture (2002), and right percutaneous nephrolithotomy (PCNL) for renal calculus (2005). Evaluation revealed a hydronephrotic non-functioning right kidney with a staghorn calculus and a small bladder calculus (Fig. 1). The nonfunction of the right kidney was attributed to the persistence of a staghorn calculus that was incompletely cleared during the first PCNL. Retrograde urethrogram (RGU) revealed a tight shortsegment stricture at the peno-scrotal junction (Fig. 2). Voiding cystourethrogram (VCUG) confirmed these findings and showed opacification of the peri-urethral glands. Further films revealed opacification of both vas deferens and seminal vesicles secondary to the intense backpressure generated proximal to the tight stricture during attempted voiding (Fig. 3). He underwent endoscopic internal urethrotomy, cystolitholapaxy and right nephrectomy. Histopathology revealed chronic pyelonephritis with focal xanthogranulomatous involvement. He voided with a good flow post-operatively. He is presently on a self-dilatation regimen with a 16 French Nelaton catheter to reduce the risk of stricture recurrence. He has been advised regarding the need for a definitive urethroplasty in case the stricture recurs. RGU and VCUG are used to delineate length and severity of urethral strictures. High-pressure voiding secondary to distal obstruction can cause reflux of urine into the reproductive tract via the ejaculatory ducts. In the presence of urinary tract infection, this reflux can lead to epididymo-orchitis, which is a known complication of urethral stricture disease.

Equivocal pelvi-ureteric junction obstruction manifesting in a renal transplant recipient

Partial and intermittent pelvi-ureteric junction obstruction (PUJO) can potentially confound the diagnosis of upper tract obstruction. We report the case of a gentleman who received a renal graft from his sister. The donor kidney had a box-shaped extra-renal pelvis, which showed unobstructed drainage on the diuretic renogram. However, it manifested in the recipient as PUJO, and he needed pyelo-native ureterostomy for deteriorating graft function. The purpose of this report is to highlight a seemingly innocuous entity in the donor that may manifest in the recipient with significant consequences on graft function. It also discusses the appropriate timing of intervention in these cases.

Maximal androgen blockade for advanced prostate cancer.

Prostate cancer has now become one of the leading types of cancer in urban India. It is now the third most common cancer in Delhi. As we advance in health care with the resultant increase in longevity, we will be seeing more of advanced carcinoma prostate. Since the early 1980.s, there have been many trials on MAB. However, the question remains whether these agents actually make a difference? The role of MAB is probably limited to the prevention of the β are reaction in patients on LHRH agonists. The non steroidal antiandrogens have a marginal benefit of increased overall survival by approximately 3% to 5% at 5 ve years. There may be a role for MAB in patients with metastatic carcinoma of prostate, low volume metastases, patients with M 1 disease with absence of metastases in the skull, ribs, long bones, and soft tissues excluding lymph nodes.