Ramanitharan Manikandan

Current concepts in the management of pelvic fracture urethral distraction defects

Objectives: Pelvic fracture urethral distraction defect (PFUDD) may be associated with disabling complications, such as recurrent stricture, urinary incontinence, and erectile dysfunction. In this article we review the current concepts in the evaluation and surgical management of PFUDD, including redo urethroplasty. Materials and Methods: A PubMed™ search was performed using the keywords “pelvic fracture urethral distraction defect, anastomotic urethroplasty, pelvic fracture urethral stricture, pelvic fracture urethral injuries, and redo-urethroplasty.” The search was limited to papers published from 1980 to March 2010 with special focus on those published in the last 15 years. The relevant articles were reviewed with regard to etiology, role of imaging, and the techniques of urethroplasty. Results: Pelvic fracture due to accidents was the most common etiology of PFUDD that usually involved the membranous urethra. Modern cross-sectional imaging, such as sonourethrography and magnetic resonance imaging help assess stricture pathology better, but their precise role in PFUDD management remains undefined. Surgical treatment with perineal anastomotic urethroplasty yields a success rate of more than 90% in most studies. The most important complication of surgical reconstruction is restenosis, occurring in less than 10% cases, most of which can be corrected by a redo anastomotic urethroplasty. The most common complication associated with this condition is erectile dysfunction. Urinary incontinence is a much rarer complication of this surgery in the present day. Conclusions: Anastomotic urethroplasty remains the cornerstone in the management of PFUDD, even in previously failed repairs. Newer innovations are needed to address the problem of erectile dysfunction associated with this condition.

Osseous metaplasia in renal cell carcinoma: report of a rare case.

Focal calcifications are frequently seen in renal masses including renal cell carcinoma (RCC). Osseous metaplasia, on the other hand, is a rare finding in RCC. We report a case of RCC with radiological evidence of speckled calcification that showed osseous metaplasia on histopathological examination. The clinical and pathologic differential diagnosis for this tumor is discussed along with a review of the literature on this unusual phenomenon.

Urethral diverticulum: a potential hazard of penile clamp application for male urinary incontinence.

Urinary incontinence is a common problem encountered after prostatectomy. After a trial of conservative management, men are generally left with a choice of surgery, drainage or absorbent devices, or a penile compression device. Artificial urinary sphincter is the current gold standard for management of post-prostatectomy incontinence with acceptable long-term success rates. However, in patients who are not fit to undergo another surgery or cannot afford these devices, especially in developing countries, penile compression devices come in handy. Use of these devices has been shown to cause a significant …

Laparoscopic ablative and reconstructive surgeries in genitourinary tuberculosis.

Background and Objectives: Laparoscopy is the present standard of care for urologic diseases. Laparoscopy in renal tuberculosis (genitourinary tuberculosis) is difficult because of inflammation and fibrosis associated with the disease. We present the outcome of our experience of laparoscopy in genitourinary tuberculosis, both ablative and reconstructive. Methods: The detailed data of patients with genitourinary tuberculosis who underwent laparoscopic surgeries between January 2011 and September 2012 were reviewed. Indications, type of surgery, duration, blood loss, intraoperative problems, postoperative outcomes, and follow-up details were noted. Results: Overall, 7 laparoscopic procedures were performed: 5 nephrectomies, 1 ureteric reimplantation with psoas hitch, and 1 combined nephrectomy and laparoscopy-assisted Mainz II pouch reconstruction. The mean operative time was 192 minutes for nephrectomy, 210 minutes for ureteric reimplantation, and 480 minutes for nephrectomy with Mainz II pouch reconstruction. There were no conversions to open surgery. The mean amount of blood loss was 70 mL for the nephrectomies, 100 mL for ureteric reimplantation, and 200 mL for nephrectomy with Mainz II pouch reconstruction. In 5 of 6 patients who underwent nephrectomy, there was severe perinephric and peripelvic fibrosis posing difficulty in dissection. However, the renal vessels could be controlled individually. The mean postoperative hospital stay was 3 days for the nephrectomies, 5 days for the ureteric reimplantation, and 10 days for the nephrectomy with Mainz II pouch reconstruction. In all cases the recovery was uneventful. Conclusions: Laparoscopy, though technically more demanding, is a feasible and safe option for ablative and complex reconstructive procedures in genitourinary tuberculosis. It offers the benefits of minimally invasive surgery. The difficulty with this procedure is mostly because of peripelvic and perinephric fibrosis, whereas the lower ureter and bladder are relatively easier to dissect.

Randomized Clinical Trial Comparing Effectiveness of Intracorpus Spongiosum Block Versus Topical Anesthesia for Performing Visual Internal Urethrotomy for Urethral Stricture Disease

OBJECTIVE To compare the efficacy and safety of intracorpus spongiosum block (ICSB) over topical anesthesia for performing visual internal urethrotomy (VIU) in a randomized clinical trial. METHODS VIU for urethral stricture can be performed under various types of anesthesia, including topical anesthesia. Although recent studies have shown that ICSB and general anesthesia have comparable efficacy for performing VIU, no studies have compared ICSB with topical anesthesia. Forty consenting patients with single, short, passable anterior urethral stricture were randomized into two groups. Group 1 patients received topical 2% lignocaine jelly and group 2 patients received 1% lignocaine ICSB for undergoing VIU. Pain perception during and after the procedure was assessed by visual analog scale (VAS). The changes in vital parameters during the procedure and procedure-related complications were recorded. Statistical analysis was done using the Mann-Whitney test or t test. RESULTS The mean±standard deviation VAS scores intraoperatively (2.85±1.34) and at 1-hour postoperatively (1.17±0.96) were significantly lower (P<01) in group 2 patients than the corresponding scores in group 1 (4.9±1.9 and 2.35±1.34 respectively). The intraoperative rise in pulse rate and in blood pressure were significantly greater (P<.05) in group 1 patients (13±5.1/min and 11.3±6.44 mm Hg) than in group 2 (8.05±5.54/min and 6.35±5.86 mm Hg). CONCLUSION ICSB is safe and more effective than topical anesthesia for providing pain relief during VIU. This should become the local anesthesia technique of choice for performing VIU.

Successful timely minimally invasive management of grade 4 renal injury in children: a report of two cases

Expectant management of renal injuries has become the standard of care but most of such experience has been with adult patients. Although some recent reports suggest equally comparable results in pediatric populations too, there is a paucity of data. We report our experience with two children who sustained grade 4 renal injury due to blunt trauma, which was managed successfully by endourological intervention facilitating preservation of renal units and review the current literature.

Bellini Duct Carcinoma: A Rare Entity.

Bellini duct carcinoma of kidney derives from collecting duct and is associated with an aggressive course and extremely poor prognosis. Here, we report an interesting case of Collecting Duct Carcinoma (CDC) with Inferior Vena Cava (IVC) thrombus and large retroperitoneal lymph nodes and diffuse desmoplastic reaction. The patient underwent left open radical nephrectomy with IVC thrombectomy and regional lymphadenectomy. Based on morphological and immunohistochemical analysis, diagnosis of collecting duct (Bellini duct) carcinoma was made. Presently, patient is on adjuvant chemotherapy with gemcitabine and cisplatin and under follow-up.

Synchronously detected secondary signet ring cell urinary bladder malignancy from the stomach masquerading as genitourinary tuberculosis

Secondary bladder neoplasms are very rare and represent 1% of all malignant bladder tumours. Among secondary bladder tumours, metastasis from the stomach accounts for about 4% of cases. These secondary tumours are generally detected during follow-up of patients already treated for gastric cancer. We report a case of metastatic adenocarcinoma of the urinary bladder from an occult primary poorly differentiated signet ring cell type gastric carcinoma masquerading clinically as genitourinary tuberculosis. Our case illustrates the importance of obtaining a bladder biopsy in suspected chronic inflammatory conditions such as urinary tract tuberculosis before starting medical management to avoid the serious consequences of missing a bladder malignancy.

Oncocytic adrenocortical carcinoma--a rare pathological variant.

Oncocytic adrenocortical carcinoma is a rare histopathological variant of adrenocortical carcinoma with very few instances reported in the literature to date. With progressive research, new insights have emerged in the molecular profiling of these tumours. This advancement has led to more clarity in reporting of this tumour. We report a case of oncocytic adrenocortical carcinoma with its attending clinical presentation, immunohistochemical profiling and characteristic electron microscopy findings.

Renal adenocarcinoma presenting as a groin swelling: a case report

Renal cell carcinoma (RCC) is known to have myriad presentations due to the extremely vascular nature of the organ. RCC are known to metastasize extensively to various organs of the body. We report a case of a 70-years-old male who presented with multiple inguinal lymph node enlargements which on excision biopsy showed metastatic adenocarcinomatous deposit. Search for the primary revealed a RCC arising from the left kidney. Inguinal lymph nodal metastasis, an uncommon site of distant metastasis in renal neoplasm, as a fi rst clinical sign leading to the diagnosis is not yet reported in literature.