Shanmugasundaram Rajaian

Auto Amputation of Penis Due to Advanced Penile Carcinoma

A middle-aged man presented with progressively enlarging ulcer on the tip of penis over a years duration and sloughing of whole penis subsequently. Examination revealed complete loss of penis and purulent discharge at its base. Biopsy of the base of the penis confirmed penile carcinoma. Imaging studies revealed extensive metastatic lesions. Palliative care was given, but he succumbed later. In this era of advanced medical care, symptoms of penile cancer are still being ignored and have led to autoamputation of penis.

Traumatic rectourethral fistula repair: A potential application of porcine small intestinal submucosa

Rectourethral fistula is an uncommon but devastating condition. Traumatic rectourethral fistula is still uncommon and repair of traumatic rectourethral fistula involves a complex procedure. Most of the urologists would prefer to repair the fistula through perineal route especially when urethral reconstruction is also required. The repaired ends of the fistula are separated with various interposition flaps and grafts in order to prevent recurrence. Gracilis interposition muscle flap is commonly used. We describe the first case of traumatic rectourethral fistula repair in a 45-year-old man using interposition of a porcine small intestinal submucosal (Biodesign™ (Surgisis®) graft.

Large bifid ureteric calculus in a patient with an ileal conduit

Urinary diversion after extirpative surgery of the bladder is done by various methods. Conduit urinary diversion is the most commonly practiced method of urinary diversion. It is relatively easy to perform and has a lower complication rate than other forms of diversion, e.g., orthotopic neobladder and continent cutaneous urinary diversion. Urolithiasis is a known and common complication of urinary diversion. Upper tract calculi in these cases often manifest symptomatically as occurs in the general population. Stones in the conduit can have a variable clinical presentation. Asymptomatic presentation is also noted in a few cases. We report a case of a large silent bifid ureteric calculus within an ileal conduit in a woman who had undergone urinary diversion 32 years earlier. Plain X-ray of the abdomen is the only investigation necessary to rule out urinary lithiasis in those who have had urinary diversion for a long time. This simple tool can diagnose the condition well in advance and aid in planning the management of this condition.

Giant hydronephrosis mimicking massive ascites

A 32-year-old man presented with a history of painless progressive abdominal distension, loss of appetite and early satiety for a duration of 2 years. He also had difficulty in breathing on exertion and after intake of food for the last 6 months. Clinical examination revealed grossly distended abdomen mimicking gross ascites (Fig. 1). Cardiovascular, respiratory and gastrointestinal systems were normal. All blood and urine investigations were normal. Ultrasonography revealed large cystic swelling with thin septations occupying whole of the abdomen and the left kidney was not separately seen. Computer tomography confirmed left gross hydronephrosis due to pelviureteric junction obstruction with papery thin renal parenchyma (Fig. 2), shifting all the bowel loops to the right side and compressing the right ureter causing right moderate hydroureteronephrosis (Fig. 3). Lack of function in left kidney was confirmed by 99mTc diethylenetriaminepentaacetic acid renogram. Right kidney was functioning normally. Left open nephrectomy was done by lumbar approach. Fourteen litres of clear urine was drained during gradual decompression of left kidney during nephrectomy. His postoperative period was uneventful. The biopsy report revealed chronic pyelonephritis with marked hydronephrosis and atrophic parenchyma. During the follow-up at 1 year, he is doing well. Giant hydronephrosis is defined as the presence of more than 1 L of urine in the collecting system. It is also defined as a kidney (i) occupying more than half of abdomen; (ii) meeting or crossing the midline; and (iii) with at least five vertebral bodies in length. The most common cause of giant hydronephrosis is congenital ureteropelvic obstruction followed by stones, trauma and tumours. The clinical features of giant hydronephrosis may include asymptomatic long-standing gradual painless distension of abdomen. Affected patients may also present with flank pain, back ache, haematuria following trivial trauma and shock. Rare presentations are respiratory distress because of diaphragmatic pressure or intraperitoneal urinary extravasation, particularly in infants. Malignant etiology is to be considered when adults with giant hydronephrosis present with gross haematuria. Giant hydronephrosis can lead to complications like renal failure, infection, malignancy and rupture of the kidney. It can mimic many acute and chronic abdominal conditions like acute peritonitis, ovarian cysts and tumours, retroperitoneal haematoma, hepatobiliary cysts, pancreatic pseudocysts, mesenteric cysts, pseudomyxoma, renal tumours and cysts, adrenal cysts, retroperitoneal tumours, splenomegaly, and massive ascites. It may be particularly difficult to differentiate from massive ascites when it occupies the whole abdomen. Establishing the correct diagnosis of

Primary extranodal marginal zone lymphoma - Epididymis.

An elderly male presented with painful swelling in the right side of scrotum. He was treated with antibiotics for epididymoorchitis without any response. Ultrasound examination revealed a hypoechoic vascular mass in the tail of the epididymis. Fine needle aspirate cytology was inconclusive. Excision of the mass was done and biopsy revealed primary extranodal marginal zone lymphoma arising from mucosa associated lymphoid tissue (MALT) of epididymis. Marginal zone lymphoma arising from the MALT of epididymis is very rare. Lymphoma should be considered as a differential diagnosis of any epididymal swelling unresponsive to conservative treatment. We report a rare case of primary extranodal marginal lymphoma of MALT arising from epididymis.

Impacted calculus within a urethral stent: A rare cause of urinary retention

An elderly male presented to the emergency department with acute urinary retention. He had poor flow of urine associated with serosanguinous discharge per urethra for 3 days duration. Earlier he underwent permanent metallic urethral stenting for post TURP bulbar urethral stricture. Plain X-ray of Pelvis showed an impacted calculus within the urethral stent in bulbar urethra. Urethrolitholapaxy was done with semirigid ureteroscope. Urethral stent was patent and well covered. Subsequently he had an uneventful recovery. We describe a unique case of acute urinary retention due to calculus impaction within a urethral stent.

There is no need to stent the ureterovesical anastomosis in live renal transplants.

Double-J (DJ) stents are used in urology practice for various reasons. In renal transplantation, DJ stenting is used to treat the complications like urine leak and ureteric obstruction. However, the role of routine or prophylactic DJ stenting during renal transplantation is debatable. Most of the urinary complications occurring following renal transplantation are because of poor surgical technique and transplant ureteric ischemia. Routine DJ stenting cannot be a substitute for sound surgical technique, which avoids ureteric devascularization and create watertight ureterovesical anastomosis. DJ stenting increases the risk for complications like recurrent urinary tract infection, stent encrustation, stone formation, hematuria, and severe storage lower urinary tract symptoms. Routine DJ stenting during renal transplantation is not mandatory. It can harm an immunosuppressed renal transplant recipient by predisposing to various complications.

Renal cell carcinoma in tuberous sclerosis.

Clinical history taking is a fundamental building block in the diagnostic process. While structured formats exist for many of the common clinical specialties, bariatric surgery is a relatively new concept. As such, it can be unclear to both surgeons and trainees exposed to these patients how such a history should be approached. This is important, as subtleties within the history can direct the surgeon towards choosing a specific operative procedure. In many bariatric units worldwide, patients are required to complete a questionnaire prior to clinic attendance assessing their eating habits, weight loss attempts and exercise routine, in addition to their pre-existing co-morbidity. This often includes an assessment of their psychosocial background to identify additional risk factors such as eating disorders, smoking, and alcohol or drug misuse. There are currently no clear guidelines regarding which surgical procedure patients should receive and thus it is largely guided by individual surgeons’ experience or preferences. Despite this, a clearly structured clinical history, incorporating the points previously raised, remains a key component in decisionmaking. We have found the following ‘ABC DEEP’ model to be a useful mnemonic to not only ensure that key points in the clinical history are recorded, but also to provide a framework for letter dictation. A series of selective questions within each category is required to provide a complete clinical assessment. A Age of patient B Body mass index C Co-morbidities D Drug history E Eating habits E Exercise habits P Psychosocial history

Squamous cell carcinoma associated with large bladder calculus.

A 70-year-old male underwent an optical urethrotomy in 2010 for treatment of a dense 3-cm anastomotic urethral stricture. His history is significant for Gleason 9 T2b prostate cancer treated with an uncomplicated prostatectomy in 1998 and external beam radiotherapy in 2003 secondary to local recurrence. His urethral catheter was removed day 3 post-optical urethrotomy. He developed right groin pain radiating to the inner thigh and had difficulty weight bearing on the right leg over the subsequent days. His symptoms intermittently worsened and he presented 5 weeks post-optical urethrotomy to the emergency department with a fever, right groin pain and inability to walk. His C-reactive protein was elevated at 137 mg/L and a urine culture positive for pseudomonas aeruginosa. A contrast-enhanced computed tomography scan of his abdomen and pelvis revealed a hypoechoic lesion in his obturator externus muscle. An initial bone scan showed no area of increased uptake to suggest osteomyelitis. On day 3 of admission, a magnetic resonance imaging showed an extensive collection within the right obturator externus measuring 3.7 ¥ 2.1 cm as well as osteomyelitis of the pubis (Fig. 1). Ultrasound-guided drainage of the collection aspirated 3 mL of purulent material which grew Pseudomonas aeuroginosa. Optical urethrotomy is considered a safe and effective treatment for urethral strictures. The most common complications are fever, bleeding, urinary tract infection, epididymitis, urinary incontinence, urinary extravasation and recurrence of stricture. We postulate that a disruption of the anatomical planes secondary to radiotherapy resulted in the extravasation of urine, from a breach in the corpus spongiosum at time of urethrotomy, into the superficial perineal space which then tracked deep to Colles’ fascia into the medial compartment of the thigh. Pyomyositis is a rare but possible complication of optical urethrotomy, with patients previously treated with local radiotherapy at particular risk.

Vesicovaginal fistula with large bladder calculus

A 61-year-old lady hailing from a remote village presented with history of continuous leakage of urine per vaginum for past 32 years and bleeding per vaginum of 1-month duration. She never voided voluntarily and always used to wear pads. Thirty-two years ago, during her first pregnancy, she developed prolonged labour and had a forceps-assisted delivery of a still born. A week later, she developed continuous urine leak per vaginum. Her menstrual habits were normal and attained menopause 16 years ago. Her past history was otherwise insignificant. General and systemic examination was noncontributory. On genital examination, a stony hard mass of about 6 ¥ 6 cm in size was palpable in the anterior vaginal wall and fornix. Continuous dribbling of urine was noted in vagina beside a large calculus during speculum examination. Blood investigations revealed normal renal function. Plain X-ray – kidney, ureter and bladder region revealed a layered calculus in the bladder region (Fig. 1a). Intravenous urogram confirmed the presence of a 6 ¥ 5-cm bladder calculus occupying the whole of a small capacity bladder with bilateral hydroureteronephrosis (Fig. 1b). Opacification of the vaginal tampon was also seen. Simultaneous cystoscopy and vaginoscopy revealed normal urethra and presence of a large calculus across the vesicovaginal fistula with bladder opening at the trigone region. Both ureteric orifices were seen at edge of the fistula. No evidence of any other foreign body was seen within the bladder or in the vagina. Cystolithotomy was done and the calculus of 6 ¥ 5 cm in size was extracted (Figs 2,3) and stone weighed 116 g. The stone analysis revealed a mixture of calcium oxalate, ammonium urate and calcium phosphate. Subsequent evaluation showed that her functional bladder capacity was about 100 mL only. Further evaluation to assess the bladder was deferred as the fistula could not be occluded and bladder was inflammed. Six months later, she underwent transabdominal vesicovaginal fistula (VVF) repair with augmentation ileocecocystoplasty and bilateral ureteric reimplantation. She is voiding normally without incontinence. VVF is the commonest of the urogenital fistulae. Its incidence is varied between the developed and developing nations worldwide. In the developing world, VVF is often a result of prolonged obstructed labour or uterine rupture resulting from it. Caesarean deliveryrelated VVF is also much prevalent in developing countries. Other causes of VVF are folk practices like female circumcision, sexual aggression and advanced cervical cancer. VVF in developed world often occur as a complication of various surgical procedures like hysterectomy for benign and malignant conditions. Vesical calculus formation in VVF is uncommon. Primary vesical calculi in patients with VVF are associated with urinary contamination and constant urinary stasis in the bladder and a long history of disease. Initial management of the stone with endoscopic or open technique followed by definitive management of VVF after a period of 3 months is often recommended. The method of management of the stone is decided by its size and distensibility of the bladder. Stones with sizes of up to 3 cm are managed by cystolitholapaxy if the bladder could be moderately distended by digitally occluding the fistula via the vagina. Larger stones, those more than 3 cm, could