Tarun Javali

Magnetic resonance spectroscopy imaging-directed transrectal ultrasound biopsy increases prostate cancer detection in men with prostate-specific antigen between 4-10 ng/mL and normal digital rectal examination.

To evaluate the ability of magnetic resonance spectroscopic imaging to improve prostate cancer detection rate.

Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - A single-center experience.

Objective: To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010. Materials and Methods: Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center. Results: The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%. Conclusion: Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

Vesicouterine fistula and concomitant ureteric necrosis following uterine artery embolization for fibroid uterus.

A 42-year-old woman presented with fever, abdominal pain, and urine leakage per vagina of 1 week’s duration. She had undergone selective UAE 5 weeks earlier, for an intramural fibroid measuring 5 cm in the anterior wall of the uterus. Embolization was carried out using 500–710 μm polyvinyl alcohol (PVA) particles followed by gel foam. During current evaluation, contrast-enhanced computed tomography (CECT) of the abdomen (Fig. 1) revealed a fistulous connection between bladder and distal uterine body. The uterus was enlarged with air. Fluid and debris were seen in the pelvic cavity. There was right hydroureteronephrosis. Cystoscopy (Fig. 2) showed sloughed off fibroid projecting into the bladder through the rent in the posterior bladder wall. On exploratory laparotomy, there was extensive necrosis of more than half of the uterus predominantly on the right-hand side, along with necrosis of the right ovary, the posterior wall and dome of the bladder, and 3 cm of the right lower ureter. Debridement of sloughed off necrotic tissue and hysterectomy with right salpingo-oophorectomy was carried out. The left ovary was normal and was preserved. Augmentation ileocystoplasty and right ureteric reimplantation were performed. Vascular overlap between the bladder and uterus may have resulted in extensive necrosis in this case. Pelage

A Novel method of ensuring safe and accurate dilatation during percutaneous nephrolithotomy

ABSTRACT Objective: To report our technique that helps locate the guidewire into the ureter enabling safe dilatation during PCNL. Materials and Methods: Cases in which the guidewire failed to pass into the ureter following successful puncture of the desired calyx were subjected to this technique. A second guidewire was passed through the outer sheath of a 9 Fr. metallic dilator cannula, passed over the first guidewire. The cannula and outer sheath were removed, followed by percutaneous passage of a 6/7.5 Fr ureteroscope between the two guidewires, monitoring its progress through both the endoscopic and fluoroscopic monitors. Once the stone was visualized in the calyx a guidewire was passed through the working channel and maneuvered past the stone into the pelvis and ureter under direct endoscopic vision. This was followed by routine tract dilatation. Results: This technique was employed in 85 out of 675 cases of PCNL carried out at our institute between Jan 2010 to June 2014. The mean time required for our technique, calculated from the point of introduction of the ureteroscope untill the successful passage of the guidewire down into the ureter was 95 seconds. There were no intraoperative or postoperative complications as a result of this technique. Guidewire could be successfully passed into the ureter in 82 out of 85 cases. Conclusions: Use of the ureteroscope introduced percutaneously through the puncture site in PCNL, is a safe and effective technique that helps in maneuvering the guidewire down into the ureter, which subsequently enables safe dilatation.

Virilizing lipoadenoma of the adrenal gland in a pre-pubertal girl: A rare case.

We report a case of a 12-year-old girl who presented with the history of hirsutism. On evaluation, she was found to have testosterone secreting adrenal gland tumor. Histopathological examination of the adrenalectomy specimen revealed a lipoadenoma.

A positive magnetic resonance spectroscopic imaging with negative initial biopsy may predict future detection of prostate cancer

Current diagnostic modalities for early prostate cancer (PCa) lack sufficient sensitivity and specificity. Magnetic resonance spectroscopic imaging (MRSI) detects biochemical changes in tissues that may predate histological changes that can be diagnosed on a biopsy. Men with MRSI suggestive of malignancy but negative biopsy may thus be harboring cancer that manifests at a later date. We report the first case in our cohort of men with positive MRSI but negative initial biopsy who, 6 years after the initial MRSI, were detected to have PCa despite a “normal” prostate specific antigen (<4.0 ng/ml).

Management of recurrent anterior urethral strictures following buccal mucosal graft-urethroplasty: A single center experience.

Objective: To describe the safety, feasibility and outcome of redo buccal mucosal graft urethroplasty in patients presenting with recurrent anterior urethral stricture following previous failed BMG urethroplasty. Materials and Methods: This was a retrospective chart review of 21 patients with recurrent anterior urethral stricture after buccal mucosal graft urethroplasty, who underwent redo urethroplasty at our institute between January 2008 to January 2014. All patients underwent preoperative evaluation in the form of uroflowmetry, RGU, sonourethrogram and urethroscopy. Among patients with isolated bulbar urethral stricture, who had previously undergone ventral onlay, redo dorsal onlay BMG urethroplasty was done and vice versa (9+8 patients). Three patients, who had previously undergone Kulkarni-Barbagli urethroplasty, underwent dorsal free graft urethroplasty by ventral sagittal urethrotomy approach. One patient who had previously undergone urethroplasty by ASOPA technique underwent 2-stage Bracka repair. Catheter removal was done on 21st postoperative day. Follow-up consisted of uroflow, PVR and AUA-SS. Failure was defined as requirement of any post operative procedure. Results: Idiopathic urethral strictures constituted the predominant etiology. Eleven patients presented with stricture recurrence involving the entire grafted area, while the remaining 10 patients had fibrotic ring like strictures at the proximal/distal graft-urethral anastomotic sites. The success rate of redo surgery was 85.7% at a mean follow-up of 41.8 months (range: 1 yr-6 yrs). Among the 18 patients who required no intervention during the follow-up period, the graft survival was longer compared to their initial time to failure. Conclusion: Redo buccal mucosal graft urethroplasty is safe and feasible with good intermediate term outcomes.

Acute pancreatitis and development of pancreatic pseudo cyst after extra corporeal shock wave lithotripsy to a left renal calculus: A rare case with review of literature.

Extracorporeal shock wave lithotripsy (SWL) is considered the standard of care for the treatment of small upper ureteric and renal calculi. A few centers have extended its use to the treatment of bile duct calculi and pancreatic calculi. The complication rates with SWL are low, resulting in its wide spread acceptance and usage. However, some of the serious complications reported in 1% of patients include acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of aortic aneurysm and intracranial hemorrhage. To our knowledge, only six cases of acute pancreatitis or necrotizing pancreatitis following SWL have been documented in the literature. Herein, we report a rare case of acute pancreatitis and formation of a pseudo cyst following SWL for left renal pelvic calculus.

Dislodged Dormia Basket

This is the first reported case of a Dormia basket being dislodged outside the ureter into the retroperitoneum during intracorporeal lithotripsy.

Fetus in bladder

This is the first reported case of vesicouterine fistula presenting with a fully formed dead fetus in the urinary bladder.