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   Table of Contents - Current issue
January-March 2017
Volume 9 | Issue 1
Page Nos. 1-114

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Electrosurgery use in circumcision in children: Is it safe? p. 1
Tariq Ibrahim Altokhais
Circumcision is one of the most common procedures performed worldwide. Bleeding is one of the most common complications following male circumcision, and to decrease the risk of bleeding, electrosurgery may be utilized. However, the use of diathermy on the penis is controversial, and there are reported complications due to the use of electrosurgery for circumcision. The aim of this review is to evaluate the utilization and relative safety of monopolar and bipolar electrosurgery for circumcision in children.
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Posthysterectomy ureteric injuries: Presentation and outcome of management p. 4
SB Patil, Nilesh Guru, VS Kundargi, BS Patil, Nikhil Patil, Kshitiz Ranka
Purpose: The purpose of the study was to evaluate the presentation and management of posthysterectomy ureteral injuries. Patients and Methods: Fourteen patients with ureteric injuries after hysterectomy for benign diseases were evaluated. The diagnosis was done based on clinical presentation, intravenous urogram, computed tomography, cystoscopy, and retrograde pyelogram (RGP) depending on the clinical situation. Results: Sixteen iatrogenic ureteric injuries in 14 patients over a 2-year period were evaluated. Hysterectomy was the cause of injury in all the cases, 12 abdominal and 2 were vaginal. Two patients presented with anuria, one had ureteric, and bladder injury with hemoperitoneum underwent emergency laparotomy and bilateral ureteral reimplantation. Another patient underwent RGP followed by stenting on the right side, left side unable to put stent so percutaneous nephrostomy (PCN) was done followed by antegrade stenting later. Two patients presented with septicemia and pyonephrosis were managed initially with PCN followed by balloon dilatation and JJ stenting. RGP and retrograde stenting was done in seven of the remaining ten patients and ureteric reimplantation in three patients. Conclusion: Patient with ureteric injury should be evaluated and intervened at the earliest. Patients presenting early, within 2 weeks after hysterectomy have higher chances of success with endourological procedures, obviating the need for open surgery.
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A study of transobturator tape in stress urinary incontinence p. 9
Rahul Vishwanath Mayekar, Archana Anilkumar Bhosale, Khushboo Vikram Kandhari, Yogeshwar Sadashiv Nandanwar, Sadaf Sadique Shaikh
Background: Stress urinary incontinence (SUI) is commonly encountered in gynecological practice. Nowadays, midurethral sling surgeries in the form of transobturator tape (TOT) surgery are recommended in its treatment. Aims and Objectives: To assess the outcome and patient satisfaction of TOT surgery in the treatment of SUI. Materials and Methods: A prospective study was undertaken for patients of SUI who underwent TOT surgery by the outside in method and followed up for 5 years. The patients were assessed clinically and by the Patient Global Impression of Improvement (PGI-I) preoperatively and at postoperative day 3, discharge and 3 months follow-up. Results: Successful surgical treatment with TOT was seen in all patients at the time of discharge. There was no recurrence of SUI seen up to 1 year, but at 5-year follow-up two patients had a recurrence of SUI on examination though they did not complain of SUI. Urinary retention, tape extrusion, and groin stitch infection were the commonly seen complications following surgery. On subjective assessment, 61 patients were completely satisfied at day 3, and all patients were completely satisfied at discharge and 3 months follow-up as per the PGI-I score. Conclusion: TOT gives an excellent outcome in the treatment of SUI.
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A prospective randomized comparative trial between open subinguinal and loupe assisted subinguinal varicocelectome: A single center experience p. 13
Hari Gopal Vyas, Vimal Bhandari, Anup Kumar, Biswajit Nanda, Harbinder Singh, Subroto Bhowmick
Introduction: In our study, we reviewed efficacy and complication rates of open subinguinal varicocelectomy (OSV) and loupe assisted subinguinal varicocelectomy (LASV) using seminal and hormonal parameters in a prospective randomized study. Materials and Methods: We prospectively studied 60 males with Grade 2 and Grade 3 varicocele. Thirty patients underwent OSV and the other 30 patients underwent LASV. Intra-operative and post-operative complications along with pre-operative and post-operative seminal, hormonal parameters and testicular volume were compared between the groups. Results: Sperm count, motility and morphology increased significantly in both groups, but the improvement was significantly better in LASV group. (Group A – improvement in sperm count, motility and morphology by 25%, 8.5%, 10.3%, respectively and in Group B – improvement in sperm count, motility and morphology by 110%, 68.59%, 71.1%, respectively. Decrease in serum follicular stimulating hormone (FSH), luteinizing hormone (LH) and increase in serum testosterone were significant in both groups, but the improvement was significantly better in LASV group. (Group A – serum FSH and LH decreased by 17.2%, 23%, respectively and serum testosterone increased by 13.7% and in Group B – serum FSH and LH decreased by 56.9%, 56.65%, respectively and serum testosterone increased by 95.9%). The recurrence (OSV = 13.2% and LASV = 0, P = 0.01) and complication rates were significantly lower in LASV group. Conclusion: Our study shows that LASV is significantly better than OSV regarding efficacy and complication rates.
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Direct visual internal urethrotomy: Is it a durable treatment option? p. 18
Dilip Kumar Pal, Sanjay Kumar, Bastab Ghosh
Objective: To evaluate the long-term success rate of direct vision internal urethrotomy as a treatment for anterior urethral strictures. Materials and Methods: We retrospectively analyzed the results for patients who underwent internal urethrotomy from January 2009 to January 2014 for anterior urethral strictures. Patients were followed till January 2016. Patients with complicated urethral strictures with a history of previous urethroplasty, hypospadias repair, or previous radiation were excluded from the study, as anticipated low success rate of direct visual internal urethrotomy (DVIU) in these patients. The Kaplan–Meier method was used to analyze stricture-free probability after the first, second, and third urethrotomy. Results: A total of 186 patients were included in this study. Stricture-free rates after first, second, and third urethrotomy were 29.66%, 22.64%, and 13.33%, respectively. Conclusions: Although DVIU may be a management option for anterior urethral stricture disease, it seems that long-term results are disappointing.
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Outcome of percutaneous nephrolithotomy in anomalous kidney: Is it different? p. 23
Gaurav Prakash, Rahul Janak Sinha, Ankur Jhanwar, Ankur Bansal, Vishwajeet Singh
Introduction: Various anomalous kidneys such as horseshoe kidney, crossed ectopic kidney, simple ectopic kidney, pelvic ectopic kidney, kidney with duplex system, and malrotated kidney are frequently associated with stone disease. Percutaneous nephrolithotomy (PCNL) is a challenging procedure in these patients because of abnormal orientation of kidney. Patients and Methods: Since 2005–2015, 86 patients underwent PCNL for stone removal in anomalous kidneys. Stone characteristics, type of calyceal puncture, number of punctures, need of relook procedures, mean hemoglobin drop, blood transfusion, mean operative time complications, mean hospital stay, stone free rate, and auxiliary procedure were analyzed. Results: Totally 91 sessions of PCNL was done in 86 patients including five of horseshoe kidney who had bilateral stone disease. Mean age, duration of symptoms, stone size, and hospital stay was 29.6 ± 12.6 years, 2.18 ± 1.41 years, 4.40 ± 1.16, and 4.17 ± 2.11 days, respectively. Sixteen patients underwent relook procedure, out of which only 6 could have complete stone clearance. Conclusion: PCNL in anomalous kidney is a safe and feasible procedure similar to normally located kidney, but requires careful preoperative planning and intra- and post-operative vigilance.
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Feasibility of laparoscopic partial nephrectomy in the obese patient and assessment of predictors of perioperative outcomes p. 27
Evan Jonathan Wiens, Deepak Kumar Pruthi, Ruchi Chhibba, Thomas Brian McGregor
Introduction: Partial nephrectomy is the gold standard for treatment of small renal masses. Our study compares outcomes for obese (body mass index [BMI] ≥30) and healthy (BMI <30) patients undergoing laparoscopic partial nephrectomy (LPN) with the intention of defining preoperative risk factors for complications and renal insufficiency in the obese. Materials and Methods: We conducted a retrospective review of 187 consecutive patients who underwent LPN. We examined the association between BMI and postoperative complication, estimated blood loss (EBL), hospital length of stay, warm ischemic time (WIT), and postoperative renal function. We did similar analyses using the RENAL nephrometry score and the comorbidity status of the patients. Results: We found no statistically significant increase in complications in obese (BMI ≥30) individuals relative to healthy (BMI <30) patients. The obese experienced approximately 100 cc more EBL (P = 0.0111). Patients experienced more complications if they had a Charlson comorbidity score ≥3 (P = 0.0065), an American Association of Anesthesiologists score ≥3 (P = 0.0042), or a history of diabetes mellitus (P = 0.0196). There was no association between RENAL nephrometry score and complication. However, patients with a score ≥8 experienced higher WIT (P = 0.0022), a greater decline in estimated glomerular filtration rate postoperatively (P = 0.0488), and an increased risk of developing chronic kidney disease ≥3 (P = 0.0065). Conclusions: Obese patients undergoing LPN are not at significantly increased risk of complication relative to nonobese patients. Comorbidity status and RENAL nephrometry score, independent of BMI, should be the main considerations of a patient's suitability for LPN.
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Urological disorders and pregnancy: An overall experience p. 32
Debasmita Mandal, Mriganka Mouli Saha, Dillip Kumar Pal
Aim: Pregnancy is an anatomical and physiological altered state and the presence of various urological problems not only aggravates the disease itself, but also results in unfavourable pregnancy outcome. Aim is to highlight obstetric outcome in pregnant women with urological problems. Materials and Methods: Longitudinal prospective cohort study conducted in tertiary care hospital, IPGME and R, Kolkata from Jan 2011 to Dec 2012. All pregnant women with urological problems were included as subjects. Results: A total of 33 subjects were followed up throughout their antenatal period. Among them majority (72.72%) presented with hydro nephrosis followed by hydroureter (60.6%), PUJ obstruction and pyelonephritis each with incidence of 15.15%, then urolithiasis (12.12%), nephrolithiasis (6.06%) and renal abscess (12.12%). Interventions required were DJ stenting (72.72%), pyeloplasty (15.15%) and others were RURSL, abscess drainage and ATT. The pregnancy outcome was complicated with preterm labor in majority of patients (45.45%), oligohydramnious (18.18%), PIH (9.09%) and still birth (6.06%). Twenty four live birth were there. Majority required NICU admissions as predominantly prematurity was an important concern. Majority women with hydronephrosis underwent DJ stenting. Conclusion: Preterm labor is an important obstetric concern. Vaginal delivery is the choicest mode of termination and LSCS can be reserved for obstetric reason. DJ stenting is safe and practical approach for continuation of pregnancy with hydronephrosis. Regular follow up, vigilant antenatal care and multidisciplinary approach from urologist, obstetrician and neonatologist will bring out successful pregnancy outcome.
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Intraprostatic ozone therapy: A minimally invasive approach in benign prostatic hyperplasia p. 37
Shabbir Hussain, Deepti B Sharma, Fanindra S Solanki, Ajay Pathak, Dhananjay Sharma
Introduction: Transurethral resection of prostate (TURP) remains the golden standard therapy since decades. There are various minimally invasive therapies (MITs) for the treatment of benign prostatic hyperplasia (BPH). Still, there is a need for therapy with lesser side effects and better outcome. We had studied the effect of intraprostatic ozone injection (IPOI) as an MIT for patients with BPH who have failed trial without catheter (TWOC). Materials and Methods: Thirty elderly patients with BPH with a prostate size of 30 g or more were enrolled for the study. Forty milliliters of ozone at a concentration of 30 μg/dl was injected in prostate (20 ml in each lateral lobe) per rectally. Prostate volume (PV) by ultrasonography was assessed after catheter removal on the 7th day and after 1 month. Observations and Results: Totally thirty patients (mean age - 67.8 years) with mean prostatic volume (MPV) of 46.10cc received IPOI. MPV came as 44.96cc on the 7th day of postozone therapy (P = 0.008). Successful voiders showed a significant reduction in PV (mean = 13.12cc) as compared to unsuccessful voiders (mean = 2.61cc) after 1 month. Conclusion: Intraprostatic ozone injection helps to reduce the PV to some extent and can be helpful in patients who have failed TWOC even on alpha blockers and are unfit for TURP. Larger studies are required to assess the efficacy and long-term results of this technique.
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Spontaneous forniceal rupture: Can it be treated conservatively? p. 41
Ahmed Gaber Al-mujalhem, Mohammed Sayed Ahmed Aziz, Mohammed Farag Sultan, Ahmed Mohammed Al-maghraby, Mohammed Abdelmonem Al-shazly
Context: Spontaneous forniceal rupture is one of the possible complications of urolithiasis. The mechanism of forniceal rupture is not well explained in the literature. Most of the cases presented with sudden onset of acute renal colic and diagnosed by noncontrast CT (NCCT). Until now there is no solid consensus about the ideal management of such a condition. Aim: To study indications and validity of conservative management of spontaneous caliceal rupture. Settings and Design: This is an observational prospective study. Materials and Methods: All cases diagnosed as spontaneous forniceal rupture in our departments from 2011 to 2015 were enrolled. All cases were diagnosed with NCCT or CT-Urography.. Non complicated patients were primarily managed conservatively. Intervention (DJ stent insertion, nephrostomy tube insertion, or urgent ureteroscopy) was reserved to complicated cases or solitary kidney. Drainage of urinoma was done in cases with sizable urinoma (more than 100 ml3). Results: A total of 40 patients: Twenty eight (70%) patients had normal serum creatinine level at presentation, while 12 (30%) patients had elevated serum creatinine. Twenty three (57.5%) patients were successfully managed conservatively, their mean size of stone was 6.2 ± 2 mm and the hospital stay was 3.1 ± 1.9 days. Eighteen patients (42.5%) underwent interventions. Their stone size was 4.5 ± 2.1 mm and the hospital stay for the interventional group was 4.2 ± 1.8 days. Statistical Analysis Used: Mann-Whitney test was used for testing difference between means because the data groups are not parametric. Otherwise, simple descriptive statestics were used. Conclusion: Spontaneous forniceal rupture is more likely to occur with smaller distal ureteric stones. Conservative management is a valid option in non-complicated cases. Intervention should be reserved to complicated cases or cases with sizable urinoma.
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Outcomes of transurethral resection and holmium laser enucleation in more than 60 g of prostate: A prospective randomized study p. 45
Ankur Jhanwar, Rahul J Sinha, Ankur Bansal, Gaurav Prakash, Kawaljit Singh, Vishwajeet Singh
Aim: Transurethral resection of prostate (TURP) is considered a gold standard surgical procedure. The management of benign prostatic hyperplasia (BPH) has undergone tremendous change in recent years and shifted from open to minimal invasive procedure. With the advancement in technology and skills of surgeons, lasers have been used more liberally, particularly holmium laser. Holmium laser enucleation of prostate (HoLEP) is seen as close rival of TURP. The objective if this study is to observe long- and short-term outcomes of transurethral resection and holmium laser enucleation in the prostate of more than 60 g. Materials and Methods: This prospective randomized study includes 164 patients. Inclusion criteria were age <75 years after failed or poor response to medical therapy, prostatic size >60 g, gross hematuria secondary to BPH, recurrent urinary tract infection, acute urinary retention, postvoid residual >150 ml, and Schafer Grade II or more. BPH associated with neurogenic bladder, stricture urethra, and carcinoma prostate were excluded from the study. Group 1 comprises patients who underwent TURP and Group 2 comprises who underwent HoLEP. Follow-up was done at 1, 3, 6, 12, and 24 months after the surgery. Results: Data of 144 patients were analyzed. The mean age of patients in TURP and HoLEP group was 66.78 ± 7.81 and 67.70 ± 7.44 years, respectively (P = 0.47), mean prostatic volume was 74.5 ± 12.56 and 75.6 ± 12.84 g, respectively (P = 0.60), operative time was 73.10 ± 10.49 and 89.56 ± 13.81 min, respectively (P = 0.0001). Mean resected tissue was 44.80 ± 9.87 and 48.49 ± 10.87, respectively (P = 0.03). The sexual function did not changed significantly in postoperative follow-up. Conclusion: HoLEP is associated with less blood loss, lower transfusion rates, and a shorter hospital stay. The disadvantage of HoLEP is longer operative time and postoperative dysuria.
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Can we predict the need for intervention in steinstrasse following shock wave lithotripsy? p. 51
Chandan Phukan, TJ Nirmal, Cornerstone V Wann, J Chandrasingh, Santosh Kumar, Nitin S Kekre, Antony Devasia
Introduction: Steinstrasse (SS) is a known complication of shock wave lithotripsy (SWL). Although the majority of SS clears spontaneously, about 6% require intervention. This study was carried out to identify the factors that determine the need for intervention in SS. Materials and Methods: This was a retrospective study of all patients who developed steinstrasse following SWL at our center. They were divided into two groups: a) Those cleared spontaneously and b) Those required intervention. The two groups were compared with regard to demographic profile, stone factors and factors related to steinstrasse. Results: Out of 2436 cases of SWL, 89 (3%) formed steinstrasse. The majority of the patients (35%) who required intervention had stone sizes of 10-14 mm. Coptcoat type III steinstrasse required significantly more interventions for clearance (P = 0.001). The site and the size of the SS was not a predictor of intervention for SS. Conclusions: Early intervention is warranted in patients with steinstrasse where the lead fragment is >5 mm (Coptcoat type III).
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Predictors of radiation exposure to providers during percutaneous nephrolithotomy p. 55
David L Wenzler, Joel E Abbott, Jeannie J Su, William Shi, Richard Slater, Daniel Miller, Michelle J Siemens, Roger L Sur
Background: Limited studies have reported on radiation risks of increased ionizing radiation exposure to medical personnel in the urologic community. Fluoroscopy is readily used in many urologic surgical procedures. The aim of this study was to determine radiation exposure to all operating room personnel during percutaneous nephrolithotomy (PNL), commonly performed for large renal or complex stones. Materials and Methods: We prospectively collected personnel exposure data for all PNL cases at two academic institutions. This was collected using the Instadose™ dosimeter and reported both continuously and categorically as high and low dose using a 10 mrem dose threshold, the approximate amount of radiation received from one single chest X-ray. Predictors of increased radiation exposure were determined using multivariate analysis. Results: A total of 91 PNL cases in 66 patients were reviewed. Median surgery duration and fluoroscopy time were 142 (38–368) min and 263 (19–1809) sec, respectively. Median attending urologist, urology resident, anesthesia, and nurse radiation exposure per case was 4 (0–111), 4 (0–21), 0 (0–5), and 0 (0–5) mrem, respectively. On univariate analysis, stone area, partial or staghorn calculi, surgery duration, and fluoroscopy time were associated with high attending urologist and resident radiation exposure. Preexisting access that was utilized was negatively associated with resident radiation exposure. However, on multivariate analysis, only fluoroscopy duration remained significant for attending urologist radiation exposure. Conclusion: Increased stone burden, partial or staghorn calculi, surgery and fluoroscopy duration, and absence of preexisting access were associated with high provider radiation exposure. Radiation safety awareness is essential to minimize exposure and to protect the patient and all providers from potential radiation injury.
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Role of calculated glomerular filtration rate using percutaneous nephrostomy creatinine clearance in the era of radionuclide scintigraphy p. 61
Sunil Raghunath Patil, Prakash Wamanrao Pawar, Abhishek Jaysukhbhai Savalia, Shankar Tanaji Mundhe, Sayalee Suryabhan Narwade, Ashwin Sunil Tamhankar
Context: Gates method tends to over-estimate glomerular filtration rate (GFR) in borderline functioning kidneys. We study the role of calculated GFR in these cases in decision-making regarding performing kidney-sparing surgery or nephrectomy. Aims: The aim of this study is to find the correlation between GFR calculated by percutaneous nephrostomy (PCN) urine creatinine clearance in obstructed kidneys and GFR by radionuclide scintigraphy. It also studies the role of this calculated GFR in borderline functioning kidneys. Settings and Design: Single tertiary care center; retrospective. Materials and Methods: A total of 46 patients in whom PCN was inserted as an emergency measure in an obstructed kidney and for whom diethylene-triamine-penta-acetic acid/ethylene-di-cysteine (DTPA/EC) scan was also done (Gates method) were analyzed retrospectively. PCN creatinine clearance was calculated for 3 consecutive days, and the mean value was used. Statistical Analysis Used: Pearson's correlational analysis; Chi-square test. Results: Overall strong correlation was found between the two GFR values (Pearson's r = 0.540692, P < 0.001). Totally 26 patients (56.52%) had comparable GFR values (P > 0.05). Among the 36 patients with borderline functioning kidneys, DTPA/EC scan significantly over-estimated GFR in one-third of the patients. The management plan was changed in 7 out of those patients (46.67%), with nephrectomy performed in all instead of kidney-sparing procedure. When the highest value of calculated GFR was compared, 28 patients had comparable GFRs (60.87%). Conclusions: GFR based on radionuclide scintigraphy may be insufficient for evaluation of residual renal function to determine the management of obstructed kidney with borderline function. For adequate decision-making, other factors including creatinine clearance via PCN should also be considered. Gates method tends to overestimate GFR as compared to calculated creatinine clearance at low GFR levels.
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Bladder explosion during transurethral resection of prostate: Bladder diverticula as an additional risk factor p. 68
D Paul Vincent
Vesical explosion during transurethral resection of the prostate (TURP) is a very rare occurrence. Very few cases have been reported in the literature. The literature was reviewed pertaining to the etiology of bladder explosion during transurethral resection. The underlying mechanism for intravesical explosion is the generation and trapping of explosive gasses under the dome of the bladder which eventually detonates when it comes into contact with the cautery electrode during TURP. Various techniques have been suggested to prevent this dreaded complication. A 75-year-old male with chronic retention of urine underwent TURP. There was Grade 2 trilobar enlargement of the prostate. There were multiple diverticula with one large diverticulum in the dome of the bladder. During hemostasis, there was a loud pop sound and the bladder exploded. Lower midline laparotomy was performed and the intraperitoneal bladder rupture was repaired. He had an uneventful postoperative recovery, and he is asymptomatic at 6 months of follow-up. Even though all the precautions were taken to avoid this complication, bladder rupture was encountered. The presence of multiple diverticula is being suggested as an additional risk factor for this complication as the bladder is thinned out and also possibly due to trapping of air bubble within the diverticulum. In such cases where there are multiple bladder diverticula, the employment of a suprapubic trocar for continuous drainage of the air bubble, could well be a practical consideration.
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Adrenal myelolipoma with osseous metaplasia and hypercortisolism p. 71
Ujwal Kumar, Shivam Priyadarshi, Vinay Tomar, Rishi Raj Vohra
Adrenal myelolipomas are rare adrenal tumors generally diagnosed incidentally. A 42-year-old female reported to us with complaints of left flank pain attributable to her left ureteric calculi. On evaluation, a large adrenal mass was diagnosed along with hypercortisolism. After adrenalectomy, the histopathology revealed adrenal myelolipoma along with osseous metaplasia not reported in English literature, to the best of our knowledge till date.
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Penile strangulation by iron metal ring: A novel and effective method of management p. 74
Somorendro Paonam, Nillachandra Kshetrimayum, Indrajit Rana
Penile strangulation by metal ring is a rare urological emergency situation which requires urgent decompression of the penis to avoid adverse effect. It is usually associated with an attempt to improve sexual act and/or to prolong erection. But sometimes, cutting of the ring to decompress the penis safely is a very difficult task particularly when the strangulating object is a hard metal object as in our case. Here, we present a case which was managed by cutting in a novel way with the help of dental micromotor with wheel shape bur.
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Seminoma of undescended testis with urinary bladder metastasis: A case report with review of literature p. 77
Syed Althaf, Kiran Shankar, Vishnu Kurpad, MN Suma
Cryptorchidism is the most common predisposing factor in the development of testicular germ cell tumors. Seminoma is the most common malignancy developing in a cryptorchid testis, usually has lymphatic but rarely hematogenous metastasis. The Urinary Bladder is an extremely rare site of metastasis of seminoma metastasis. A 29-year-old male patient presented to us with a history of infertility and an intra-abdominal mass. He was investigated and treated and was found to have an intra-abdominal seminoma with synchronous urinary bladder metastasis. He was treated with appropriate chemotherapy and continues to be in good health.
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Renal cell carcinoma: Atypical metastasis to inguinal lymph nodes p. 80
Qamar Saeed Chaudhry, Tanweer Ahmed Naveed Bhatty, Ziauddin Khan, Elsawi Medani Osman
Renal cell carcinoma (RCC) is a common tumor of the urinary tract. It is known to have variable presentations due to the extremely vascular nature of the organ. RCC are known to metastasize to lungs, bone, and brain commonly but atypical metastasis to various sites are reported in literature but as very rare pathology. We report a case of a 60-year-old female who presented with multiple inguinal and axillary lymph node enlargements which on excision biopsy showed metastatic RCC. RCC can present with synchronous metastatic deposits in the various organs. RCC can metastasize to some atypical sites as well such as thyroid, orbit, and neck as mentioned earlier in literature. The patient presenting with extra-regional lymph nodes like inguinal and axillary is extremely rare, and so far only one clinical case could be found from India in 2008. A 61-year-old female presented in the emergency department with left flank pain and hematuria. Imaging showed left swollen kidney but multiple lymph nodes in retroperitoneum, left inguinal and axillary region. Excisional biopsy confirmed metastatic renal clear cell carcinoma. The case was referred to an oncologist after left radical nephrectomy for further treatment. Renal cancer is quite common aggressive disease. Due to its vascular nature, it may present quite atypically as evident from literature. Although treatment of metastatic carcinoma is still controversial surgery is the mainstay of treatment and guidelines consider metastasectomy and cytoreductive nephrectomy as valid option followed by targeted systemic therapies. RCC has quite a high potential to metastasize in the versatile pattern, in our case, it is evident that valid management is still surgery but needs support from the multidisciplinary team.
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Endogenous endophthalmitis as a septic complication postureteroscope candiduria p. 83
Fam Xeng Inn, Umi Kalthum Md. Noh, Mohd Hafidzul Jasman
Ureteroscopy (URS) is commonly used by urologists to treat ureteral stones. It is a relatively low-risk procedure. Both urinary tract obstruction and contamination of instrument can cause candiduria post-URS, and this infection can be treated with an antifungal medication. Candidemia is known as hematogenous dissemination, and ocular tissue is a common invasion. However, endogenous endophthalmitis, due to postureteroscope candiduria, has not been reported up to date. This is a devastating complication that may lead to visual loss. Here, we describe a case of endogenous endophthalmitis as a consequence of candiduria after URS.
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Prostatic intraepithelial neoplasia-like ductal prostatic adenocarcinoma: A case suitable for active surveillance? Highly accessed article p. 86
Soroush Rais-Bahrami, Melissa R Dillard, Grace G Zhu, Jennifer B Gordetsky
In contrast to typical prostatic ductal adenocarcinoma, prostatic intraepithelial neoplasia (PIN)-like ductal adenocarcinoma is a rare variant of prostate cancer with low-grade clinical behavior. We report a case of a 66-year-old African-American male with an elevated serum prostate-specific antigen who underwent multiparametric prostate magnetic resonance imaging (MRI) and MRI/ultrasound fusion-guided biopsies. Pathology demonstrated low-volume Gleason score 3 + 3 = 6 (Grade Group 1), acinar adenocarcinoma involving one core and PIN-like ductal adenocarcinoma on a separate core. Herein, we discuss the potential role of active surveillance for patients with this rare variant of prostate cancer found in the era of advanced imaging with multiparametric MRI for prostate cancer.
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Epididymal metastasis from prostate adenocarcinoma: An unusual and challenging diagnosis suspected in gallium-68 prostate-specific membrane antigen-positron emission tomography/computed tomography and histologically confirmed p. 89
Sofia Santos-Lopes, João Lobo, Rui Henrique, Jorge Oliveira
A few cases of prostate adenocarcinoma (PCa) metastases to the epididymis have been documented in literature. We report a case of a 69-year-old man with a left epididymal metastasis, 6 years after radical prostatectomy and adjuvant radiation therapy for PCa. Although he developed biochemical recurrence, only gallium-68 prostate-specific membrane antigen-positron emission tomography/computed tomography revealed high uptake in the left testis and retrovesical space. An unrecognized painless firm nodule was palpable on the left epididymis. Radical orchiectomy was performed, and histopathological examination confirmed PCa metastasis located in the epididymis. To the best of our knowledge, this is the 27th reported case of epididymal metastasis from PCa.
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Isolated urachal malakoplakia mimicking malignancy p. 92
Saisriharsha Pakalapati, Sanjay Parachuri, Venkateshwara Rao Kakarla, Mahesh Babu Byrappa
Malakoplakia is an unusual inflammatory disease with uncertain pathogenesis affecting any organ in the body, but predominantly genitourinary tract, with specific predilection to the bladder. We report a rare case of isolated malakoplakia of the urachus in a 29-year-old male patient who presented with lower urinary tract symptoms without any hematuria. Investigations revealed sterile pyuria with no bacterial growth in urine. Radiological investigations revealed a mass in the urachal region. The patient underwent cystoscopy with biopsy followed by pelvic lymph node dissection and partial cystectomy with excision of the urachal mass. Histopathological examination of the mass revealed malakoplakia. Postoperative course was uneventful. To the best of our knowledge, this is the first ever case report of isolated urachal malakoplakia without any concomitant malignancy or bladder involvement reported in our country and one of the very few reported worldwide.
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Isolated bone marrow metastasis of testicular tumor: A rare cause of thrombocytopenia p. 96
Uma Kumar, Prashant Ramteke, Prasenjit Das, Ajay Gogia, Pranay Tanwar
Isolated bone marrow metastasis of testicular tumor is very rare. Here, we report this case of a 21-year-old male who was admitted to our hospital with generalized body pain, which was severe and weakness for one month. He had a history of an operative intervention for the left testicular mass about 6 months ago which was diagnosed as mixed germ cell tumor on histopathological examination. The blood investigations showed anemia, low platelets, and elevated tumor markers. Bone marrow aspiration and biopsy examination showed metastatic deposits of mixed germ cell tumor. There were no foci of disease in any other part of the body. The patient was given chemotherapy, i.e. cisplatin, etoposide, and bleomycin. After completion of chemotherapy, there was drastic improvement in pain and weakness. A repeat examination of bone marrow done after 3 month was free of tumor.
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Non-transitional cell carcinoma of the upper urinary tract:A case series among 305 cases at a tertiary urology institute p. 99
Mohamed Mohamed Elawdy, Diaa-Eldin Taha, Yasser Osman, Mohamed Abd El-Hamid, Mohsen El-Mekresh
Non-transitional cell carcinomas (non-TCC) of the upper urinary tract as squamous cell carcinoma (SCC), adenocarcinoma, and small cell carcinoma (SmCC) are rare with few case reports in the literature. We retrospectively reviewed our patients who surgically treated for upper tract urothelial carcinoma from 1983 to 2013 for non-TCC pathological cancer characteristics and survival. Among 305 patients, only 5 (1.6%) cases were found: One case of SmCC, another had adenocarcinoma, and 3 SCC cases. None of them had intravesical recurrence and the cancer-specific survival for non-TCC cohort is markedly decreased (log-rank = 0.01) compared to TCC patients.
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Ureteric erosion and obstruction: A rare but dreaded complication of intrauterine contraceptive device p. 103
Vinod Priyadarshi, Nidhi Sehgal, Dipanwita Sen
Though intrauterine contraceptive device (IUCD) is a safe and most frequently used long-term contraceptive method, it has some complications. Uterine perforation and intra-abdominal migration have been reported often, but a retroperitoneal migration is exceptional. Here, we are reporting an IUCD which perforated the uterus and migrated to the retroperitoneum; impinging into and obstructing left ureter causing severe hydroureteronephrosis due to the development of the left lower ureteric stricture.
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Ex-vivo partial nephrectomy after living donor nephrectomy: Surgical technique for expanding kidney donor pool p. 107
Yaw A Nyame, Paurush Babbar, Ahmed A Aboumohamed, Ryan L Mori, Stuart M Flechner, Charles S Modlin
Renal transplantation has profound improvements in mortality, morbidity, and overall quality of life compared to renal replacement therapy. This report aims to illustrate the use of ex-vivo partial nephrectomy in a patient with a renal angiomyolipoma prior to living donor transplantation. The surgical outcomes of the donor nephrectomy and recipient transplantation are reported with 2 years of follow-up. Both the donor and recipient are healthy and without any significant comorbidities. In conclusion, urologic techniques such as partial nephrectomy can be used to expand the living donor pool in carefully selected and well informed transplant recipients. Our experience demonstrated a safe and positive outcome for both the recipient and donor, and is consistent with other reported outcomes in the literature.
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Hydrocele with a surprise: Malignant mesothelioma of the tunica vaginalis - Case report and review of literature p. 110
Pankaj N Maheshwari, Olajide O Abiola, Vinayak G Wagaskar, Ajay T Oswal
Hydrocele is a very common condition that is simple to evaluate and treat. Management of hydrocele is usually delegated to the junior members of the surgical team. Sometimes this simple condition can spring huge surprises. A 20-year-old man presented with acute onset large, painless fluctuant left hemi-scrotal swelling. Scrotal ultrasonography showed thickened tunica vaginalis. A diagnosis of left hydrocele was made and repair by excision of sac was planned. During the procedure, the sac was found studded with red nodular growths; histopathology reported malignant mesothelioma of tunica vaginalis. Metastatic evaluation showed extensive retroperitoneal lymph nodal involvement. Despite receiving adjuvant chemotherapy with radiotherapy patient died due to extensive metastasis within 16 months. This case is presented for rarity of diagnosis, young age of presentation, absence of etiological factor and rapidly progressive clinical course.
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Beckwith–Wiedemann syndrome and recurrent bilateral renal calculi p. 113
Wisit Cheungpasitporn, Stephen B Erickson
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