Penile strangulation is a challenging clinical situation and usually requires prompt treatment. Penile strangulation by a nonmetallic or thin metallic ring is easily overcome by severing/cutting the object; however, a heavy and long metal ring causing penile strangulation is not only difficult to sever but also it may worsen the scenario if removal is tried with inappropriate method. Here, we report four cases of penile strangulation by different objects which were successfully removed by aspiration and string method. We found that instead of using heavy cutting instruments and other surgical methods, string and aspiration technique is much better.
Chromosomal instability and aberrations are known in many cancers including renal cell carcinoma. Detailed understanding of these changes has led to an improved drug discovery and continued developments in other therapeutic options. Chromosomal aberrations have a potential to be used to monitor disease including prognostication. There has been a growing experience in cytogenetic techniques and gap between clinic and laboratory has narrowed significantly in the recent past. Nevertheless, more work on validation of these techniques, establishing threshold and interobserver agreement needs to be carried out for these diagnostic/prognostic tests before utilizing them in clinics as a part of “personalized medicine” care. The review presented here is a summary of common genetic disorders in renal cancer and some of acquired genetic changes which can be used as biomarkers. The review also describes basics of commonly used genetic techniques for wider clinical community involved in the management of renal cancer.
Introduction: This study is conducted to evaluate the long-term outcomes, including effectiveness and complications, of artificial urinary sphincter (AUS) implantation in men with primarily stress urinary incontinence.
Materials and Methods: Consecutive patients with complete data sets and a continuous follow-up with the device in place for 5 years or more were included. We analyzed effectiveness through pads per day use, and complications were assessed based on device revisions and explantations. Various risk factors for revisions were evaluated and revision free-survival at 15 years was estimated.
Results: Thirty-four male patients were implanted and followed for a mean of 116.5 months (range: 60–285). Mean pads per day use was significantly decreased from 3.6 at baseline to 0.6 at 1 year, 1.1 at 5 years, and 1.06 at last visit (P < 0.0001). During follow-up, 12 patients (35%) required between 1 and 3 device revisions and 1 (3%) required 5. The device revision-free survival was 76% (confidence interval [CI] 58%–87%) at 5 years and 56% (CI 32%–75%) at 15 years. A higher mean number of dilations or incisions for bladder neck contractures was a statistically significant risk factor for revisions in univariate analysis (odds ratio 1.8; 95% CI 1.02–3.2). No other significant risk factors for revisions were found. Explantations were performed in four patients for device erosion at 60, 69, 153, and 200 months.
Conclusions: The AUS provides excellent long-term outcomes with continued improvement in continence rates and <50% of patients requiring revisions at 15 years. The previous history of bladder neck contractures and dilations may predispose to an increased rate of revisions.
Aims: Female patients often seek physical therapy (PT) for chronic low back pain (CLBP). This study aimed to evaluate the prevalence of pelvic floor disorder (PFD) and the association between PFD and neuropathic pain (NP) in a population of women referred to PT for CLBP, as these parameters are rarely investigated in this context.
Materials and Methods: This cross-sectional survey study included women aged 30–60 years who were referred to PT for CLBP. In addition to demographic and clinical information, the patients completed structured assessment questionnaires such as the validated Pelvic Floor Distress Inventory (PFDI-20), which was used to determine the prevalence of PFD, and the self-completed Leeds Assessment of Neuropathic Symptoms and Signs to differentiate nociceptive pain from NP.
Results: Among the 225 women included in the study, the mean body mass index was 31.6 ± 4.7 and the mean age was 46.7 ± 7.7 years (~79% were older than 40 years). The majority were not employed (i.e., homemakers), currently married, and sexually active. In addition, almost all had children (approximately 69% were grand multiparous), the majority of whom had been delivered through spontaneous vaginal delivery. Approximately 33% of women were postmenopausal and only 3% used hormone replacement therapy. Slightly more than half suffered from NP and approximately 43% experienced at least one PFD. Notably, patients with NP had significantly higher PFDI-20 overall and subscale scores, compared to those without NP.
Conclusions: Although PFD and NP are not routinely assessed in PT practice, both conditions are prevalent among and may interact in women with CLBP.
Introduction: Transurethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP), both are considered standard endosurgical treatment of benign prostatic hyperplasia (BPH). Many studies have evaluated changes in sexual function following treatment of BPH. However, data are sparse on comparative study between the two standard options of the treatment of BPH.
Aim: The aim of this study was to compare changes in sexual function following HoLEP versus TURP using the International Index of Erectile Function-15 (IIEF-15) questionnaire.
Materials and Methods: A prospective study carried out for 4 years from May 2013 to April 2017. All patients with bothersome lower urinary tract symptoms due to BPH, who got admitted to the hospital for surgical management, were enrolled for the study and they underwent either HoLEP or TURP. Postoperatively, they were followed for 6 months at 1-, 3-, and 6-month interval.
Main Outcome Measures: Statistical testing was conducted with the Statistical Package for the Social Science system version 17.0. Continuous variables are presented as mean ± standard deviation, and categorical variables are presented as absolute numbers and percentage. The comparison of normally distributed continuous variables between the groups was performed using Student's t- test. For within the groups, paired t-test was used at 1 month, 3 months, and 6 months from the baseline.
Results: All the five domains of sexual function based on the IIEF-15 questionnaire remained significantly low at 6-month postsurgery in both the groups.
Conclusions: By comparing the changes in sexual function between HoLEP and TURP group at the end of our study (6 months), we found no difference between the groups with regard to erectile function or overall sexual function as assessed by total IIEF-15 score.
Purpose: This study aims to compare the various distraction methods used during office cystoscopy to decrease pain and dissatisfaction among patients.
Materials and Methods: Two hundred patients undergoing rigid cystoscopy between January 2017 and July 2017 were randomized into four groups of 50 patients: (1) Group I: Patients who listened to music during the cystoscopy, (2) Group II: Patients allowed real-time visualization of the cystoscopy, (3) Group III: Patients who listened to music and had real-time visualization of the procedure, (4) Group IV: Control group undergoing cystoscopy without any distraction used. A visual analog scale (VAS) (1–10) was used for a self-assessment of pain, satisfaction, and willingness for repeat cystoscopy.
Results: Demographic characteristics, mean age, procedure duration, and procedure indications were statistically similar between the four groups. The mean VAS pain score were significantly lower in the three study Groups (I, II, and III) where distraction methods were used during cystoscopies as compared to the control Group IV (P < 0.001) and the satisfaction VAS scores and VAS scores for willingness to undergo a repeat procedure were significantly higher in the study groups (P < 0.001). Statistically significant decreased postprocedural pulse rate and blood pressure in comparison with to their preprocedural values were observed when distraction methods were used (P < 0.01). Patients undergoing cystoscopies listening to music and real-time visualization (Group III) had better VAS scores than the others (P < 0.01).
Conclusions: Distraction methods reduce pain and increase satisfaction among patients. Best results are with combined listening to music and direct real-time visualization.
Objectives: To report a technique for ureteroscopic laser lithotripsy (URSL) and retrograde placement of a double-J (DJ) stenting through the ureteroscope working channel without the use of a fluoroscope compared to the conventional technique.
Patients and Methods: Between June 2015 and December 2017, 170 patients selected for URSL for treatment of ureteral stones and DJ insertion was evaluated. Patients are divided into two groups according to the use of fluoroscopy. In Group A (100 patients), fluoroscope is used and group B (70 patients) without fluoroscopy guidance. In group B, URSL is performed first and followed by DJ insertion by the semi-rigid ureteroscope 8.5-11 Fr under vision without fluoroscopy.
Results: Stone free rate in 96% versus 94.3% for groups A and B respectively. This technique was successful in all the included patients: 166 retrograde DJ stenting post URSL for ureteric calculi and 4 cases for anuria. Group A are exposed to radiation with mean 26.6 seconds in URSL procedure and 4.8 seconds for DJ stenting. Group B was exposed to zero dose. For group A, the stents size was 6 Fr for 70% of patients and 15 % for 4.7 Fr and 15% for 7 Fr stenting. In Group B, stents of 4.7 Fr and length 24-26 cm were used in all patients. Failure of DJ insertion is reported in 9% for group A and 13 (18.5%) patients for group B.
Conclusions: This study report the feasibility and efficacy of the completely fluoroscopy free URSL and DJ stenting to treat ureteric stones.
Introduction: With significant advances in the area of interventional radiology, angioplasty and stenting have become preferred first-line treatment in patients with significant renal artery stenosis. However, not all patients have favorable anatomy to undergo minimally invasive treatments, and reconstruction of the renal artery is an option. In select cases, either improved renal function or maintenance of existing function and sometimes resolution of hypertension can follow surgical treatment.
Material and Methods: This was a prospective observational study conducted from August 2010 to June 2016. Patients <45 years of age with uncontrolled hypertension secondary to renovascular hypertension (RVH) and refractory to medical management and renal arterial disease unfavorable for percutaneous intervention were included in the study. All patients were evaluated thoroughly using computed tomography angiography and diethylenetriaminepentaacetic acid renal scan. Patients underwent autotransplantation either into the right or left iliac fossa. Some kidneys required bench reconstruction of the renal artery and/or its branches before being implanted into either iliac fossa.
Results: Nine patients were included in the study. The mean age was 27 years. Seven were males and two were females. Five patients had bilateral renal artery stenosis. After autotransplantation, initially five patients became free of antihypertensive medicines, but on the follow-up, two patients showed rising trend of blood pressure. The evaluation revealed narrowing at anastomosis site in both patients with salvageable kidney function in one patient. Angioplasty with stenting was done in this patient while the second patient underwent secondary nephrectomy. At 2 years of follow-up, four patients required no antihypertensive medicines.
Conclusion: Autotransplantation can be a successful treatment of severe RVH and should be considered in patients with renal arterial disease unfavorable for percutaneous intervention.
Introduction: Urolithiasis is one of the most common renal diseases with a significant burden on health-care system worldwide. Here, we evaluated the stone volume and its relationship with duration of operation, blood loss, and total stone clearance in patients with staghorn calculi.
Materials and Methods: This was a prospective, single-center study conducted from October 2015 to September 2017. Patients of either sex aged more than 18 years of age with a confirmed diagnosis of staghorn calculus were eligible to participate in the study. Eligible patients were divided into three groups based on stone volume (assessed by three-dimensional computed tomography): Group 1 (≤5000 mm3), Group 2 (>5000 to ≤20,000 mm3), and Group 3 (>20,000 mm3).
Results: A total of 85 patients were enrolled in the study (Group 1, n = 9; Group 2, n = 66; and Group 3, n = 10). The mean age was 43.68 years, and 62.4% of patients were male. The mean operative time increased significantly from Groups 1–3, (31.67, 60.14, and 92.30 min, respectively). The mean pre- and postoperative hematocrit was highest in Group 3 (2.82%) (P < 0.0001). Overall, the correlation between stone volume and operative time and difference in hematocrit showed a positive relationship. A total of five patients had residual calculus, and only four patients reported complications.
Conclusions: The results showed that patients with larger stone volume need more operative time and may have more blood loss.
Background: Testicular torsion (TT) is one of the most common emergencies in pediatric urology. Family awareness of this condition could lead to early diagnosis and intervention and salvage of the effected testicle. The purpose of this study is to assess parental awareness about TT and their source of knowledge. We also evaluated the response of the parents to their children's scrotal pain.
Methods: A quantitative, observational, cross-sectional study was conducted from March 2017 to September 2017 at our institution. The study target were parents attending the pediatric urology clinic and the comparison group included parents attending the general pediatric clinic in the same period. We distributed a questionnaire and then compared the results in both groups.
Results: A total of 200 parents participated in this study (100 parents from each clinic). Nineteen percent of pediatric urology clinic parents were aware and 14% of general pediatric clinic parents were aware about TT with no statistically significant difference observed (P = 0.341). The parents in urology clinic choose doctor as their main source of knowledge (42.1%), while in general pediatric clinic, doctor and through a friend as the main source of knowledge had the same percentage (28.6%). Response of the parents to their children's scrotal pain during working hours in urology and general pediatric clinics was to drive their children to the emergency room immediately with 85% and 82%, respectively. The response of the parents after working hours in both clinics did not show difference, with 83% of parents in pediatric urology clinic and 85% in general pediatric clinic driving their children immediately to the emergency room.
Conclusion: TT in boys is a common problem we face as pediatric urologists and it may lead to testicular loss if not diagnosed and treated early. We found that the awareness of TT in children is low in our community and it is our responsibility to raise it to improve our children's well-being.
Introduction: Percutaneous nephrolithotomy (PCNL) is still the mainstay and the treatment of choice for most complex renal stones. The success of PCNL is defined by achieving a stone-free rate (SFR). Lower calyceal access PCNL is established to be the safest percutaneous access to the renal system, but controversy is present when it comes to SFR in comparison to upper calyceal and middle calyceal accesses.
Aim: We aim to prove that lower calyceal access PCNL is the safest PCNL access and has the same efficacy as upper calyceal access PCNL for staghorn stones.
Methodology: All lower calyceal access PCNLs done from May 2012 to August 2017 were included in the study. Postoperative complications were reported using the modified Clavien Grading System.
Results: Sixty-seven patients were included in the study. The mean age was found to be 49.39 years; most (36 [53.73%]) patients were male. The prevalence of diabetes, hypertension, dyslipidemia, and chronic kidney disease was 40.91%, 47.76%, 37.31%, and 20.00%, respectively. The mean hospital stay was 7.9 days; mean operative time was 138.52 min. The mean staghorn stone burden was 476.34 mm2. About 80.59% (n = 54) of patients had complete stone resolution after the first session. Only 3 (4.47%) patients had complications and classified as Grade 2 on the modified Clavien Grading System and the remainder were classified as Grade 1, two patients needed postoperative blood transfusion, and one had a renal pelvis perforation.
Conclusion: When it comes to safety and efficacy, the use of lower calyceal single-access PCNL has a very low complication rate compared to upper calyceal access PCNL, especially pneumothorax and bleeding.
Context: Analgesia during extracorporeal shockwave lithotripsy for renal stone is an essential component. It not only makes the procedure comfortable but also increases the stone-free rate.
Aims: The aim of this study was to evaluate the efficacy of triple oral analgesic agents on stone fragmentation and pain relief in comparison to injectable analgesic agents.
Settings and Design: This prospective randomized study included 68 patients of renal calculi of size 5–15 mm.
Subjects and Methods: Group A had 32 patients, who received injection pentazocine and injection diclofenac, 45 min before the procedure. Group B consisted of 28 patients, who received a combination of oral acetaminophen, 325 mg, oral diclofenac 50 mg, and oral tramadol 37.5 mg, 45 min prior. Procedural findings, pain score visual analog scale (VAS), fragmentation rate, and outcome were recorded.
Statistical Analysis Used: Independent t-test and Pearson's correlation test.
Results: A total of 60 patients were analyzed. The mean age was 40.2 ± 11.8 years. Both groups were comparable in body mass index, stone size, number, and density. Group A required more shocks than Group B (4274 vs. 3693, P = 0.043). A lower energy level of shocks (kV) was tolerated in Group A (2.5 vs. 3.2, P = 0.002). Group A required more sittings than Group B (2.3 vs. 1.9, P = 0.037). VAS score was significantly less in Group B (2.9 vs. 4.9, P = 0.0001). The overall fragmentation rate was similar among groups (81.2% vs. 89.3%); hence, the successful outcome was (59.4% vs. 75.0%, P = 0.274). The occurrence of adverse events was also equivalent in both groups (P = 0.199).
Conclusions: Triple oral regime provides better analgesic effect and quicker stone-free rate than injectable agents but with similar final outcome.
Introduction: Performing shock wave lithotripsy (SWL) under intravenous sedoanalgesia and the ability to predict the effectiveness of SWL is essential in determining the most appropriate treatment for patients.
Patients and Methods: This study consisted of 56 children aged between 1 and 16 years mean age 6.7 ± 4.3 years with renal and ureteric stones who underwent SWL. Incomplete child data were excluded from the study, leaving 47 patients. The procedure was performed under sedoanalgesia with diazepam and ketamine was given intravenously during SWL session. We study the effect of the following factors (age, site, size, opacity of stone, degree of pelvicalyceal dilation, previous urological surgery, number of shock waves, and number of sessions) on stone clearance after SWL.
Results: Forty-seven children range from 1 to 16 years, mean age 6.7 ± 4.3 years. There were 39 (83%) with renal stone and 8 (17%) with ureteric stone. The mean size of stone was 12.2 ± 4.4 mm ranging 6–25 mm. Of 47 children, 36 (76.6%) were stone-free. Age below 6 years, pelvic stones, children without surgery, number of shock waves, and number of sessions were significant factors that affect the stone-free rate after SWL, while the stone size, opacity, and calyceal system dilatation were not statistically significant factors.
Conclusions: The present analysis shows that stone-free status for children with urolithiasis depends on the age of presentation, previous history of ipsilateral stone treatment, stone location, and number of sessions. Pediatric lithotripsy under intravenous sedoanalgesia is feasible, general anesthesia is not mandatory, and any anesthetic complications were not encountered.
Context: Pelvic fracture urethral distraction defect (PFUDD) may be challenging for the treating urologist. Anastomotic urethroplasty is the established surgical procedure for the treatment of PFUDD. Few studies in literature focus purely on PFUDD, and majority of the studies include anterior urethral stricture as well. The period of these studies is relatively short. We conducted a retrospective analysis of patients who underwent primary or redo anastomotic urethroplasty for PFUDD over a period of 12 years at a tertiary care center in northern India.
Aims: The aim is to study anastomotic urethroplasty for pelvic fracture urethral distraction defect with regard to long-term success rate and complications.
Settings and Design: This was a retrospective study. Subjects and
Methods: This retrospective study was conducted in the Department of Urology, King George's Medical University, Lucknow, India, from August 2004 to July 2016. All patients who underwent progressive perineal anastomotic repair of PFUDD were included in this study. Demographic findings, type of pelvic fracture, length of distraction defect as per retrograde urethrography (RUG) and micturating cystourethrography, any history of erectile dysfunction in the preoperative or postoperative phase, and urinary incontinence in postoperative phase were analyzed. Decision regarding catheter removal was taken after pericatheter RUG at 4 weeks. Follow-up was done at 3 and 6 months in postoperative period.
Results: A total of 226 anastomotic repairs were done in 221 patients. Of the 221 patients, 51 (23%) were redo urethroplasty. The mean age of patients was 27.6 years. The mean length of distraction defect was 2.7 cm. The mean duration of hospital stay was 6 days. Primary urethroplasty was successful in 163 (93.14%) of 175 patients and redo urethroplasty in 44 (86.27%) of 51 patients. Out of 165 patients, 18 (10.9%) patients reported occasional incontinence while 6 (3.63%) patients reported mild incontinence.
Conclusions: Anastomotic urethroplasty is the definitive procedure for PFUDD. Our success rate for primary deferred anastomotic urethroplasty is 93.14% and for redo anastomotic urethroplasty is 86.27%.
Aims: The aims of this study were to determine the frequency and clinical significance of individual urodynamic signs, which revealed on the basis of the results of comprehensive urodynamic examination of patients with the idiopathic overactive bladder (IOAB), to produce definitions of these features, and to describe any necessary remedial action.
Materials and Methods: To identify the most common features and artifacts, we conducted a combined urodynamic examination of 137 patients with IOAB (105 women and 32 men). Age, comorbidities, and urodynamic parameters were analyzed to determine the association between bladder sensation and contractility.
Results: It was found that most patients suffer from the same type of bladder function impairment, often related to the decrease in the average effective capacity of the bladder, frequent urination, urgency urination, and urgent urinary incontinence events. Imperative nature of urination in patients with IOAB leads to the reduction maximum cystometric capacity in 75.9% of patients, increased bladder sensitivity threshold in 70.8%, detrusor overactivity in 35.8%, change in bladder compliance in 43.1%, and urethral instability in 24.8% of patients.
Conclusions: Decreased ability of the bladder to accumulate and hold the urine under the normal or low intravesical pressure and frequent association of bladder instability with signs of obstructive urination are major peculiarities of the impaired urodynamics of the lower urinary tract in patients with IOAB.
Introduction: Today is the era of “wireless” in technology and here comes era of “sutureless” in the field of surgery. Every surgeon wishes for better wound healing with better cosmesis without complications and early back to routine activities. All this is possible by use of adhesive for wound edges of circumcision is shown by us in this study. In addition, other aim was to study the efficacy, safety, functional outcome, and cosmesis of isoamyl cyanoacrylate when used as adhesive for wound edges of pediatric circumcisions.
Materials and Methods: Group A comprised 162 pediatric patients who underwent sutureless circumcisions and Group B comprised a similar number, i.e., 162 pediatric patients who had undergone circumcision by conventional method using absorbable interrupted sutures. Comparative analysis of both the groups was done based on various parameters such as bleeding, infection, foreign body reaction, excessive swelling, and wound dehiscence. In addition, visual analog pain scoring was done after 6 h and after 12 h postoperative.
Results: Complications were more commonly seen in sutured Group B versus sutureless circumcision-Group A. In addition, postoperative pain and need of analgesics were seen more commonly in sutured Group B patients. Wound healing and final cosmesis were far better in Group A patients.
Conclusion: Our results show that isoamyl cyanoacrylate is comparatively safe, efficient, has better functional outcome and good cosmesis when used as adhesive for wound edges of pediatric circumcisions. Sutureless circumcision technique is better than conventional sutured circumcision.
A 47-year-old healthy male had a scrotal lesion for about 10 years which was gradually increasing in size and not associated with pain or tenderness. It was dwarfing the penis and attained its present size of 14 cm × 7.5 cm × 6 cm. There were no discharging sinuses, tenderness, or ulceration. He had no significant past or family history. Laboratory examination revealed unremarkable serum calcium, serum phosphate, serum total protein, serum uric acid, and serum parathormone levels. A clinical diagnosis of epidermal inclusion cysts was suggested. The lesion was entirely excised and sent for histopathologic examination.
A double J stent (DJS) is the main therapy for ureteral obstruction when conservative treatment fails. Antegrade migration in the bladder – or retrograde migration in the ureter – are well-known complications. We present a case with intravascular migration of a DJS into the inferior vena cava. Inferior venocavagraphy confirmed the position of the stent, and thrombus formation was excluded at its tip. The stent was retracted endoscopically. After the procedure, limited contrast leakage was seen at the perforation site on venography. The current available literature is reviewed. Based on this, a management algorithm is drawn up.
Cystic renal lesions are one of the commonly encountered urological conditions. They can be either benign or malignant. The Bosniak classification is employed to differentiate benign cysts from the malignant ones and to recommend treatment options. Bosniak type 4 cysts are mostly malignant. Rarely, benign tumors can be encountered in Bosniak type 4 cysts. We present a 59-year-old female who presented with a hilar Bosniak type 4 cyst in the right kidney. She underwent open exploration of the right renal tumor. The tumor was infiltrating into the renal vessels and could not be separated from the renal vein. In view of preoperative and intraoperative suspicion of malignancy, radical nephrectomy was done. Postoperative histopathological examination revealed the tumor to be an oncocytoma. The benign nature of the cyst could not be conclusively determined by preoperative investigations and intraoperative findings. Postoperative histological examination uncovered the rare cystic presentation of this benign tumor.
Bladder cancer is extremely rare in children. We report a case series of two children with transitional cell bladder cancer who presented with lower urinary tract symptoms. Pathology revealed a low risk for recurrence and progression tumor. In such a case, early diagnosis is crucial and surgical treatment is usually the only treatment needed.
Primitive neuroectodermal tumor (PNET) of the kidney is an extremely rare renal neoplasm with only about 50 reported cases in the literature. These tumors behave aggressively and carry a poor prognosis. A 22 years female patient presented with right lumber and right hypochondrium lump of 4 months duration. Commutated tomography revealed large right renal mass with renal vein and inferior vena cava (IVC) thrombus. Magnetic resonance imaging abdomen demonstrated the extension of tumor thrombus up to the junction of hepatic vein and IVC. Preoperative percutaneous needle biopsy was performed. Histopathology demonstrated small round to oval cells with scanty cytoplasm and cells are arranged in clusters. Immunohistochemical staining demonstrated a highly specific cluster of differentiation 99, confirming the diagnosis of a PNET.
Pure testicular choriocarcinoma is a rare histological subtype of germ cell tumor (GCT) and typically presents with distant metastases and aggressive features leading to a generally poor prognosis. Unique to choriocarcinoma among GCT histological subtypes is the propensity of spontaneous hemorrhage into metastatic lesions. We report a case of pure testicular choriocarcinoma in a 46-year-old male with postoperative acute pulmonary hemorrhage secondary to tumor invasion of the lungs, and the subsequent management of his disease with a discussion of relevant literature.
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