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A woman in her 30s had robotic pyeloplasty done for right ureteropelvic junction obstruction. Incidentally she developed dengue viral fever starting on postoperative day 1 itself, which progressed to dengue haemorrhagic shock by 1 week, complicating pyeloplasty due to pelvicalyceal haematoma. Dengue associated shock was superimposed with subsequent gram-negative bacterial sepsis, further complicated later with Trichosporon fungal sepsis. She was managed under multidisciplinary care, involving urology, infectious disease and ICU care. Her diagnostic and difficult management issues due to these rare sequential medical issues in an otherwise usually uncomplicated postsurgical phase are discussed along with short review of literature. This case highlights the importance of early diagnosis, timely supportive care and appropriate management in such tropical infections with significant associated mortality.

Objective To present our ‘ureter-first’ approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes’ pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors. Methods A standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented. Results 51 consecutive cases were done using ureter-first approach. UPJ was >1 cm in 8 cases. 3 of these had UPJ >2 cm. 8 other cases had a low-insertion below level of kidney while 3 had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months. Conclusions A uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.

To evaluate the anatomical changes in kidney orientation in prone position with use of horizontal or vertical bolster alignment. Patients having renal stone(s) on ultrasonogram or X-ray underwent split bolus computed-tomo-urography (CTU) in prone position with horizontal and vertical bolster positions. CTUs were read by a single radiologist to quantify the cranio-caudal, antero-posterior, side to side and rotational movements of kidneys as relevant to prone percutaneous nephrolithotomy. 19 adult patients with 38 renal units and mean basal metabolic index of 25.6 kg/m2 underwent CTU. Greater inferior displacement of both kidneys was seen with horizontal bolsters as compared to vertical bolsters. The right upper calyceal-diaphragm distance was 2.1 ± 1.5 cm and the lower calyceal-diaphragm distance was 2.0 ± 1.6 cm greater with the horizontal bolsters (p

To validate the detection of clinically significant prostate cancer (Gleason's score ≥7) by PI-RADS v2 and to assess the ability of quantitative MRI parameters to detect clinically significant prostate cancer (CSPCa) in Indian men.Adult men (n = 95) with serum PSA4 ng/ml were prospectively evaluated with multiparametric MRI (mpMRI) followed by histopathological evaluation using systematic 12-core prostate biopsy in 69 patients and prostatectomy specimens in 26 patients, performed within six weeks of mpMRI. The imaging and the pathology were divided into 12 sectors per prostate. For the validation of PI-RADS v2, a cut-off of PI-RADS v2 score ≥ 3 and PI-RADS v2 score ≥ 4 were compared to histopathology as a reference standard. Further, quantitative parameters, apparent diffusion coefficient (ADC), KPI-RADS score ≥ 4 showed higher specificity (89%) than PI-RADS score ≥ 3 (72.2%) at the cost of mild but not significant reduction of sensitivity (sensitivity-87.6% vs 91.9), (n = 1,140 sectors, 95 patients). PI-RADS v2 and quantitative parameters demonstrated the ability to discriminate sectors positive vs negative for CSPCa: AUC (area under the curve) for ADC was 0.928, PI-RADS v2 was 0.903, KPI-RADS v2 is a reliable method for the detection and localization of clinically significant prostate cancer in Indian men, suggesting applicability beyond European or American demographics. Quantitative mpMRI parameters can detect clinically significant prostate cancer with similar test characteristics as PI-RADS v2.

Objective: To evaluate the role of routine nephrectomy for tuberculous non-functioning kidney (TNFK) after receiving anti-tubercular therapy (ATT) by demonstrating whether live tubercle bacilli persist in nephrectomy specimens after treatment or not. Materials and methods: Patients with TNFK who underwent nephrectomy after completion of at least 6 months of ATT were included in this prospective cohort study. We sent tissue/pus from a nephrectomy specimen for acid-fast bacilli (AFB) staining, polymerase chain reaction (PCR) and culture to look for live bacilli. Bacilli were considered alive only if AFB culture was positive. Results: Twenty-four patients underwent nephrectomy for TNFK between April 2015 and October 2017 (18 laparoscopic and 6 open nephrectomy). Laparoscopic nephrectomy was associated with lower blood loss (225 ml versus 408 ml, p = 0.0003) and shorter hospital stay (3 versus 3.8 days, p = 0.06) compared with open nephrectomy; however, mean operative time and overall complications were similar. Eight specimens were AFB smear and/or tuberculosis PCR positive, out of which three showed viable bacilli upon culture. Drug sensitivity testing showed multi-drug resistant strain in all three patients who were treated with second-line ATT. Conclusion: It is preferable to do routine nephrectomy for TNFKs as they are more likely to harbour live bacilli and lead to disease recurrence. Viability testing for AFB must be performed on all operated specimens to identify drug resistant bacilli so that patients may be treated with second-line therapy if required. Level of evidence: 4.

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Background Primary malignant melanoma of the female urethra is an exceedingly rare tumor. It represents 0.2% of all malignant melanomas. Divergent differentiation towards non-melanocytic lineages has not been reported in urethral melanoma. Case presentation We report a rare case of neuroendocrine differentiation in a large primary small cell malignant melanoma involving the urethra, in a 62-year-old lady, who presented with obstructive urinary symptoms. Clinical and radiological workup revealed a large urethral mass with liver and lymph nodal metastases. A biopsy was performed from the urethral and liver lesions which showed poorly differentiated tumor cells with small cell morphology and presence of melanin pigment. These cells were immunopositive for melanocytic and neuroendocrine markers. Ultrastructural examination showed presence of melanosomes and neurosecretory granules in the tumor cells. Conclusions Although malignant melanoma with neuroendocrine differentiation is exceptionally rare, it needs to be recognized among the other well-known variants of malignant melanoma.

Novel energy devices such as ultrasonic shears (US) are widely used in laparoscopic surgery due to convenience and outcomes. However, these are expensive and add to the procedure cost. Electrocautery (EC) can often provide similar surgical outcomes and existing literature in unclear on the benefits of one over the other. We conducted a randomized trial between US and EC use in laparoscopic nephrectomy. Twenty patients undergoing laparoscopic nephrectomy between January 2019 and January 2020 at our tertiary referral center were included. Patients were randomly allocated in 2 groups according to energy used, i.e., EC and US. We assessed operative time, blood loss, intra- and postoperative complications, drain output and duration, hospital stay, readmission rates within 30 days of discharge, and surgeon satisfaction with the instruments used. The mean operative time and estimated blood loss were 113 min and 170 ml in EC group while 106 min and 180 ml in US group (p > 0.05). The mean change in hematocrit values after surgery were 6.12% and 5.27% in EC and US group, respectively (p = 0.812). There were no significant differences in mean hospital stay (2.7 in EC group, 2 days in US group), drain output (35.6 ml in EC and 26.3 ml in US group), and drain duration (1.7 days in EC and 1.9 days in US group). One patient in EC group had retroperitoneal hematoma due to Veress needle injury. Similarly only 1 patient in US group had severe intraoperative bleeding requiring conversion to open procedure. Two patients in the EC group had postoperative complications, i.e., fever and purulent collection under surgical site. Electrocautery and ultrasonic shears appear to be comparable in efficacy and safety in laparoscopic nephrectomy. However larger prospective studies are required to confirm our findings.

INTRODUCTION AND OBJECTIVE:During prone percutaneous nephrolithotomy (PCNL) rolled blankets or foam or gel bolsters are often placed underneath the patient to allow for chest and abdominal wall exp...

Level of evidence: 4

Introduction: Very few randomized controlled trials are available globally to support routine use of enhanced recovery after surgery (ERAS) protocol after radical cystectomy (RC), and none so far has been conducted in the Indian subcontinent. The aim of the present study was to evaluate hospital stay and 30-day perioperative outcomes following RC with the implementation of the ERAS protocol. Materials and Methods: Fifty-four patients undergoing open RC were randomized to ERAS versus conventional surgical care (CSC) at our center from April 2017 to May 2018. Key interventions included avoidance of mechanical bowel preparation, early nasogastric tube removal, early enteral feeding, and early obligatory ambulation. Follow-up was done till 30-day postoperatively or till discharge, whichever longer. Results: Twenty-seven patients in each group were analyzed. The demographic profile of the groups was similar. Length of stay in each group (8 days [5–57] ERAS vs. 9 days [5–31] CSC group, P = 0.390) was similar, with time to recovery of bowel function being significantly less in ERAS group (12 h [12–108] vs. 36 h [12–60] for bowel sounds [P = 0.001], 48 h [12–108] vs. 72 h [36–156] for passage of flatus [P = 0.001], and 84 h [36–180] vs. 96 [60–156] for passage of stools [P = 0.013]). Perioperative complication rate (12 patients (44.4%) vs. 14 (51.9%), P = 0.786) was similar. Conclusions: ERAS protocol leads to faster bowel recovery compared to conventional care in patients undergoing open RC but fails to demonstrate a shorter length of stay and lower complication rate.

Background: Nephron-sparing surgery (NSS) is the standard of care for small renal masses whenever feasible. This study aims to evaluate the perioperative outcomes of NSS performed by open (open partial nephrectomy [OPN]) or laparoscopic (laparoscopic PN [LPN]) or robotic (robotic PN [RPN]) approach over the past 6 years and to study the correlation of histopathological grade of renal cell carcinoma with the RENAL score. Materials and Methods: A retrospective analysis of prospectively collected data of all patients who underwent NSS was done. Results: A total of 135 patients underwent NSS. The mean tumour size was 4.4 cm. About 61 patients underwent OPN, 24 had LPN and 50 had RPN. Although tumour size was larger in OPN group (P = 0.01), tumour complexity based on the RENAL score was similar in OPN and RPN groups (P = 0.15). The OPN group had shorter operative time (P = 0.008) but more blood loss (P = 0.001) and length of hospital stay (P = 0.049) as compared to LPN or RPN group. Maximum radiological diameter of tumour (P = 0.017) appeared to be a significant predictor of operative time, while the open surgical approach (P = 0.003) and tumour stage (P = 0.044) were found to be significant predictors of blood loss. Hilar clamping time was similar in OPN and RPN groups (P = 0.054) but higher in LPN group (P = 0.01). However, post-operative decline in renal function (estimated glomerular filtration rate) (P = 0.08) and margin status were comparable among the three groups. The most common histopathology was clear cell carcinoma (70%), and RENAL score was identified as a significant predictor of histopathological grade of tumour (P = 0.008). Conclusion: Open, laparoscopic and robotic approaches to PN provide similar patient outcomes. OPN was usually preferred for larger tumours. The post-operative decline in renal functions and complications were comparable among the three approaches. RENAL score correlated significantly with histopathological grade and hence could help in predicting tumour behaviour pre-operatively.

Objectives: Transurethral resection of bladder tumour (TURBT) is a standard procedure for both diagnosis and management of bladder cancer. Intravesical seeding of cells shed during TURBT supposedly plays an important role in tumor recurrences. This may be due to the inherent nature of the procedure, which refutes the basic oncological principle and demands for piecemeal resection. Additionally, high pressure of irrigation fluid during TURBT has the treacherous potential for systemic absorption of tumor cells into circulation and metastatic tumor seeding. By measuring circulating tumor cells (CTC) before and after TURBT, it may be possible to ascertain whether TURBT induces measurable seeding of cancer cells into the circulation. Methods: All consecutive patients undergoing TURBT for newly diagnosed bladder mass were enrolled. Cases with resection time less than 10 min, prior intravesical or radiation therapy, chronic cystitis, neurogenic bladder, metastatic disease at presentation, and final histology other than transitional cell carcinoma were excluded. Peripheral venous blood samples were drawn before and after (within 2 hours) of TURBT, and analyzed using flow-cytometry to ascertain the number of CTC. The peripheral blood mononuclear cells were separated, suspended in FACSTM buffer, stained with specific antibodies to CD-45, EpCam, Cytokeratin 18 & 19, and immediately acquired on a FACSCantoTM II cytometer (BD Biosciences, 4-2 configuration). A cell positive for cytokeratins 18, 19 & EpCam and negative for expression of CD45 was defined as a CTC. The number of CTC in pre and postoperative samples were compared and correlated to the final histopathology. Results: 32 patients were studied. No perforations were encountered. 4/32 (12.5%) patients had raised CTC count following TURBT. All 4 of these patients had high grade and at least T2 (ie, muscle invasive) disease. Overall, rise in CTC count was seen in 4/8 patients (50%) with muscle invasion and 4/13 cases (30.79%) with high-grade disease. There was no significant difference in the average resection time between the group showing rise in CTC versus the other (34 vs 32 .5 minutes, respectively; P=.43). Conclusions: This study provides objective evidence that tumor cells are released into the circulation during TURBT and are detectable in peripheral venous circulation. This occurs predominantly in patients with higher grade and higher stage disease.

To compare the outcomes between cutaneous ureterostomy and ileal conduit urinary diversion in patients with solitary functioning kidney, undergoing radical cystectomy. This study was a retrospective analysis of the patients, with solitary functioning kidney, who underwent radical cystectomy with either cutaneous ureterostomy or ileal conduit from January 2014 to May 2019. Baseline characteristics, perioperative outcomes, and follow-up renal function were evaluated and compared. For renal function outcomes, we assessed the estimated glomerular filtration rate (eGFR) and included patients with a follow-up of at least 2 years. A total of 43 patients were included in the study, 23 of them underwent cutaneous ureterostomy and 20 underwent ileal conduit urinary diversion. The two groups were similar with respect to their baseline demographic and clinical characteristics. Operative time (

Objectives: To qualitatively assess the clinical usefulness of patient-specific high-fidelity three-dimensional (3D) print model of kidney before partial nephrectomy (PN) and to identify subset dom...

To evaluate the anatomical changes in kidney orientation in prone position with use of horizontal or vertical bolster alignment.Patients having renal stone(s) on ultrasonogram or X-ray underwent split bolus computed-tomo-urography (CTU) in prone position with horizontal and vertical bolster positions. CTUs were read by a single radiologist to quantify the cranio-caudal, antero-posterior, side to side and rotational movements of kidneys as relevant to prone percutaneous nephrolithotomy.19 adult patients with 38 renal units and mean basal metabolic index of 25.6 kg/mHorizontal bolsters provide significantly more caudal displacement of the kidneys; the right kidney being displaced more as compared to the left. However, there is also an increase in the skin-calyceal distance with horizontal as compared to the vertical bolsters. These assessments may help the surgeons decide optimal bolster position individualized to the patient.

Female external genital anatomy is poorly understood, particularly with respect to its blending with physiological concepts of continence. There are several pertinent questions which remain poorly answered, even though of late there has been a relative surge of new procedures being described for female urethral reconstruction. Where exactly is the female external sphincter? What keeps continence preserved in dorsal approaches and what keeps it intact in ventral ones? Can the urethrotomy be extended into the bladder neck without jeopardizing the continence? Similarly, vascular supply of urethra and surrounding structural supports of urethra are important before one can safely understand various approaches to urethral reconstruction in females. After complete obliteration or transection, what keeps the two ends of the urethra vascularized? Which anatomical structures are responsible for female sexual function? What bed provides vascular support to the graft on dorsal and ventral sides?, etc. are all questions which are important to improve the results of urethral reconstruction in females. An effort has been made in this chapter to review the existing literature and present a contemporary understanding in this regard.

This chapter outlays the surgical steps for performing the dorsal onlay approach to female urethral reconstruction using a free graft. It is the most widely used technique, though the experience remains very limited due to the rarity of the disease itself. A success rate of 80% and above is expected in the intermediate term with minimal morbidity.

Management of female lower urinary tract symptoms (LUTS) is often not well understood among general practitioners, gynecologists, and even urologists. There are no specific guidelines in this regard, particularly for management of voiding dysfunction. This chapter presents a broad outlook to stepwise rational management of female LUTS in outpatient clinic, based upon current literature and clinical practices. In general, any associated gynecological, neurological, or other co-morbid illnesses should be treated simultaneously. The diagnosis of voiding dysfunction requires a minimum of uroflowmetry and post-void residue, but the index of suspicion must be kept high for any patient coming with LUTS irrespective of the presence of voiding symptoms. A simplistic algorithmic approach to females presenting with LUTS is presented.

Pelvic fracture-associated urogenital injury is an important but uncommon cause of urethral stricture in females. Bladder neck is also frequently injured in such cases. Early repair of injury is recommended whenever feasible given the general condition of patient and availability of expertise. Patients presenting at a later stage with obliterate strictures have limited surgical options for repair. The length of available urethra, stricture characteristics, associated genital or pelvic floor injuries, and continence guide the choice of treatment in these cases. It is imperative that the surgeon be well versed with the surgical anatomy and principles of reconstruction for an optimum outcome before undertaking such repairs.

Urethral stricture disease and urethroplasty in females have gained recent interest with newer urethroplasty techniques being described for various types of strictures. This chapter provides an insight into evaluation and management options for a woman with urethral stricture. Female urethral stricture remains a rare disease, and the clinical presentation overlaps with other functional causes of obstruction. The diagnosis is highly dependent on actual demonstration of a fibrotic ring on endoscopy. Results of minimally invasive options are dismal beyond one attempt. Many surgical reconstruction options are now available with good reported short-term outcomes. Given the anatomical and physiological differences between male and female urethra, female urethral stricture disease leaves a lot to be desired for improving our understanding of this disease.

While the anatomical closure rates of vesicovaginal fistula (VVF) following transabdominal (TA) and transvaginal (TV) repairs seem comparable, studies comparing urinary and sexual outcomes following successful repair are lacking. We aimed to report patient-reported outcomes on sexual and urinary functions after long-term follow-up with successful repair. We retrospectively reviewed 81 women who had successful VVF repair at our institute. Pre-, intra- and post-operative details were retrieved from electronic data software. Patient-reported sexual and urinary function outcomes were assessed using the Female Sexual Function Index (FSFI) questionnaire and International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF), respectively, at last follow-up. We also compared such outcomes among TA and TV repairs. Of 81 women, 28 (34.6%) had TA and 53 (65.4%) had TV repairs. Mean age was 37.5 years and mean fistula diameter was 12.9 mm. The most common aetiology was hysterectomy. Thirty-three patients (40.7%) had previous failed repairs. At a mean follow-up of 29.8 months, 24 (34.3%) women had sexual dysfunction and 15 (18.5%) women experienced urinary dysfunction. The TA and TV groups had comparable mean FSFI scores (28.7 ± 6.1 vs. 30.9 ± 5.2, p = 0.13) and ICIQ-SF scores (0.7 ± 1.7 vs. 0.5 ± 1.4, p = 0.59). In multivariate analysis, fistula size and site were significant predictors of urinary dysfunction whereas multiparity was the most significant predictor of sexual dysfunction. Sexual and urinary dysfunction is found in a considerable number of women after VVF repair. However, our data suggest comparable long-term sexual and continence outcomes between TA and TV repairs.

A 30-year-old woman presented with vesicovaginal fistula after a forceful intercourse. She was diagnosed as a case of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome 14 years ago and had underwent McIndoe’s vaginoplasty using amniotic membrane. Similarly, another 14-year-old girl presented with an iatrogenic urethral and bladder neck injury during an attempt at McIndoe’s vaginoplasty 4 months ago at another centre leading to urinary fistula with absent vagina. A laparoscopic salvage was done for both the cases along with repair of genitourinary fistula using sigmoid colon. There was no further requirement of vaginal dilation. Both patients remain fully continent at 1 year follow-up. Laparoscopic sigmoid vaginoplasty is a worthy minimally invasive salvage method for the patients of MRKH who develop fistulous complication after a previous attempt at neovagina creation. The bowel wall provides a structurally strong layer to withstand the repeated sexual trauma of the vagina.

Objectives To report our single center experience in the management of untreated adult classical bladder exstrophy. Materials and Methods A retrospective review of 25 adults aged ≥18 years who underwent repair of the classical bladder exstrophy from April 2000 to February 2020 was performed. Patients with prior repair and neoplastic changes in the exposed bladder mucosa were excluded. The patients and primary caretakers were actively involved in the decision-making of the surgical procedures best suited them. Work-up included upper tract evaluation and random bladder mucosal biopsy. Results The mean age of presentation was 25 years. Primary schooling was completed by only 32% patients. The majority (72%) of the patients opted continent catheterizable pouch. Penn pouch was the most common pouch performed. In 3 patients, a complete primary repair was done in a single setting. In 4 patients with lack of education and difficult access to nearby health care settings, ileal conduit was performed. In all except 3 (13.1%), abdominal wall closed primarily. None of the patients required osteotomy. At a mean follow-up of 6.5 years, all patients with continent pouches were continent. One patient required revision of left ureteroneocystostomy at 20 months follow-up. All except one patient, who had complete primary repair were continent at a mean follow-up of 6 years. Conclusion Management of adult classical bladder exstrophy is challenging. The various pouches extend the surgical options. Ileal conduit may be a simple alternative to complex reconstructions in unmotivated patients with poor access to the hospital.

Background: Anti-incontinence suspension procedures in women include Burch colposuspension or needle suspension procedures. Even though bladder injury is a known complication of any needle urethral or colposuspension procedure in women, it is rare. Delayed presentation may occur with lower urinary tract symptoms or hematuria. However, synechiae formations in bladder have rarely been reported. In this study, we report two cases presenting late with synechiae formation inside the bladder as a result of the suspension suture actually passing through the bladder and thus sewing the posterior and anterior walls of bladder together. Case Presentation: Two ladies presented late after Burch colposuspension with nonresolving urinary symptoms. Both these ladies demonstrated a "smiley bladder sign" caused by a filling defect on cystogram. Cystoscopy revealed a synechial pillar attaching the anterior and the posterior walls, reminiscent of stalagnate-like column in the bladder cavity in both cases. Both cases were managed endoscopically with laser incision avoiding injury to the ureteral orifices. Conclusion: A rare previously undescribed complication of Burch colposuspension and its typical appearance on cystogram is reported along with its endoscopic management. These cases highlight the use of intraoperative cystoscopy to prevent such complications.

Office cystoscopy may be associated with urinary tract infection (UTI) in up to 10–20% of patients. Current practice of surgical part preparation in males with povidone-iodine excludes distal urethra in males, leaving a possibility for resident intra-urethral flora to cause post-procedural UTI. We designed this randomized study to assess whether additional cleaning of distal urethra with povidone-iodine solution can help reduce post-procedural incidence of UTIs in this setting. Additionally, urethral swab culture was done in the entire cohort to identify the prevalent microflora in the distal male urethra and to evaluate its role in causation of post-procedural UTI. Using a specialized urethral swab culture methodology, 85% males demonstrated some bacteria and 16% showed common uro-pathogens. 28 (14.5%) cases had post-procedure culture positive UTI. The incidence of UTI in control group (22%) was significantly more than the intervention group (7%) (p value

Objective To describe a novel tubularized bladder flap technique for repair of post-traumatic obliterate bladder neck and urethral stricture in women. Traumatic genitourinary injury in females is rare, and generally associated with pelvic fracture. Obliterate bladder neck is frequent in such cases. The options for obliterate strictures are limited with Tanagho‘s repair as one option. Limitations of Tanagho's repair include bladder neck being shifted anterosuperiorly posing voiding issues, posteriorly directed suture-line risking fistula formation with vagina and rotational tug of bladder putting tension at suture line. Here we present our initial results with our novel technique. Methods The young females with bladder neck obliteration with or without associated urogenital fistula were operated. A novel U-shaped anterior bladder wall flap was used to fashion a urethral tube and bladder neck. Native bladder neck fibres remained at bladder neck itself after reconstruction without limitation of length of urethral tube and continence outcome. Urogenital fistula was also repaired with omental interposition. Results Three tubes 3.5, 3, and 3.5 cm tubes were fashioned in the 3 cases, respectively. No perioperative complications were reported. Catheter was removed at 3 weeks. All cases had normal voiding and continence at follow-up of 15, 7, and 3 months, respectively. Conclusion Our novel flap technique has provided good early results and aims to overcome the limitations of Tanagho's repair.

INTRODUCTION AND OBJECTIVES:Introduction - Radical cystectomy for invasive bladder carcinoma is associated with significant perioperative morbidity. Enhanced recovery after surgery (ERAS) protocols...

Objectives: To study the presentation and natural course of cystitis cystica et glandularis. Methods: A retrospective analysis of patients with histopathologically confirmed cystitis cystica et glandularis from March 2016 to March 2018 who at least completed their 2 years’ follow-up was performed. Perioperative details along with the last available follow-up were included in the analysis. Results: A total of 10 patients were included. The mean age (± standard deviation) was 33.4 (±14.0) years and nine (90%) were men. The most common presentation was storage and voiding lower urinary tract symptoms (80%) along with haematuria (40%) and dysuria (20%). Four patients had the presence of hydronephrosis in preoperative imaging, of which three patients had bilateral mild hydroureteronephrosis. All the patients underwent transurethral resection of the bladder tumour as all were diagnosed with urinary bladder mass on preoperative imaging. All the patients had a trigonal lesion with a bullous appearance partially obstructing the bladder neck. Six patients underwent double J stenting in the perioperative period. The mean (± standard deviation) follow-up duration was 32.8 (±7.5) months. Patients were kept on regular surveillance with imaging and cystoscopy as indicated. Eight patients (80%) developed recurrence in the follow-up period. The mean number of recurrences was 1.5 (±1.1). One of the patients had to undergo augmentation ileocystoplasty with bilateral ureteric reimplantation because of the recurrent lesion with small contracted bladder, while another patient underwent cystectomy with urinary diversion owing to recurrence and refractory lower urinary tract symptoms. Besides, there was no evidence of malignancy after this entity in any of the patients. Conclusion: Cystitis cystica et glandularis is a rare clinic pathological entity which often mimics bladder tumour. Cystitis cystica et glandularis is common in men and often presents with lower urinary tract symptoms. Transurethral resection forms the mainstay of treatment. However, it is often associated with upper tract hydronephrosis. Its controversial premalignant nature compounded with recurrence and risk of upper tract deterioration warrants close surveillance. Level of evidence: 4

Objective Tumor cells are shed during transurethral resection of bladder tumor (TURBT) and form the basis for use of single dose immediate chemotherapy instillation to reduce recurrences. Systemic dissemination of these cells along with the irrigation fluid is also possible but not consistently proven. In this study, we evaluated such dissemination of tumor cells into the circulation during TURBT and its clinical impact. Methods Patients with primary presentation of bladder tumor who underwent TURBT were included. Peripheral venous blood samples before and after TURBT were analyzed for circulating tumor cells (CTCs) using flow-cytometry. A CD45 negative cell with positive expression of cytokeratin 18, 19, and EpCam was defined as CTC. The CTC counts, pre and post TURBT, were compared and correlated with final histopathology. The patients were also followed up for any local and/or systemic recurrences. Results Nine (16.98%) out of 53 patients developed a measurable rise in CTCs after TURBT. All of these patients had high grade and muscle invasive disease. Overall, a measurable rise in CTCs was seen in 9 out of 17 (52.94%) patients with muscle invasive disease. There was no difference in the clinico-pathological stage or the status of cystectomy and/or chemotherapy between those who did or did not show a rise in CTCs. On follow up, 7 patients with muscle invasive disease developed local and/or systemic recurrences and the rise in CTCs was not found to be associated with adverse oncological outcomes. Conclusions This study confirms the hypothesis of inadvertent dissemination of tumor cells into the circulation during TURBT, especially in patients with high grade and muscle invasive disease. The long-term oncological impact of such dissemination remains to be confirmed.

Pelvic fracture with urethral injury in girls is an uncommon entity that is usually associated with concomitant vaginal lacerations. Management options vary from immediate exploration and urethral anastomosis to delayed urethroplasty. We report our experience of managing a 10-year old girl presenting 6 months after a pelvic fracture with urethrovaginal injury and a completely obliterated urethral meatus managed successfully with a single-stage bladder tube repair.

Background: Drainage of any deep seated abscess often requires placement of catheters along with other conservative measures. These catheters are removed when the drainage volume reduces to clinically insignificant levels. However, if left in situ, there are potential complications. One such complication necessitating additional surgical procedure is highlighted in this case report. Malecot's catheter and children may be more at risk for such a complication. Case Presentation: A 7-year-old girl presented with recurrent episodes of right flank pain associated with high-grade fever with chills for the last 5 months and right perinephric drain in situ. She had earlier presented at an outside center and was found to have bilateral renal calculi and left lower ureteral calculi along with right perinephric abscess and pyonephrosis. She underwent right perinephric drain and bilateral Double J (DJ) placement 4 months ago. The perinephric drain initially drained around 250 mL pus each day and progressively ceased to drain by 15–20 days. However, the drain was left in situ and the girl was referred for management of bilateral renal and left ureteral calculi. Pending her consultation, the drain and stents remained forgotten. At presentation, blood urea and serum creatinine were 20 and 0.2 mg%, respectively. Urine culture was sterile. Non-contrast computerized tomography kidney, ureter, and bladder radiograph showed right perinephric drain, bilateral DJ stents with bilateral renal (lower and middle caliceal) calculi, and a chain of left upper ureteral calculi. A small loculated subcapsular collection was also noted at the lower pole of right kidney. All efforts made to pull out the drain under local anesthesia were in vain. The drain was found to be impacted and could not be taken out. Decision was taken to remove the drain laparoscopically. Drain was removed effectively and B/l DJ stents were changed followed by staged procedure for calculi. Conclusion: Malecot catheters may be more prone to ingrowth of tissue because of their inherent design of wider holes, all located at the tip of the catheter. This unique case emphasizes the need for careful follow-up of a patient with perinephric drain and difficulties with the removal of a Malecot catheter compared with a pigtail catheter, particularly in children. Laparoscopic removal of retained Malecot catheter as perinephric drain is a safe option of treatment in such a case.

Introduction: It is believed that the outcomes of robotic surgery depends not only on the experience of the console surgeon but also the patient-side assistant. However, objective data supporting it is lacking. The aim of this study was to objectively determine change in operative outcomes with increasing experience of patient-side assistant. Materials and Methods: We performed a retrospective analysis of 222 urologic robotic procedures performed by two teams of surgeon-assistant and split the data into two chronological halves according to date of surgery. We considered that the assistant was inexperienced in the 1st half and had become experienced by the 2nd half, and we compared mean operative time and blood loss between these two halves of his experience. Results: We observed that with increasing experience of the assistant, the mean operative time reduced from 138.06 to 124.32 min (P = 0.001) and mean blood loss decreased from 191.93 to 187.61 ml (P = 0.57). On subset analysis, a consistent trend of reduction in the mean operative time was noted for both the assistants separately and for all surgical procedures included in the analysis. Maximum reduction was noted for pyeloplasty which was the most commonly performed surgery. The mean blood loss had a varied relation to the experience of the assistant and did not reach statistical significance in either direction. Conclusions: With increasing experience of the patient-side surgeon, the mean operative time for all robotic procedures showed a consistent trend of reduction across all types of surgery with greater reduction for commonly performed procedures.

Isolated renal involvement by myxoid adipocytic tumour is a very rare presentation. We are reporting a horseshoe kidney with ureteropelvic junction obstruction (UPJO) with myxolipoma, which was revealed after routine histopathological evaluation postbilateral open pyeloplasty. We evaluated the patient thoroughly and after detailed discussions with the patient and parents, took the decision to manage the patient on active surveillance with interval imaging and renal dynamic scans. Managing a myxolipoma associated with UPJO is a novel experience as a surgeon, by virtue of its extreme rarity. Isolated myxolipoma of renal pelvis in association with UPJO and horseshoe kidney has never been reported earlier to the best of our knowledge. The patient has not progressed at follow-up of 30 months with occasional mild abdominal discomfort. We intend to closely monitor the patient in similar fashion. Any significant progression of disease or renal failure shall entail nephrectomy with excision of mass and subsequent renal replacement therapy.

Entero-urinary fistulas are uncommon in urological practice and may have widely varying aetiologies ranging from benign to malignant or iatrogenic in nature. All permutations of entero-urinary fistulas have been reported in the literature except an appendico-renal fistula. Here, we present one such case, presenting with urinary tract infections and perineal urethrocutaneous fistulae. He was ultimately diagnosed to have a spontaneous appendico-renal fistula as underlying pathology behind the symptoms.

Renal cell cancer (RCC) is known to produce metastasis to unusual sites both synchronously and metachronously several years after the primary treatment. We report a rare case of RCC with three different, sequential, and each time isolated rare site metastasis to ureteric stump, surgical site, and urinary bladder over a period of 6 years after radical nephrectomy. At each recurrence, metastasectomy was carried out and no systemic therapy was administered. Eleven years after radical nephrectomy and 5 years after last resection, the patient remains disease free. Multiple recurrences can occur in RCC and complete surgical resection results in disease free survival.

Transurethral resection of prostate (TURP) has long been the most commonly performed surgical procedure for the management of benign prostate enlargement (BPE), but has several associated limitations. Over the years, laser techniques have developed as major contenders as alternative therapies for BPE. However, simultaneously, TURP has also flourished and with relatively recent development of resection in saline (bipolar TURP), the tussle between laser techniques and TURP has further gained momentum. A systematic search was performed on Medline using the various Medical subject headings related to the surgical management of BPE including TURP, bipolar, lasers, holmium laser enucleation of prostate (HoLEP), photo-selective vaporization of prostate (PVP), etc., All articles types including meta-analysis randomized controlled trials, review articles, guidelines from various urological associations, single center studies from 2002 onward were considered for review. Bipolar TURP, HoLEP, and PVP provide equivalent outcomes for large prostate adenoma (

Posturethroplasty sexual dysfunction (SD) is multifactorial and its true incidence is unknown. Even with the current evidence suggesting that it is uncommon, de novo SD causes dissatisfaction even after a successful surgery. Posterior urethroplasty carries the highest chance of SD, mostly attributable to the pelvic fracture itself rather than the urethroplasty. With anterior urethroplasty, transecting bulbar urethroplasty leads to greater SD compared with penile or nontransecting bulbar urethroplasty. Most patients with posturethroplasty SD recover within 6 months after surgery.

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.

Functional evaluation of the renal unit has often been quoted as a standard practice for management of stone disease of the upper urinary tract. However, there is very little available evidence from the existing literature to directly support or refute this practice. Here we try to critically review the existing literature on related questions, put into perspective its clinical utility and attempt to rationalize the concept of functional evaluation in patients of renal stone disease in the contemporary era of minimally invasive surgery.