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Extramedullary plasmacytoma (EMP) is an uncommon presentation and usually occurs in conjunction with multiple myeloma (MM). An EMP without developing MM at any point is an extremely rare presentation, and only seven such cases have been reported in the literature to date.We present a case of EMP, who presented with multiple recurrent lesions in rare sites like nasal cavity, testis and skin without the involvement of bone marrow at any point of disease course. He was treated with multiagent chemotherapy (DT-PACE) and continues to be in remission at 29 months post-chemotherapy, which is the longest amongst all the cases reported so far.There are no clearly defined guidelines to treat EMP. Our case had a clinical presentation at very unusual sites and was treated with DT-PACE regimen as against the previous seven reported cases and had the most prolonged period of remission.

Introduction: We retrospectively reviewed the patient characteristics, outcome, and complications of renal transplantation in pediatric age group performed at our center and compared the results with various centers in India and other developed countries. Materials and Methods: Patients younger than eighteen years of age who underwent renal transplantation from 2003 to 2014 at our institute were reviewed. Demographic data of the transplant recipients and donors, etiology of ESRD, mode of dialysis, surgical details of renal transplantation, immunosuppression, medical and surgical complications, and post-transplant follow-up were assessed. Graft survival was determined at 1, 3 and 5 years post-transplant. All data collected were entered into Microsoft excel program and analyzed using SPSS 20. Kaplan–Meier method was applied to determine the graft survival at 1, 3, and 5 years. The log-rank test was applied to test the statistical significance of the difference in survival between groups. Results: Thirty-two children underwent transplantation comprising of 18 females and 14 males. The mean age was 14.5 years (range 10–17 years). The primary cause of renal failure was glomerular diseases in 53% (17/32) of patients. Seventeen postsurgical complications were noted in our series. Two grafts were lost over a follow-up of 5 years. The 1, 3, and 5 year graft survival rates were 96.7%, 92.9%, and 85%, respectively. There was no mortality. Conclusion: The etiology of ESRD in our region is different from that of developed countries. The mean age at which children undergo renal transplantation is higher. Graft survival at our center is comparable to that of developed nations. Renal transplantation can be safely performed in children with ESRD.

Cystoscopy (CS) is considered to be the gold standard in the follow-up of non-muscle invasive bladder cancer. However, CS is invasive, time-consuming, and expensive. On the other hand, modern sensitive transducers have improved the imaging of urinary tract rendering transabdominal ultrasonography (US) more effective in visualizing intraluminal filling defects in the bladder than it was in the past. Twenty-five follow-up patients of low-risk bladder cancer meeting the inclusion and exclusion criteria were included in study. Ultrasonography of the bladder was performed by a single senior radiologist, and subsequently, these patients were subjected to flexible cystoscopy under local anesthesia. Pain score was calculated for each of the cystoscopies done. Findings of transabdominal ultrasound of the bladder were correlated and compared with those of cystoscopy. Subjects with US and/or CS findings suggestive of recurrence underwent transurethral resection of bladder tumor (TURBT) under general anesthesia and confirmation of the bladder carcinoma was achieved by the histopathological examination. Mean patient age was 60.56 years with range of 29 to 77 years. The sensitivity of modern ultrasonographic techniques was found to be 84.61% with specificity of 91.7% taking flexible cystoscopy as the gold standard for detection of recurrence. The accuracy of US was 88% with positive predictive value of 91.7% and negative predictive value of 84.61%. Technological evolution has improved the accuracy of ultrasonography in diagnosis of bladder carcinoma. It represents a valuable surveillance tool in selected sub group of low risk non-muscle invasive bladder cancer patients.

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years-three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80-150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2-5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.

The aim of this research was to study the success and morbidity of supracostal access for percutaneous nephrolithotomy (PCNL), as it is often avoided for fear of complications.Between July 2000 and May 2007, 565 patients underwent PCNL, of whom 110 had a supracostal access. All procedures were performed in a single sitting under general anesthesia. Data were analyzed prospectively for indications, stone clearance rates, and preoperative and postoperative complications.Indications for supracostal access included large pelvic stones in 39 patients, partial or complete staghorn stones in 32, calyceal stones with major stone bulk above the level of 12th rib in 35, and upper ureteric stones in four. Patients' ages ranged between 13 and 71 years (mean 44.2 years). Fifty-six cases were left sided and 54 right sided, whereas 103 (93.6%) were radiopaque stones. All tracts were in the 11th intercostal space, though one had an additional tract in the tenth space. Single-tract access was used in 101 cases (91.8%), but nine (8.2%) required a second tract. Overall stone clearance rate with PCNL monotherapy was 86.4%, and this increased to 97.3% with secondary procedures. Overall complication rate was 11.8% and included hydrothorax/hemothorax in ten, perinephric collection in one, infection/sepsis in two, and excessive bleeding in two. Postoperative hospital stay ranged from 2 to 15 days.The supracostal approach gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. Complications when present may be managed easily with conservative measures.

The present study highlights six cases of pneumococcusuria during the time period of May 2008 to May 2010. All the patients had a co-existing predisposing factor with the isolation of Streptococcus pneumoniae in urine. Five of the six patients having signs and symptoms of urinary tract infections (UTI) were treated and cured of the same. It becomes essential to consider pneumococcal UTI in the presence of clinical signs and symptoms associated with urinary tract abnormalities like hydronephrosis and renal stones. S. pneumoniae may be regarded as an emerging pathogen in UTI. Precise microbiological diagnosis must correlate with the clinical signs and symptoms for the administration of appropriate antibiotic therapy.

A 35-year-old man presented with a gradually worsening left-sided loin pain and high-grade fever 10 days in duration. He gave a history of left flank injury due to a road traffic accident 4 months previously, accompanied by pain and transient mild hematuria that was managed conservatively without further evaluation. Computed tomo- graphic scan revealed undisplaced fracture of the left 10th rib with a large perinephric hematoma/abscess causing significant compression and displacement of the left kidney. The collection was evacuated by open drainage, and its culture yielded a hydrogen sulfide (H2S)Yproducing variant of Salmonella paratyphi A resistant to nalidixic acid. Blood and urine cultures were sterile. Drainage with culture-specific antibiotics (ceftriaxone followed by cefixime) was curative. Primary perinephric abscess due to S. paratyphi A without any evidence of systemic involve- ment is rare and classically S. paratyphi A is H2S-negative. We hereby report a case of H2S-positive S. paratyphi A causing primary perinephric abscess of posttraumatic hematoma.

There is a continuing reluctance among transplant surgeons to procure a right-kidney allograft laparoscopically. We describe our experience with right laparoscopic donor nephrectomy (RLDN) by three techniques.We retrospectively analyzed all seven RLDNs performed at our center from January 2002 to June 2005. The technique used in a particular case depended on the anatomy of the renal vasculature and included transperitoneal (N = 1), retroperitoneoscopic (N = 4), and retroperitoneoscopy-assisted approaches without the use of hand port or other assist devices (N = 2). No stapling or manual-assist devices were used in the last four cases for division of the renal vessels.The mean blood loss, operating time, hospital stay, and serum creatinine concentration on day 7 were 94.3 +/- 46.9 mL (SD), 212.8 +/- 66 minutes, 4.9 +/- 1.9 days, and 1.1 +/- 0.2 mg/dL, respectively. The overall warm ischemia time was 217 +/- 116 seconds. Our preferred technique currently is to go for a total retroperitoneoscopic approach to the right kidney initially. If the renal vein appears short, we make a small subcostal incision to retrieve the kidney openly at this stage (retroperitoneoscopy-assisted approach) with minimal risks to the donor and recipient.Retroperitoneoscopic RLDN performed without hand-assist or stapling devices is safe and cost-effective and yields kidneys with excellent function. Rather than have a fixed approach to RLDN, we suggest a choice depending on the length of the renal vessels observed during surgery.

Idiopathic retroperitoneal fibrosis (RPF) is one of the causes of obstructive uropathy. This disease, ever since its original description in 1948, has undergone much trial and error in its management. We present a case of a rare type of idiopathic RPF causing obstructive uropathy, which is perirenal and different from the classical RPF seen around the great vessels. To our knowledge, such a type of RPF has not been described. We treated the patient by a combined surgical approach in the form of ureterolysis and omentoplasty, followed by medical management with steroids and tamoxifen. The combined regimen yielded excellent results, and the patient is doing well at 9 months of follow up. The rarity of the presentation, with predominant bilateral perirenal fibrosis, and response of perirenal RPF to steroids and tamoxifen, is highlighted in this case presentation.

Target molecule Treatment (TMT) have emerged as the primary treatment in metastatic renal cell carcinoma. Majority of the patients in pivot trials were post nephrectomy cases. The benefit of cytoreductive nephrectomy in the era of TMT is debated. The role of these molecules in the adjuvant settings and in neo adjuvant/pre surgical role has evoked interest. In this review the different molecules used in the treatment of metastatic renal cancer and its effect on the primary renal tumour is discussed. Information available in the public domain about the presurgical/neoadjuvant targeted molecular treatment (TMT) is reviewed to understand the benefits and adverse effects of this modality of treatment. Sunitinib and sorafenib are the most commonly used and effective molecules in the neo adjuvant/re surgical treatment of renal cell carcinoma . Bevacizumab is less effective and has more chance of surgical complications in these settings mainly due to poor wound healing secondary to prolonged wash off period . The patent and the surgeon should be aware of the unpredictability and possible adverse effects before advising these molecule pre operatively. The response of the primary renal tumour to the target molecule is different from that of the metastatic tumour. The side effects of the molecules and its effect on the peri operative morbidity and mortality should also be considered when we advise these molecules as pre surgical/neo adjuvant treatment.

Purpose: We present a comprehensive account of clitoral anatomy, including its component structures, neurovascular supply, relationship to adjacent structures (the urethra, vagina and vestibular glands, and connective tissue supports), histology and immunohistochemistry. We related recent anatomical findings to the historical literature to determine when data on accurate anatomy became available. Materials and Methods: An extensive review of the current and historical literature was done. The studies reviewed included dissection and microdissection, magnetic resonance imaging (MRI), 3-dimensional sectional anatomy reconstruction, histology and immunohistochemical studies. Results: The clitoris is a multiplanar structure with a broad attachment to the pubic arch and via extensive supporting tissue to the mons pubis and labia. Centrally it is attached to the urethra and vagina. Its components include the erectile bodies (paired bulbs and paired corpora, which are continuous with the crura) and the glans clitoris. The glans is a midline, densely neural, nonerectile structure that is the only external manifestation of the clitoris. All other components are composed of erectile tissue with the composition of the bulbar erectile tissue differing from that of the corpora. The clitoral and perineal neurovascular bundles are large, paired terminations of the pudendal neurovascular bundles. The clitoral neurovascular bundles ascend along the ischiopubic rami to meet each other and pass along the superior surface of the clitoral body supplying the clitoris. The neural trunks pass largely intact into the glans. These nerves are at least 2 mm in diameter even in infancy. The cavernous or autonomic neural anatomy is microscopic and difficult to define consistently. MRI complements dissection studies and clarifies the anatomy. Clitoral pharmacology and histology appears to parallel those of penile tissue, although the clinical impact is vastly different. Conclusions: Typical textbook descriptions of the clitoris lack detail and include inaccuracies. It is impossible to convey clitoral anatomy in a single diagram showing only 1 plane, as is typically provided in textbooks, which reveal it as a flat structure. MRI provides a multiplanar representation of clitoral anatomy in the live state, which is a major advantage, and complements dissection materials. The work of Kobelt in the early 19th century provides a most comprehensive and accurate description of clitoral anatomy, and modern study provides objective images and few novel findings. The bulbs appear to be part of the clitoris. They are spongy in character and in continuity with the other parts of the clitoris. The distal urethra and vagina are intimately related structures, although they are not erectile in character. They form a tissue cluster with the clitoris. This cluster appears to be the locus of female sexual function and orgasm.

A51-year-old male, who had undergone laparoscopic deroofing of a simple renal cyst on the left side two years ago, presented with left flank pain of one month’s duration near the port site, along with low-grade fever. There was no abdominal distension or mass, nor alteration in bladder or bowel habits. He was not a diabetic nor had he any other important medical history. Physical examination revealed a temperature of 100.4 F, soft abdomen with severe tenderness over the left iliac fossa, and unremarkable left flank and costovertebral angle. The white blood cell count was 19,000/mcL, and the serum creatinine concentration was 1.52 mg/dL. A magnetic resonance imaging scan of the abdomen revealed a collection with enhancing septations in the left posterior pararenal space, extending into the psoas and quadratus lumborum muscles and adhering to the posterolateral abdominal wall. There was left perirenal stranding (Fig. 1) and a small left renal upper polar cortical cyst (Fig. 2). Blood and urine culture studies yielded no growth. Empiric antibiotic therapy was of no benefit and the patient returned with a pointing abscess about to rupture. The collection was incised and drained after ruling out any urine leak from the left upper urinary tract by retrograde urography, and a closed suction drain was left in the abscess cavity. The pus sample sent for culture yielded growth of nonfermenting gram-negative bacilli, identified by VITEK 2 compact system (bioMerieux, Inc., St Louis, MO) as Achromobacter xylosoxidans with a 99% probability and an ‘‘excellent identification’’ confidence level. The isolate was susceptible to piperacillin, levofloxacin, co-trimoxazole, ceftazidime, cefoperazone-sulbactam, and meropenem, but resistant to aminoglycosides and tetracycline using Clinical and Laboratory Standards Institute (CLSI) break points for nonEnterobacteriaceae. The drain was removed on the fifth post-operative day and the patient was discharged on oral levofloxacin and cotrimoxazole. Three days after discharge, the patient returned in sepsis with similar complaints and pus draining from the incision. On retaking the history, it was determined that the patient had stopped taking the antibiotics after discharge. On examination, his temperature was 101.6 F and he had tenderness of the left flank. Abdominal ultrasonogram showed minimal residual collection at the abscess site. A second incision and drainage was performed immediately under cover of intravenous cefoperazone-sulbactam. A small amount of purulent material was drained and the abscess wall was debrided. The benign-looking small cortical cyst towards the upper pole was left undisturbed on both occasions. After 1 wk of intravenous antibiotic and supportive therapy, the patient was discharged in good health on oral co-trimoxazole and levofloxacin for 2 wks. On clinic follow-ups at 1 mo and 3 mos, there was no evidence of any continuing infection or any local symptom or abnormal findings on imaging studies other than the unchanged cortical cyst. Achromobacter xylosoxidans is a non-fermenting gramnegative, motile oxidase-positive bacillus belonging to the Alcaligenaceae family [1]. It is characterized by the ability to utilize xylose and glucose oxidatively. Identification using traditional phenotypic test often is unreliable and A. xylosoxidans can be mistaken for non-aeruginosa strains of Pseudomonas or for strains of Burkholderia cepacia complex. Achromobacter xylosoxidans is an opportunistic pathogen capable of causing nosocomial and community-acquired infections, with the source being either endogenous or from a contaminated aquatic hospital environment [2]. It frequently has been iso

Background Laparoscopic donor nephrectomy (LDN) is more difficult on the right than the left and is typically not recommended for the right kidney. Materials and methods Between November 2002 and May 2003, three patients underwent right-sided donor nephrectomy: one transperitoneally and two retroperitoneoscopically. All procedures were performed in the right kidney position. Three ports were placed for retroperitoneoscopic approach and four for transperitoneal, including one to retract the liver. Renal arteries were clipped thrice and divided, and renal veins divided using an endo-GIA30 stapler. Kidneys were retrieved in all cases by extending the lower port incision by 7 to 8 cm. The records of donors and recipients, including early graft outcomes were reviewed. Results Kidney retrieval time and total warm ischemic time were 3:30 minutes and 5 minutes, respectively, for transperitoneal LDN and 3:40 to 4:10 minutes and 5 to 7 minutes, respectively, for retroperitoneal LDN. The operating times were 176, 224, and 160 minutes, respectively. The first donor (transperitoneal) was discharged on the fourth postoperative day, and the other two (retroperitoneal) on the third day. The serum creatinine of all recipients normalized within 72 hours, with normal isotope renal scans on the fifth postoperative day. Conclusions Right-sided LDN is feasible and safe without adversely affecting graft quality. The retroperitoneal approach is technically easier, gives a longer length of renal artery, and has a quicker convalescence.

Background Laparoscopic donor nephrectomy (LDN) is being adopted rapidly by transplant centres around the world as it offers less postoperative pain, quicker convalescence, and better cosmetic result when compared with the open approach. There may, however, be a steep learning curve with this technique. Method A retrospective review was performed to evaluate the donor morbidity and graft outcome of 21 consecutive LDN performed at one centre between May 2002 and August 2003. Results Eighteen LDN were performed on the left and three on the right side. All left and one right LDN were done transperitoneally while the remaining two right side kidneys were removed by a retroperitoneal approach. The mean (±SD) operating time and warm ischemic time were, respectively, 236 minutes (± 46) and 4 minutes (± 1). The mean time for resuming oral intake was 23 hours (SD ± 22.7). The median length of hospital stay was 5 days (range 3 to 18). One patient was reoperated for bleeding and required four units of packed cell transfusion. One recipient displayed delayed graft function requiring dialysis for 14 days. There were no graft losses. The mean creatinine of the recipients at the time of discharge was 1.15 mg/dL (± 0.21). Conclusions There is undoubtedly a learning curve with LDN. Nevertheless, with prior skills in similar procedures such as laparoscopic radical nephrectomies, it is feasible to diminish the learning curve and morbidity of LDN to yield results consistent with those in the published literature.

We determined the long-term outcome of radiological and surgical intervention in young patients with renovascular hypertension.Between 1989 and 2001, 85 patients with a mean age +/- SD of 21 +/- 10.3 years, including 59 with Takayasu's arteritis (TA) and 26 with fibromuscular dysplasia (FMD), underwent radiological (percutaneous transluminal angioplasty) or surgical treatment for renovascular hypertension due to renal artery stenosis. The technical success, complications and clinical response of each treatment were compared.Of the patients 29 with TA and 20 with FMD underwent a total of 56 balloon angioplasties. Technical success was achieved in 94.58 renal units with a clinical response in 41 patients (83.9%). However, the re-stenosis rate was 24.13% in TA and 10% in FMD cases. A total of 41 surgical procedures were performed in the 28 and 7 patients with TA and FMD, respectively, including aortorenal bypass with vein in 12, and with a polytetrafluoroethylene graft in 4, lienorenal bypass in 4, iliorenal bypass in 2, gastroduodenal bypass in 1, autotransplantation in 1, nephrectomy in 14 and partial nephrectomy in 2. The clinical response rate to renal revascularization procedures was 94.4%, whereas it was only 50.0% for nephrectomy/partial nephrectomy during a median followup of 42 months (range 9 to 96).Percutaneous transluminal angioplasty and renal revascularization provide comparable long-term results in the management of renal artery stenosis due to TA and FMD. Although it is technically complex, surgery for TA is safe and effective. However, the rate of re-stenosis following angioplasty for TA is higher compared with FMD.

Background Laparoscopic donor nephrectomy (LDN) has become widely popular in developed countries but not so in developing countries. One explanation for this maybe the difficulty in getting access devices due to the prohibitive cost. We report our method of terminal hand-assisted LDN in which successful donor nephrectomy is feasible without expensive access devices. Method The patient is placed in the corresponding classic renal surgery position. Three ports are placed for left-sided and four for right-sided LDN. After complete mobilization of the kidney laparoscopically, the assistant's right hand is introduced for left-sided LDN through a 7-cm left lower quadrant transverse muscle-splitting incision. For right-sided LDN, the surgeon's right hand is inserted through a corresponding ipsilateral incision (for right-handed surgeons). A simple method to prevent the leakage of pneumoperitoneum is described. The hand inside the abdomen aids in the final steps and completes the extraction of the kidney swiftly. Manual mopping, lavage, and hemostasis are also possible. Results Five cases of LDN at our centre were done in this fashion, four on the left side and one on the right. The mean kidney retrieval time after clamping the renal artery was 3:18 ± 0:46 minutes (range 2:30 to 4:30). Postoperative stay was 4 to 5 days. Recipient serum creatinine normalized within 3 to 4 days. Conclusions Short duration terminal hand-assist for LDN without any special access device is possible without the fear of excessive gas leakage. It is helpful to reduce prolonged warm ischemia and to relieve the surgeon's apprehension, at least in the initial learning phase of LDN.

Severe hypertension resistant to multiple antihypertensive drugs represents an indication for bilateral pretransplant renal ablation by surgery or angioembolization. Besides causing severe pain and renal postinfarction syndrome, angioembolization may be ineffective. We present our experience with simultaneous bilateral laparoscopic pretransplant nephrectomies in patients with end-stage renal disease and severe uncontrollable hypertension. Among the three patients considered for bilateral pretransplant laparoscopic nephrectomy between September 2002 and August 2003, the procedure was successfully performed in two patients. Left nephrectomy was performed transperitoneally and right nephrectomy retroperitoneoscopically. In one of the three patients, a prior attempt at angioembolization had produced a dense perirenal reaction, rendering laparoscopic surgery impossible. Total operating time for bilateral laparoscopic nephrectomies was 260 and 280 minutes. Within 1 month following the nephrectomies, all patients became normotensive with minimal or no antihypertensive medications. We conclude that simultaneous bilateral laparoscopic nephrectomy is feasible and less morbid in end-stage renal disease patients. Prior angioembolisation can make laparoscopic surgery difficult or impossible.

Prophylactic ureteric stenting has been shown to reduce ureteric leaks and collecting system obstruction following renal transplantation and is in widespread use. However, the optimal time for removal of ureteric stents after renal transplantation remains unclear. Aim of this study was to compare the result of early versus late removal of ureteric stents after kidney transplantation of the laparoscopically retrieved live related donor grafts. Eligible patients were live donor kidney transplant recipients with normal urinary tracts. All recipients underwent extravesical Lich-Gregoire ureteroneocystostomy over 4F/160 cm polyurethane double J stents by a uniform technique. They were randomized on seventh postoperative day for early removal of stents on postoperative day 7 (Group I), or for late removal on postoperative day 28 (Group II). The incidence of urinary tract infections, asymptomatic bacteriuria, and urological complications were compared. Between 2007 and 2009, 130 kidney transplants were performed at one centre of which 100 were enrolled for the study, and 50 each were randomized into the two groups. Donor and recipient age, sex, native renal disease, immunosupression, number of rejection episodes, and antirejection therapy were similar in the two groups. The occurrence of symptomatic urinary tract infection during the follow-up period of 6 months was significantly less in the early stent removal group [5 out of 50 (10%) in Group I, vs 50 out of 15 (30%) in Group II, P=0.02]. Asymptomatic bacteriuria was documented in 2 out of 50 (4%) in Group I and 4 out of 50 (8%) in Group II (P=0.3). There was no statistically significant difference in the rate of ureteric leak, ureteric obstruction, or hematuria in the two groups (P=1.0). We conclude that, in kidney transplant recipients of laparoscopically retrieved live donor grafts, early stent removal at the end of first week reduces the incidence of urinary tract infection without increasing the rate of urine leak or ureteric obstruction.