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Purpose: Complication rates with ventral onlay technique of oral mucosa graft urethroplasty have been attributed to the poor ventral support for the graft. We herein describe a new technique which overcomes these problems and also discuss the short-term follow-up. Materials and Methods: In a prospective study conducted between January 2006 and June 2008, 13 patients with proximal stricture of the bulbar urethra underwent ventral bulbar augmentation. In this technique, the graft was sutured only to the bulbar urethra and the rest of spongiosal tissue was closed superficially. Longitudinal incisions were given in the partial depth of the bulb, adjacent to the suture line and were sutured together over the first suture line. Results: The mean follow-up period was 16.4 months (range, 6 to 30 months). Two of the patients developed restricture; one at the proximal anastomosis of the graft with native urethra and one at the distal anastomosis. Remaining 11patients have satisfactory postoperative uroflow rates and are doing well. The success rate at the last follow-up was 84.6%. Conclusion: This technique exploits the local bulbar anatomy by successfullymoving the lateral bulbar tissue medially, below the ventrally placed mucosal graft. This results in a thicker ventral bulbar platform which provides enhanced support to the graft. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The purpose of this study was to determine the frequency of androgen decline in the aging male (ADAM) in a group of Indian men working in the health sector. MATERIALS AND METHODS: A free medical health checkup camp was organized for the male workers aged between 40 and 60 years employed in surgical departments of our hospital. Of 180 listed male workers, 170 attended this camp and 157 eligible men participated in the study. After clinical history and systemic inquiry, the participants were requested to complete the Saint Louis University's ADAM questionnaire, and their serum levels of free and total testosterone were measured. RESULTS: Symptomatic andropause was found in 106 men (67.5%) on the basis of their responses to the questionnaire, of whom 41 (38.7%) had low serum free testosterone levels and 32 (30.2%) had low serum levels of total testosterone. Fifty-one men were asymptomatic according to the questionnaire and in this group, 11 (21.6%) had low serum free testosterone levels and 6 (11.8%) of these had low total testosterone levels. The frequency of andropause was 33.1% on the basis of low serum free testosterone levels and it was 26.1% when both symptoms and low serum free testosterone levels were taken into account. CONCLUSION: In our study, the high frequency of symptoms related to ADAM was unusual. This might be due to the nature of the questionnaire itself. Serum free testosterone measurement may be a better single test for diagnosis of hypogonadism than serum total testosterone measurement. [ABSTRACT FROM AUTHOR]

Competing Interests: Declaration of Competing Interest There is no conflict of interest of Financial interest of any kind

GATA binding protein 3 , a zinc finger transcription factor , has now been demonstrated as a valuable and sensitive marker for conventional urothelial carcinoma with sparse literature related to its expression in various histological variants. It is a prospective study where 74 consecutive cases of bladder carcinoma were included between August 2016 and January 2017 followed by immunohistochemistry to assess GATA 3 expression in conventional as well as different urothelial carcinoma (UC) variants. Overall, 57 of the 74 lesions (77%) demonstrated nuclear staining for GATA 3. GATA 3 expression significantly correlated with histological grade ( P  < 0.001) and muscle invasion ( P  = 0.005). Divergent differentiation was observed in 54% (40/74) of the total cases. The study included 12 different variants of urothelial carcinoma. All or majority of the cases of clear cell (6/6, 100%), glandular (6/8, 75%), and sarcomatoid (4/6, 66.7%) variants expressed GATA 3 in a moderate to strong fashion and belonged to group III or IV. Nested variant, small cell carcinoma, pure squamous cell carcinoma, and squamous component of urothelial carcinoma with squamous differentiation do not show any GATA 3 expression. GATA 3 was expressed more intensely as well as in greater number of tumor cells at lymph node metastatic tumor deposits as compared to the primary tumor. GATA 3 expression was not significantly associated with tumor stage or patients' clinical outcomes. GATA 3 is expressed in majority of variants of UC albeit with variable staining; however, situation is challenging in some variants known to be associated with poor prognosis like nested variant, small cell carcinoma, and squamous cell carcinoma where it is not expressed. Hence, the sensitivity of this determinant is diminished in these variants, which may affect the interpretation of GATA 3 stains at metastatic sites as well as their distinction from secondary bladder involvement, by tumors of non-urothelial origin., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Indian Association of Surgical Oncology 2021.)

Background: Androgen-deprivation therapy (ADT) as a treatment modality in advanced prostate cancer has deleterious effect on bone mineral density (BMD) and quality of life (QOL). Using FRAX (Fracture Risk Assessment) model, candidates at high risk of fractures can be predicted and appropriate treatment can be initiated at early step to prevent skeletal-related events. Objectives of the present study were to evaluate bone health, implication of FRAX tool in advanced prostate cancer and to see the impact of ADT and Bone-directed therapy (BDT) on FRAX and FACT-P QOL scores., Material & Method: We conducted a prospective longitudinal study of 83 localized and metastatic prostate cancer patients from March 2017 to Dec 2020. FRAX tool using BMD femoral neck (GE-Lunar) was used to compute the probability of 10-year Major osteoporotic fracture (MOF) and hip fracture risk %. Patients who received monthly Zolendronic acid with or without Vitamin-D/calcium supplementation were classified as BDT group. FRAX and FACT-P were measured at baseline and 12 months follow-up and compared between different therapeutic modalities to see the impact on clinical outcomes., Results: Majority of patients had skeletal metastasis (78.3%) and high-grade disease at presentation. Secondary osteoporosis was the most commonly (82.05%) observed clinical risk factor (CRF) followed by smoking (19.23%). Hip fracture risk ≥3% accounted for larger proportion of patients than did MOF risk ≥20% (21.2% and 2.5%, respectively). Statistically significant reduction was observed in both MOF and hip fracture risk in BDT group, while worsening on ADT. ADT duration correlated positively with both MOF and hip fracture risk (R 2 =0.148, P<0.001 and R 2 =0.164, P<0.001, respectively). FRAX score accurately predict future fracture events in majority (80%) of high-risk patients. Statistically and clinically significant worsening in PWB, EWB, PCS, FACT-P Total, FACT-P TOI and FAPSI scores were observed in patients on ADT. Statistically and clinically significant improvement was noted in physical well-being in BDT group. However, other QOL domains and FACT-P total scores remained stable., Conclusions: ADT caused duration depended worsening of FRAX and FACT-P score in these patients while improvements of FRAX were seen on BDT. FRAX tool is advantageous in identifying the patients who require early intervention or therapy to decrease skeletal-related events., Competing Interests: None., (AJCEU Copyright © 2021.)

Introduction: Use of androgen deprivation therapy (ADT) in carcinoma prostate (CaP) has deleterious effect on bone mineral density (BMD) leading to increase incidence of osteoporosis and skeletal-related events. We evaluated bone health status and impact of bone-directed therapy (BDT) and ADT on BMD in these patients from Jan 2015-Dec 2018., Materials and Method: Baseline bone health was assessed using Tc-99 MDP Bone scan/DEXA scan for patients on ADT. Monthly zoledronic acid (ZA) was given to high-risk candidates (T-score ≤2.5 or previous hip/vertebral fracture) or Skel et al. metastatic patients who were receiving ADT. Baseline and follow-up (at 12-months) BMD using DEXA scan at various sites (spine, femur total, femur neck and radius) and subjective improvement in bony pain using Numeric Pain Rating Score after administration of ZA were compared., Results: A total of 96-patients of locally advanced and metastatic prostate cancer receiving ADT with or without BDT were included in the study cohort. Mean age of presentation was 68.4±15.61 years. Median serum PSA was 32.2±13.1ng/mL. There was significant improvement in mean BMD (T-score) in 64-patients post ZA therapy at 12-months (at femoral total, femoral neck and spine; 0.95, 0.79 and 0.68, respectively) (p < 0.05) while there was significant deterioration in mean BMD at 12-months (at spine, femoral neck and femoral total; -0.77, -0.55 and -0.66, respectively) in 32 patients who did not receive ZA and were on ADT (p < 0.05). Pain scores significantly decreased in patients after 12-months of ZA use (-2.92±2.16, p < 0.01)., Conclusion: Bone-directed therapy (Zoledronic acid) leads to both subjective and objective improvement in bone health of prostate cancer patients on ADT., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Genital tuberculosis (TB) in women is a chronic disease with low-grade symptoms. Genital tract tuberculosis is usually secondary to extragenital TB. The fallopian tubes are most commonly affected, and along with endometrial involvement, it causes infertility in such patients. Involvement of the cervix and the vulva is very rare. We present one such rare case of vulvar tuberculosis presented with a large ulcer diagnosed on histopathology and treated with antitubercular chemotherapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The etiology of prostate cancer (PCa) is multi-factorial including environmental and genetic factors. Present study evaluates the association between level of pesticides, stress level and CYP1A1 gene polymorphism with PCa patients., Methods: A case control study was conducted with 102 PCa patients and age match symptomatic (n= 107) and asymptomatic benign prostatic hyperplasia (BPH, n= 70) patients. Pesticide level was characterized by Gas Chromatography. The oxidative stress and scavenging mechanisms were determined by biochemical method. Two polymorphisms of CYP1A1 gene, rs4646903 and rs1048943, were analyzed by polymerase chain reaction (PCR) followed by restriction fragment length polymorphism and allele specific PCR method., Results: Higher level of pesticide namely beta-hexachlorocyclohexane (β-HCH), Malathion, Chlorpyrifos and Fenvalerate were found in PCa group (all p value: < 0.05). Kruskal Wallis H test depicted that level of β-HCH and Malathion significantly correlated with higher grade of PCa (all p< 0.05). The PCa Patients with simultaneously low antioxidant activity and high stress level tended to suffer worst clinical outcomes. Dominant model of rs4646903 and rs1048943 suggested that substitution is associated with a higher risk of PCa (OR: 2.2, CI: 1.6-3.8, p: 0.009 and OR: 1.95, CI: 1.1-3.4, p: 0.026; respectively) and this risk was also influenced by smoking and pesticide exposure., Conclusion: Environmental and genetic factors are reported to raise risk; person with high level of these pesticides especially in high risk genotype might be more susceptible to PCa.

Objective: To highlight changing trends of the clinical spectrum, and compare the management options and predictors of Fournier's gangrene (FG) outcomes in a tertiary care referral center., Material and Methods: This study included patients with FG between August 2005 and July 2017. Patients were classified as "responders" and "nonresponders." We compared the baseline characteristics, clinical spectrum, biochemical data, management modalities, outcomes, and FG severity index (FGSI) and age-adjusted Charlson Comorbidity Index (ACCI) between responders and nonresponders., Results: We studied 72 patients and further divided them to responders (60 patients) and non-responders (12 patients). All were males; the mean age was 56.27+19.27 years (range, 47-85 years). The most common complaints were perineal discomfort (n=62; 86.1%) and fever (n=48; 66.7%). FG originated from the penoscrotal region in 64 patients (88.8%) and perineal region in 8 patients. Diabetes mellitus was the most common comorbidity (36%). The mean duration of the presentation was 10.19 days (range, 7-30 days). Sixteen patients underwent split skin grafting. The mortality rate was 8.3%. Nonresponders had distinct findings relative to responders: advanced age (71.5±7.17 vs. 53.23±19.85 years; p=0.00); high blood sugar (245.83±116.26 vs. 139.06±35.64 mg/dL; p<0.01); leukocytosis (27166.67±10295.75 vs. 10558.4±3130.64 cumm; p<0.01); elevated serum creatinine (3.78±1.43 vs. 1.38±1.00; p<0.01); hyponatremia (127.33±11.84 vs. 137.33±3.42 meq/l; p<0.01), elevated international normalized ratios (1.66±0.28 vs. 1.32±0.07; p<0.01); and high FGSI (9.83±1.11 vs. 6.46±1.68;p<0.01) and ACCI scores (6.33±0.49 vs. 5±0.82; p<0.01). On univariate and multivariate regression analysis, raised blood sugar and deranged international normalized ratios at presentation were significantly associated with decreased response to treatment (p<0.05)., Conclusion: An advanced age, diabetes mellitus, renal impairment, leukocytosis, altered sensorium, shock at presentation, deranged international normalized ratios, and high FGSI and ACCI scores can be used as predictors for poor response. FG risk scores adequately characterize the severity and prognosis of FG, but clinician's judgement is vital. The management comprises of a multidisciplinary approach, including parenteral antibiotics, urgent surgical debridement, and comorbidities optimization.

Objective: Assessment of results of repairing vesicovaginal fistula (VVF) with or without the use of interposition flaps., Material and Methods: This prospective randomized study was conducted between January 2012 to December 2017 in the Department of Urology, King George's Medical University, Lucknow, India. Obstetric and gynecological simple fistula of ≤4 cm were included for evaluation. Those with complex or complicated fistula or fistula due to malignancy were excluded. Patients were divided into two groups (group 1 and group 2) depending upon route of repair i.e., transvaginal or transabdominal, respectively, as per the characteristics and location of the fistula. These two groups of patients were randomized into two subgroups (1A, 1B and 2A, 2B) based on the inclusion or omission of the interposition flap during fistula repair. Perioperative and postoperative parameters (blood loss, mean operating time, hospital stay, and requirement of analgesics) and success rates of fistula repair were compared. All complications that occurred in the postoperative period till the last follow-up appointment were recorded. The Clavien-Dindo Classification was used to stratify the complications., Results: Fifty-seven patients underwent transvaginal repair in group 1 (29 with Martius flap: group 1A; 28 without Martius flap: group 1B), while 69 patients underwent transabdominal repair in group 2 (35 with interposition flap: group 2A; 34 without flap: group 2B). Blood loss, mean operating time, hospital stay, and the requirement of analgesics were comparable between each subgroup-1A versus 1B and 2A versus 2B, respectively. The overall success rate of repair across all groups was 96.04% (121/126). The success rate was 93.1% in transvaginal repair with Martius flap versus 96.43% in transvaginal repair with no flap (p=1.0). Success rate was 97.1% in transabdominal repair with an omental flap versus 97.06% in without an omental flap (p=1.0). Mean follow-up period was 39.6 months (range: 6-68 months). Out of 29 patients with Martius flap interposition, 9 (31.03%) of them reported a significantly reduced sensation on the labia majora. Of these 9 patients, 5 reported numbness while the remaining 4 experienced pain as compared to the patients in subgroup IB, who did not report any altered sensation in the labia. (p=0.0019)., Conclusion: The success rates are similar in simple VVF repair (fistula size less than 4 cm) irrespective of the use of interposition flaps. However, overall morbidities following repair with the interposition flap are higher when compared with repair without interposition flap, either by the transvaginal or by the transabdominal route.

Objective: Neoadjuvant chemotherapy followed by radical cystectomy is considered the standard of care for patients with muscle invasive bladder cancer. In the last decade, interest in neoadjuvant chemotherapy has slowly shifted from methotrexate, vinblastine, doxorubicin and cisplatin regime to gemcitabine and cisplatin regime. There are many publications on gemcitabine and cisplatin regime in literature which cover different aspects of treatment. This review aims to summarise the findings published so far on gemcitabine and cisplatin regime and present it in a concise manner., Methods: A systematic literature review was conducted searching the PubMed ® database in December 2016 using the medical subject heading (MeSH) with the terms gemcitabine, cisplatin, chemotherapy, muscle invasive bladder cancer, and neoadjuvant. All relevant studies were included and results were analysed., Results: A total of 13 studies were included which published between 2007 and 2015. These 13 studies comprised of 754 subjects suffering from muscle invasive bladder cancer. The proportion of male patients ranged from 60% to 86.4% and the median age ranged from 54.2 to 77.3 years in various studies. Complete pathological response (pT0) was seen in 30.0% of patients and pathological downstaging (

Percutaneous nephrostomy (PCN) catheter placement is a commonly performed procedure in the urological practice for various indications like percutaneous nephrolithotomy, pyonephrosis, infected hydronephrosis and after failed attempt of ureteric stenting. The nephrostomy catheter is usually associated with low complication and morbidity rate, but prolonged indwelling nephrostomy tube may be hazardous in some cases. We hereby report a case of squamous cell carcinoma of skin around the PCN, which was attributed to chronic inflammation and persistent irritation from a long-term neglected indwelling nephrostomy catheter for last 3 years. The patient was managed with wide local excision of skin carcinoma and ureterocalicostomy for pelviureteric junction stricture. The authors report the first documented case with aforementioned presentation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: This study aims to explore the utility of GATA binding protein 3, a zinc finger transcription factor, expression in genitourinary carcinoma, especially urothelial carcinoma., Settings and Design: It is a prospective study where 74 consecutive cases of urothelial carcinoma along with 10 cases each of prostatic adenocarcinoma (PC) and conventional clear cell renal cell carcinoma were included between August 2016 and January 2017., Methods and Materials: All the cases were histopathologically evaluated and immunohistochemically stained for GATA binding protein 3. Only nuclear positivity was considered as positive. Immunoreactivity score for GATA expression was calculated based on the staining intensity as well as percentage., Statistical Analysis Used: The statistical analysis was done using Statistical Package for Social Sciences Version 15.0 statistical analysis software. P value of <0.05 was considered statistically significance., Results: GATA3 expressions were seen in 77% of the cases of urothelial carcinoma, whereas none of the clear cell renal cell carcinoma and prostatic adenocarcinoma cases was GATA3 positive. GATA3 expression significantly correlated with histological grade and muscle invasion with a weaker or negative expression in high-grade muscle invasive tumor as compared to low-grade and noninvasive neoplasm. Significantly weaker expression of GATA3 was found in cases with severe nuclear pleomorphism, mitosis >10/10 hpf, presence of necrosis, and tumor-infiltrating lymphocytes. No significant change in the status of GATA3 expression was seen in follow-up cases between initial Transurethral resection of bladder tumor (TURBT) and post-recurrence TURBT or radical cystectomy specimens., Conclusions: GATA3 as a sensitive and specific marker for urothelial carcinoma can be effectively used to exclude other genitourinary malignancies, PC, and renal cell carcinoma, at metastatic site. This marker can also be effectively used in predicting the probable grade and invasion in biopsy material with poor morphological characteristics, thereby helping in appropriate management in such cases., Competing Interests: None

Objective: Maintaining the optimum bone health is one of the important concerns in patients with prostate cancer, but it usually remains neglected. Failure to screen these patients is detrimental to both the length and the quality of life. The estimation of bone mineral density (BMD) and more recently the World Health Organization's fracture risk assessment (FRAX) algorithm in appropriate patients is recommended by several specialty organizations/associations at the time of instituting androgen deprivation therapy (ADT) for metastatic and high-risk individuals. It provides a 10-year risk evaluation of hip and major osteoporotic fractures (MOF). Using this web-based new investigating tool, candidates at high risk of fractures can be predicted more accurately according to clinical risk factors (CRF) alone or in combination with the femoral neck BMD. The FRAX application for senile osteoporosis has been studied and reviewed extensively, but no systematic review has ever been conducted for assessing the implication of FRAX in prostate cancer. This review article will give insight about the validity, role, and utility of this investigating tool in clinical practice for fracture risk assessment in these individuals., Material and Methods: This systematic review was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and Cochrane review principles. We searched the PubMed, Cochrane database of systematic reviews, and the EMBASE electronic database until December 2018 using the medical subject heading terms prostate cancer and FRAX., Results: A total of nine studies meet the inclusion criteria and were included in the review. These studies enrolled a total of 3704 patients (sample size range, 78-1220) of localized, metastatic, castration resistant prostate cancer with or without ADT and/or on photon or radiotherapy. The factors that influenced FRAX included age, ethnicity, baseline BMD, duration of ADT, presence of CRF, and measurement methods (CRF, with/without BMD, computed tomography based). An advanced age and duration of ADT were the most robust risk factors. A 10-year MOF and hip fracture risk estimation was higher when the femoral neck BMD was not incorporated in the FRAX measurement. Despite several well-known strengths of using FRAX in the fracture risk assessment of suitable candidates with prostate cancer, several risk factors such as the mode/duration of ADT, mode of radiotherapy, Vitamin D levels, bone remodeling markers, and recent/recurrent fractures need to be incorporated in the FRAX calculator for improving the predictive ability. In contrast to senile osteoporosis with a longer life expectancy, the fracture risk in patients with prostate cancer need to be measured more frequently and for a shorter time. Therefore, models like Garvan calculator with both 5- and 10-year risk estimates have to be developed for these patients. Additionally, its utilization is of limited value in the presence of recurrent fractures or falls., Conclusion: The FRAX algorithm is beneficial in identifying patients who require early intervention or bone-directed therapy as an early step to decrease skeletal-related events and other morbidity. Several risk factors need to be added for improving the FRAX predictive value. This model is still underutilized in the clinical practice and increasing the awareness among treating physicians will help in optimizing the bone health and the quality of life of this important population subgroup.

Competing Interests: Competing interests: None declared.

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%., Competing Interests: There are no conflicts of interest.

Competing Interests: Competing interests: None declared.

Caroli's disease is a rare congenital disorder with incidence rate of approximately 1 in 1 000 000 population. Renal anomalies which may be associated with Caroli's disease include medullary sponge kidney (MSK), cortical cysts, adult recessive polycystic kidney disease and rarely autosomal dominant polycystic kidney disease. Exact incidence of MSK in patients of Caroli's disease is not known. There are only a handful of reported cases of this association in literature. We hereby report a case of Caroli's disease with MSK with nephrocalcinosis. He presented to primary health centre with symptoms of urethral stricture due to lichen sclerosus et atrophicus and was managed with repeated co-axial dilatation but was never evaluated for underlying chronic renal insufficiency due to MSK. The thorough clinical examination and proper evaluation is important in patient of urethral stricture with underlying chronic renal insufficiency to avoid delayed diagnosis, management and related complications., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Urethral calculus causes variety of symptoms from simple dysuria to acute urinary retention. The diagnosis is many times not easy. A plain X-ray of the pelvis may aid in diagnosis. Due to variety of symptomatic presentations sometimes it is not the first diagnosis that comes to one's mind. Management is by removal of the calculus via various methods ranging from endoscopic to open surgery. We present the case of an adult male, who was initially thought to have periurethral abscess due to stricture urethra but during investigations was found to have urethral calculus as the cause for his symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Giant hydronephrosis (GH) is a rare clinical entity with about 600 cases and defined as the adult renal pelvis containing greater than 1 L of fluid, or at least 1.6% of the body weight or kidney occupying the hemiabdomen. The pelvic-ureteric junction (PUJ) obstruction is the most frequent cause of GH. We thus report a case of massive abdominal distension due to GH secondary to PUJ obstruction who presented with acute duodenal obstruction due to extrinsic compression and was managed with percutaneous nephrostomy followed by open nephrectomy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Nephrocutaneous fistula is a rare complication of surgical procedures involving the kidney. Fistula formation is also a complication seen in gossypiboma. We present the case of a patient who was initially suspected to have nephrocutaneous fistula after open pyelolithotomy. Later while undergoing open resection of fistula, he was found to have a retained surgical sponge (gossypiboma) near the lower pole of kidney. Gossypiboma is a term used for mass formed around a surgical sponge accidentally left in the body. It is most of the times not diagnosed by radiological imaging and thus results in unnecessary investigations to rule out other causes for the patient's symptoms. Having a high index of suspicion may lead to an earlier diagnosis. But the prevention of gossypiboma is of the utmost importance. A meticulous approach while operating by the surgeon and operating rooms staff is very important in doing so., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

A 22-year-old woman met with road traffic accident 6 months back following which she underwent exploratory laparotomy with intraperitoneal bladder rupture repair. She presented with urethrovaginal fistula due to a fragment of fractured pubic bone impinging into the anterior vaginal wall. The findings were confirmed on CT scan and cystoscopy. The patient was managed with removal of the bony spicule and transvaginal repair of urethrovaginal fistula with Martius fat pad interposition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Pediatric population has increasing incidence of renal calculus and it is estimated to be around 50/10,000 population. The treatment of choice for large and complex stone in anomalous kidney is percutaneous nephrolithotomy (PCNL). The fate of insignificant residual fragment after PCNL in pediatric patients is not well documented. Here, we are reporting our long-term experience and follow-up of insignificant residual fragment in pediatric patients with anomalous kidney in comparison to normal kidney. Intuitional ethical approval was taken. A retrospective analysis of PCNL in pediatric (<18 years) anomalous kidney was performed from 2001 to 2013. The data of 52 pediatric patients with anomalous kidney (group B) have been compared to 251 normal kidneys (group A). The mean age of the patients was 7.83 + 3.45 (range 3-18) in group A and 8.21 ± 3.25 (range 5-18) in group B. The mean size of the insignificant residual fragment was 2.2 + 0.5 mm (1-4) in group A and 2.1 + 0.6 mm (range 1-4) in group B. Most of these residual fragments were single in number (72.55 vs. 67.30%, respectively). 54.98% children in group A and 67.30% in group B were symptomatic in the follow-up. Stone size was increased, stable and spontaneously passed in 49.8 vs. 71.15, 22.7 vs. 19.23 and 27.49 vs. 9.61% (p < 0.03), respectively, over mean follow-up of 50.34 months. Insignificant residual fragments in children are notorious for regrowth (49.8% in normal and 71.15% in anomalous kidney) in future. Most of the children will require symptomatic treatment (55.37 vs. 82.69%) or reintervention (39 vs. 46%) for insignificant residual fragment.

An adult man presented with off and on painless haematuria, which was diagnosed as bladder mass on contrast-enhanced CT. He underwent transurethral resection of bladder tumour with complete resection. A diagnosis of embryonal rhabdomyosarcoma was made following histopathology and immunohistochemistry report. The patient was planned for radical cystectomy but was found to have large recurrent infiltrating bladder mass with liver and bone metastasis. Hence, the plan for radical cystectomy was deferred and the patient was counselled regarding chemotherapy (vincristine, cisplatin and doxorubicin regime). The patient tolerated the first cycle of chemotherapy, but his condition deteriorated prior to the second cycle and the patient expired., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: To report our experience with sigmoid vaginoplasty in patients with different forms of disorder of sexual development and their long-term follow-up., Materials and Methods: This is a retrospective study of patients who underwent sigmoid vaginoplasty between July 2004 and June 2015 at our center. Follow-up included a physical examination to assess vaginal length and width, cosmetic appearance of the neovagina, and occurrence of any complications., Results: The current study included eight patients with mean age 19.5 years. The mean operative time was 164 min. No significant intraoperative or immediate postoperative complications occurred. Follow-up period ranges from 21 months to 12 years with mean of 7.5 years. In all patients, the neovagina was found to have a satisfactory cosmetic appearance. Seven patients are sexually active and satisfied., Conclusion: Sigmoid vaginoplasty is safe and acceptable procedure in patients having vaginal agenesis. Sigmoid vaginoplasty has acceptable cosmetic results and complication rate., Competing Interests: There are no conflicts of interest.

Introduction: For dorsal onlay graft placement, unilateral urethral mobilization is less invasive than standard circumferential urethral mobilization. Apart from success in terms of patency of urethra, other issues like sexual function, overall quality of life and patient satisfaction remain important issues while comparing outcomes of urethroplasty., Aim: To prospectively compare the objective as well as subjective outcomes of two approaches., Materials and Methods: Between July 2011 and January 2015, 136 adult males having anterior urethral stricture with urethral lumen ≥ 6 Fr. were prospectively assigned between two groups by alternate randomization. Operative time, complications, success rate (no obstructive symptoms, no need of any postoperative intervention, Q max > 15mL/sec), sexual functions (using Brief Male Sexual Function Inventory) were compared., Results: Baseline parameters were similar in both groups (68 in each group). Overall success rate was similar in both groups (89 % and 91 % respectively). Improvement in total LUTS scores was similar in groups. Changes in overall health status (VAS and EQ 5D) was equal in both groups. Erectile function score was significantly decreased in DO than DL group while ejaculatory function and sexual desire remained stable after urethroplasty in both groups., Conclusions: In anterior urethral stricture buccal mucosa graft provides satisfactory results as onlay technique. No technique whether dorsolateral and dorsal techniques is superior to other. Dorsolateral technique needs minimal urethral mobilization and should be preferred whenever feasible., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Here we present the case of a 40-year-old man, who underwent deceased donor renal transplantation. Towards the end of this operation, open-ended double J stent was inserted in the transplanted kidney. Modified Lich-Gregoir ureterovesical anastomosis was performed. Prior to the abdominal closure, it was discovered that proximal end of the stent had pierced the renal parenchyma and extruded on the external surface of the transplanted kidney. We contemplated removing the stent and reinserting it but decided against that due to various reasons. The stent was left as such. The patient was managed conservatively with satisfactory outcome in the postoperative period. To the best of our knowledge, this is first such report of conservative management of stent extrusion in transplanted kidney in the literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Vesicouterine fistula (VUF) is an uncommon cause of female genito-urinary fistula. Most of these fistulas are due to lower segment uterine cesarean section (LSCS). Traditionally, open surgical repair has been the traditional treatment. However, laparoscopic repair of VUF is a minimally invasive technique and few case reports have been published with short term follow up. In the present study, we are presenting our long- term outcome of laparoscopic repair of VUF., Material and Methods: A retrospective analysis of 8 patients with VUF was performed from 2010 to 2015. Approval of Institutional Review Committee was obtained. All had history of LSCS of whom 3 had history of prolonged obstructed labor. Radiological imaging included ultrasound of kidney, ureter and bladder for all patients and hysterosalphingography in 4 patients and contrast enhanced computed tomography scan in 4 patients., Results: Median age of the patient was 25.5 years (range, 22-32), and median follow up was 2.3 years (range, 1 -4). The most common presentation was cyclical menstrual bleeding through urine (menouria) in all, associated amenorrhea in 6 and vaginal leakage of urine in 2 cases. All patients underwent laparoscopic repair with successful outcomes. The mean operating time was 155±14.5 min (range, 135-186 min) with a median blood loss of 100 mL (range, 50-210 mL). Successful pregnancy was completed in 2 patients and other patients were taking contraceptives., Conclusion: Laparoscopic repair of VUF is a safe and effective minimally invasive technique with successful pregnancy in long- term follow up., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Objective: The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cosmetically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of performing laparoscopic ureteral reimplantation with Boari flap in 3 patients., Material and Methods: This prospective study was conducted between January 2011 December 2014. The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruction were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the manangement of long segment ureteral defect was evaluated., Results: The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilateral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range 8.2-9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was 100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19 months (range 17-22 months). None of the patients experienced any complication related to the procedure in perioperative period., Conclusion: Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term results. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

The objective of the study is to identify factors predicting development of pyonephrosis in patients of renal calculus disease (RCD), as this knowledge is largely unknown. Patients of RCD without pyonephrosis (Group 1) or with pyonephrosis (Group 2) presenting between December 2013 and November 2015 were evaluated. All patients of RCD who had undergone either percutaneous nephrostomy (PCN) or surgical management (percutaneous nephrolithotomy/pyelolithotomy/nephrectomy) were included. Patients treated conservatively, by extracorporeal shock-wave lithotripsy and patients of bilateral RCD were excluded. Data regarding demography, co-morbidities, associated urologic disease, previous intervention, clinical presentation, urinary culture, renal function, grade of hydronephrosis, stone characteristics were collected. 501 patients were included (Group 1: 410; Group 2: 91). Mean age in years (35.02 versus 35.48), sex ratio (2.12:1 versus 2.25:1) and mean body mass index (kg/m 2 ) (22.27 versus 22.15) were similar in both groups. Prevalence of diabetes mellitus (3.41% versus 3.29%, p = 1.000) was similar. Group 2 patients had longer duration of symptoms (5.77 versus 8.96 months, p < 0.0001), associated urological diseases such as ipsilateral PUJO and ureteric calculus (4.63% versus 12.08%, p = 0.0125), moderate/severe-grade hydronephrosis (49.75% versus 92.30%, p < 0.0001), presence of staghorn calculus (20.73% versus 62.63%, p < 0.0001), multiple calculi (48.29% versus 68.13% p = 0.0007) and nonfunctioning kidney (1.70% versus 71.42%, p < 0.0001) as predictors of pyonephrosis. In logistic multivariate analysis, additionally, past history of urological surgery (p = 0.044) was found associated with pyonephrosis. Our study identified some conditions associated with patients of pyonephrosis. To prove their role as risk factors we recommend further studies.

Iatrogenic renocolic fistulae, although have been described in literature, is a rare clinical complication. Recently its incidence is on rise due to advent of minimally invasive surgery and percutaneous surgery of kidney. It has been reported after percutaneous nephrolithotomy but its incidence after percutaneous nephrostomy is quite uncommon and rarely reported. Though spontaneous renocutaneous fistula has been reported, acquired renocutaneous fistula is very uncommon and fistula after gun shot injury has not been reported to the best of our knowledge. Herein, we present two different varieties of renal fistula with completely different history and presentation. But the interesting point is that both were managed conservatively in a similar fashion and both of them responded well., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aims: Bladder outlet obstruction (BOO) in large and small prostates is managed in a similar manner despite considerably different pathophysiology, which can result in higher failure rates. We investigate the clinical and urodynamic features and study the outcome of patients with benign prostate hyperplasia (BPH) according to their prostate size., Subjects and Methods: We prospectively analyzed 100 BPH patients undergoing urodynamic study between January 2015 and August 2016 and divided them into two groups according to their prostate size: small (≤30 mL) and large prostate (>30 mL) groups. We compared the groups regarding age, International Prostate Symptom Score, maximal flow rate (Qmax), postvoided residual, serum prostate-specific antigen (PSA), prostate volume measured by ultrasonography (USG), and urodynamic findings., Statistical Analysis Used: For testing the hypothesis, we used the Chi-square test, Student's t -test, and one-way analysis of variance when comparing between groups and conducted the logistic regression analysis for determining predictive factors of BOO., Results: Although the total prostate volume significantly correlated with the PSA, patients with a small prostate had lower Qmax (5.27 ± 4.8 mL/s vs. 6.14 ± 6.66 mL/s; P = 0.74), higher incidence of abnormal baldder capacity (39.9% vs. 31.25%), lower voiding efficiency (39.3 ± 40.5% vs. 40.57 ± 32.11%), low compliance (44.4% vs. 31.3%), higher incidence of indeterminate detrusor contractions (38.9% vs. 37.5%), lower incidence of detrusor underactivity (33.3% vs. 28.1%), lower BOO index (40.9 ± 43.2 vs. 49.10 ± 44.48), lower bladder contractility index (77.8 ± 48.84 vs. 92.09 ± 52.79), and lower PdetQmax (51.44 ± 42.23 vs. 61.38 ± 42.01 cmH 2 O). Small prostates had higher failed voiding trials postsurgery., Conclusions: BOO patients with a small prostate showed poor urodynamic parameters and reported higher postoperative complications., Competing Interests: There are no conflicts of interest.

Ureterocele in an elderly is a rare entity. The presence of stone within ureterocele along with a large bladder calculus is an even rarer presentation. This phenomenon has not been reported so far to the best of our knowledge. We present an unusual case of a large bladder calculus with a concomitant stone in the associated ureterocele. The diagnosis was missed in the first instance due to the masking effect by the larger bladder calculus. Herein, we discuss this case and its management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: Photovaporization of prostate (PVP) is a newer surgical modality of benign prostatic hyperplasia (BPH) which is gaining importance recently. There are a few randomized controlled trials that showed safety and efficacy of PVP in comparison with transurethral resection of prostate (TURP) with limited follow-up period (<2 years). Here, we are presenting a comparative study performed on potassium titanyl phosphate (KTP) PVP laser versus TURP for the treatment of BPH with long-term follow-up period., Material and Methods: After institutional ethical clearance, 150 patients were prospectively included in the study from January 2010 to March, 2012. Improvement of International Prostate Symptoms Score (IPSS), Qmax, post-void residual (PVR) urine, International Index of Erectile Function (IIEF)-5 score and complications were assessed at 12, 24, 36 and 48 months., Results: Mean age of the study group was 65.3±7.86 years in the TURP and 63.6±8.12 years in the PVP groups (p=0.45). IPSS symptom score improved significantly in both TURP and KTP groups (p<0.003). There was improvement in Q max during follow-up in both groups (p<0.001) which was maintained at 48 months. Most of the patients in both groups were satisfied with symptoms and bothersome at 48 months. All the sexual parameters are similar to both groups except retrograde ejaculation. Overall complication noted in 23 patients (15.33%)., Conclusion: Both KTP Laser PVP and TURP afford durable relief from symptoms of BPH at 48 months follow-up. Both procedures are safe and associated with minimal complications. Both procedures do not have any detrimental effect on sexual function on long-term follow-up. Quality of life remains high even at 4 years in both groups., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Purpose: The purpose of this study was to evaluate the clinical outcome and efficacy of transurethral resection of the prostate in patients of benign prostatic enlargement (BPE) with underactive bladder., Materials and Methods: Retrospective study of 174 patients, who underwent transurethral resection of prostate (TURP) between 2008 and 2015, for lower urinary tract symptoms with BPE with bladder underactivity. Clinical history, physical examination, renal function test, urinalysis, cystourethroscopy, transabdominal or transrectal ultrasonography, and urodynamic study were recorded. Patients having a history of neurologic conditions, spinal trauma or surgery, pelvic trauma or surgery, diabetes mellitus with end organ damage, urethral pathology or surgery, and prostatic cancer were excluded from the study., Results: The mean follow-up period was 22.4 ± 6.2 months. Mean prostate volume was 42.8 ± 6.4 ml and mean serum prostate-specific antigen was 2.3 ± 1.8 ng/ml. The International Prostate Symptom Score changed from 24.6 ± 4.2 preoperatively to 10.8 ± 5.8 postoperatively which was found statistically significant. Quality of life (QOL) score changed from 4.8 ± 1.2 to 2.6 ± 0.4. Twenty-two patients out of 174 remained on a per-urethral catheter or clean intermittent catheterization due to voiding failure after TURP beyond 1 month., Conclusions: TURP should be considered a viable treatment option in men with enlarged prostate with underactive detrusor who had poor response to medical treatment. Preoperative counseling and postoperative follow-up are crucial in the management of such patients., Competing Interests: There are no conflicts of interest.

Objective: The objective of this study is to evaluate our methods for management of renal caliceal diverticular stones (CDS)., Materials and Methods: We conducted a retrospective study from January 2005 to July 2015 and included patients who were treated for renal CDS. Patients were evaluated for treatment modality, puncture site (in case percutaneous nephrolithotomy [PCNL] attempted), operative time, stone clearance rate, and complications. During PCNL, if the infundibulum was found to connect the diverticulum to the calyx, then a double J stent was placed. No attempt was made to dilate the diverticular neck or to create a neoinfundibulum., Results: Twenty-four patients were treated for CDS during the study period. Two patients underwent shockwave lithotripsy, and 22 were managed by PCNL. Mean stone size was 16.37 mm (range: 6-35 mm) and mean diverticulum size was 20.62 mm (range: 12-37 mm). No fulguration was done in initial 17 patients, while fulguration by Holmium Laser was performed in the last five cases treated with PCNL. Mean operative time was 70.31 min (range: 47-90 min). Mean follow-up was 34 months, diverticulum resolved in 14 patients and reduced in size in 7 patients., Conclusion: Caliceal diverticular calculi can be treated most efficiently by PCNL. Stone-guided puncture and no attempt to dilate or create neoinfundibulum reduces operative time and morbidity while yielding high stone-free rate., Competing Interests: There are no conflicts of interest.

Aim: Transurethral resection of prostate (TURP) is considered a gold standard surgical procedure. The management of benign prostatic hyperplasia (BPH) has undergone tremendous change in recent years and shifted from open to minimal invasive procedure. With the advancement in technology and skills of surgeons, lasers have been used more liberally, particularly holmium laser. Holmium laser enucleation of prostate (HoLEP) is seen as close rival of TURP. The objective if this study is to observe long- and short-term outcomes of transurethral resection and holmium laser enucleation in the prostate of more than 60 g., Materials and Methods: This prospective randomized study includes 164 patients. Inclusion criteria were age <75 years after failed or poor response to medical therapy, prostatic size >60 g, gross hematuria secondary to BPH, recurrent urinary tract infection, acute urinary retention, postvoid residual >150 ml, and Schafer Grade II or more. BPH associated with neurogenic bladder, stricture urethra, and carcinoma prostate were excluded from the study. Group 1 comprises patients who underwent TURP and Group 2 comprises who underwent HoLEP. Follow-up was done at 1, 3, 6, 12, and 24 months after the surgery., Results: Data of 144 patients were analyzed. The mean age of patients in TURP and HoLEP group was 66.78 ± 7.81 and 67.70 ± 7.44 years, respectively ( P = 0.47), mean prostatic volume was 74.5 ± 12.56 and 75.6 ± 12.84 g, respectively ( P = 0.60), operative time was 73.10 ± 10.49 and 89.56 ± 13.81 min, respectively ( P = 0.0001). Mean resected tissue was 44.80 ± 9.87 and 48.49 ± 10.87, respectively ( P = 0.03). The sexual function did not changed significantly in postoperative follow-up., Conclusion: HoLEP is associated with less blood loss, lower transfusion rates, and a shorter hospital stay. The disadvantage of HoLEP is longer operative time and postoperative dysuria., Competing Interests: There are no conflicts of interest.

Introduction: Various anomalous kidneys such as horseshoe kidney, crossed ectopic kidney, simple ectopic kidney, pelvic ectopic kidney, kidney with duplex system, and malrotated kidney are frequently associated with stone disease. Percutaneous nephrolithotomy (PCNL) is a challenging procedure in these patients because of abnormal orientation of kidney., Patients and Methods: Since 2005-2015, 86 patients underwent PCNL for stone removal in anomalous kidneys. Stone characteristics, type of calyceal puncture, number of punctures, need of relook procedures, mean hemoglobin drop, blood transfusion, mean operative time complications, mean hospital stay, stone free rate, and auxiliary procedure were analyzed., Results: Totally 91 sessions of PCNL was done in 86 patients including five of horseshoe kidney who had bilateral stone disease. Mean age, duration of symptoms, stone size, and hospital stay was 29.6 ± 12.6 years, 2.18 ± 1.41 years, 4.40 ± 1.16, and 4.17 ± 2.11 days, respectively. Sixteen patients underwent relook procedure, out of which only 6 could have complete stone clearance., Conclusion: PCNL in anomalous kidney is a safe and feasible procedure similar to normally located kidney, but requires careful preoperative planning and intra- and post-operative vigilance., Competing Interests: There are no conflicts of interest.

A 1-year-old male infant presented with fever and abdominal lump for 3 months with increased leucocyte count (15 300/mm 3 ) and serum creatinine (0.83 mg%). Abdominal ultrasound and renal scan demonstrated solitary left kidney with dilated tortuous left ureter. Voiding cystourethrogram was unequivocal. Left percutaneous nephrostomy was placed after poor response to perurethral catheterisation. His serum creatinine dropped to 0.58 mg/dL. Subsequent percutaneous nephrostogram and CT nephrostogram showed dilated left pelvicalyceal system, dilated, tortuous left ureter. A diagnosis of obstructed megaureter was made and ureteric plication and reimplantation planned. Intraoperatively, there were primitive ureteral valves until proximal one-third of the ureter. The distance between the upper ureter and bladder was ∼6 cm. This defect was bridged by Boari flap. The postoperative period was uneventful and now after 6 months of follow-up, he is doing fine., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)